© Credit Jabin Botsford for The New York Times “I realize that I’m gambling,” said Steve Huber, who has chosen not to sign up for health insurance under the Affordable Care Act.
After seeing television ads for Kentucky's new online insurance marketplace, Mr. Huber, 57, made several attempts to explore the website but found it too complicated. Moreover, his income has dropped in recent years, he said, and he felt certain that he could not afford coverage. So he never priced plans or researched whether he qualified for financial assistance.
"I realize that I'm gambling," he said, stopping at a coffee shop before a sales call. "But I don't have a lot of patience, and I'm on a pretty tight budget anyway."
After a surge of last-minute sign-ups, eight million people bought private coverage through the federal and state marketplaces during the initial six-month enrollment period, exceeding the Obama administration's target. Mr. Huber represents the next challenge for the administration as it struggles to reduce the ranks of the uninsured and broaden support for the president's signature health care law.
For every individual who did sign up, there were others who resembled Mr. Huber: people who have decided to stay uninsured for now, despite the law's requirement that most Americans get coverage this year or pay an income tax penalty of $95 or more.
A common thread running through stories of the unenrolled is cost. Many people either do not qualify for federal subsidies or believe that the assistance is not enough to make insurance affordable, interviews with consumers and experts suggested. According to enrollment counselors in several states, people who have gone without health insurance or major illness for years can be especially resistant to investing in coverage.
To be sure, some of those who chose not to sign up were motivated by ideological opposition to Mr. Obama, to the law's mandate that they buy insurance, or to both. And for many others, confusion and lack of understanding, including about whether they could get financial help buying coverage, were the overriding reasons.
But a New York Times/CBS News poll of uninsured people in December found that of those who did not plan to get coverage, half said that cost was the main reason. Nearly three in 10 said they objected to the government's requiring it, while about one in 10 said they felt they did not need it.
© Credit Chester Higgins Jr./The New York Times Heidi Reinberg said the financial penalty for not buying coverage was preferable to the cost of premiums and deductibles.
She did check out her options through New York's marketplace but said she was not impressed. She did not qualify for a subsidy based on her 2013 income, she said, and was particularly put off by the high deductibles on many of the plans available to her.
With an income that fluctuates unpredictably, she said that she could not justify a new expense for something that was "not a priority."
"It doesn't scare me not to have it," said Ms. Reinberg, adding that she exercised, ate healthily and rarely got sick. "I'd rather pay down my credit cards than take on another bill for something I don't know that I'm going to need."
She acknowledges that she could have major medical expenses as she ages. And she might buy insurance in the future if her income stabilizes, she said. But for now, like many others, she has decided that the financial penalty for not buying insurance is more palatable than the cost of premiums and deductibles.
"I know what the penalty is going to be," she said, "and I can get my head around that."
There is no demographic data on the uninsured who could have bought coverage through the exchanges but chose not to. But a federal report last year on the overall uninsured population eligible for coverage under the new law estimated that 45 percent had incomes low enough to qualify for financial assistance buying exchange plans. Many others were poorer and eligible for Medicaid because their state opted to expand the program. Another federal report last year said that young and healthy people made up nearly half of the uninsured, and that more than half were men.
For Mr. Huber, the salesman, the complexity of the process was enough to make him give up trying to enroll.
In 2011, Mr. Huber lost a better-paying job with health benefits. For a while, he paid $450 a month to continue his employer-based coverage under the federal Cobra law. But that quickly grew unaffordable, and he has been uninsured for the last two years. He has a new job as a battery salesman but is making about half of what he used to, he said.
Not having insurance has also carried a price. A bout of diverticulitis, an intestinal inflammation, left him with a $1,100 medical bill last fall. He stretches his blood pressure medicine, taking it "exactly half as often as I'm supposed to," and pays out of pocket when he sees his internist.
Declaring himself impatient and not good with computers, Mr. Huber said he had become flummoxed when trying to explore Kynect, Kentucky's insurance marketplace, including late last month, when the online application form would not accept his phone number. He did not know that he could have sought enrollment help, he said.
"I tried four times and said, 'Forget this,' and logged off," he said.
He said he would probably try again during the next open enrollment period, from Nov. 15 through Feb. 15, perhaps enlisting an insurance agent's help. As for the tax penalty, he had heard it would be $95 for everyone and was surprised to learn he could owe more.
"They can get in line, I guess," he said of the Internal Revenue Service, shaking his head.
© Credit Jabin Botsford for The New York Times Drew Lacy, a self-employed carpenter in Louisville, Ky., said a glitch with the state’s online marketplace dissuaded him from signing up for a new plan. His old plan will be canceled this fall.
Mr. Lacy enrolled last fall in a plan with monthly premiums of about $200 after a subsidy and what appeared to be a $250 annual deductible. But in December, his broker informed him that Kynect had miscalculated because of a programming error.
The error, which the exchange acknowledged, affected about 2,100 people. Mr. Lacy's deductible, he learned, would actually be much higher; other out-of-pocket costs would be higher, too.
Put off by the error, he canceled his enrollment and did not explore other options.
"I went from being very hopeful and excited to do this to being infuriated," he said, standing in his carpentry shop in a former distillery.
Mr. Lacy had been covered for several years by an inexpensive, bare-bones plan - "If I was in a helicopter crash, it might pay for something," he joked. But he wanted more comprehensive benefits so that he could see doctors for elbow and neck problems, among other things.
For now, he is holding on to his old plan, which costs $98 a month and has a $3,500 deductible. But it will be canceled this fall, he said, because it does not meet the new coverage requirements of the Affordable Care Act. At that point, he might check back in with Kynect.
"Let's see what this actually turns out to be and what changes are made," he said.
Tammy Williams of Bothell, Wash., based her decision to opt out partly on philosophical resistance to the law.
"The government comes into our life and makes these decisions for us without even asking us," said Ms. Williams, 56. "It just makes me want to rebel."
Ms. Williams, who earns less than $40,000 a year at a small marketing firm in Seattle, said she did not want to hand over what little discretionary money she had after rent and other living expenses to an insurance company. She has been uninsured since moving a year ago from Ohio, where she had a job with health benefits.
She qualified for a subsidy to help buy coverage through Washington's marketplace, but said that she still would have had to pay around $135 a month for the least expensive plan, with a $6,000 deductible that she said made it unfeasible.
"I am opting out," she said on the last day of the enrollment period, adding that she might instead buy dental coverage outside the marketplace to take care of a chipped crown and a cavity.
A political independent, Ms. Williams said she at first chided herself about not buying coverage, thinking, "There's plans out there that make it a good thing for people, and I'm just going for rebelling against the government."
But when she looked closely at the costs, she decided her resentment was justified.
"If given a voice - 'Do you want to participate or not?' - I would have said no," Ms. Williams said. "But I don't remember being asked."
Yet for all the resisters, there were people who intended not to enroll, then changed their minds at the last minute.
Cindy Whitely, who works for a small home-improvement company in Louisville, initially decided not to buy insurance through Kynect because, even with a subsidy, it would have cost more than $400 a month for her family of three.
But her income fell over the winter, and when an enrollment counselor she met in the fall called recently to see if she wanted to reconsider, she agreed. With less income, she and her husband qualified for a bigger subsidy, and their 6-year-old son qualified for Medicaid.
Just before the March 31 deadline, they bought a plan with monthly premiums of $176 and an $1,800 deductible - still expensive "for something I may never use," she said. In her 44 years, Ms. Whitely said, she has never had health insurance.
For her, the mandate and its threat of a penalty were important. "I'm doing it more because I have to," she said.
Still, she is relieved that her son now has Medicaid coverage. And now that she has health insurance for the first time, she has already begun worrying about losing it. Might she have to give it up if her income grows and her subsidy shrinks?
"If work picks back up and I jump right back up there," she said, "then I'm stuck."
A major problem with health insurance in general, and the major contributor to un-affordability, is that the unhealthy cancer ridden gluten ass across society is given the same pricing as those people that do make some attempt to monitor their health and take care of their selves physically, mentally and spiritually.
Weight alone should make all health insurance pro rated. If a person is 30 pounds overweight they should pay 30% premium on top of baseline. If other factors are included, like smoking and alcohol, then there should be additional premiums. The people that should find health insurance too expensive should be those that are at the highest risk to drain the insurance pool with heart conditions and cancers and strokes and a general susceptibility to disease because of compromised immune system, and bodily systems in general.
Age should not be focused on, as there are myriad examples of people at an advanced age that are no more of a health risk than a fat ass at age 40. But one thing that must be understood is that once a person starts down the pharma solution road, the number and frequency of drugs to alleviate symptoms of poor health choice increases exponentially.
In other words, no more free rides for being a lazy eff up.