It started with a click.

Determined to cross “Buy health insurance” off her list, Robin Allen sat down at her computer last fall and Googled the federal government website where consumers can enroll in plans that meet coverage requirements of the Affordable Care Act. She typed in some basic health information, her phone number, and within minutes her phone was ringing.

Allen was impressed that an agent was available to help her at 9:30 p.m. She went to bed enrolled in a plan the agent promised had no deductible, low-cost vision and dental coverage, and all the doctors she would need — all for a $300 monthly premium.

“I didn’t have any reason to believe that was not the way it should be done,” said Allen, 55, of Erdenheim, Montgomery County, who had been covered by her husband’s employer plan until they divorced.

Except Allen hadn’t been on the government’s website, healthcare.gov. The broker she spoke to doesn’t sell major medical insurance and she realized months later that the plan he sold her didn’t even cover basic health services.

She had landed on an insurance-quote website, where user information is handed off to brokers who may sell comprehensive health plans — but often mislead people into buying products with little coverage. These websites spend millions of dollars for top billing on Google when people search such keywords as Obamacare plans and ACA insurance. Their ads are designed to get clicks, often using Healthcare.gov in their hyperlinked text, and lead to homepages splashed with Obamacare phrases.

This type of lead-generation website has been around for years but has become a bigger consumer concern since the Trump administration loosened regulations on short-term, limited-duration health plans. Today, it’s possible for plans never intended to serve as long-term, primary health insurance to be sold as year-round coverage.

Many Republicans argue that limited-benefit plans should be available for people who do not want all the coverage the ACA requires of major medical insurance. Some consumers may not want certain ACA mandates, such as maternity and mental-health coverage. But limited-benefit plans often leave out a lot more, such as coverage for preexisting conditions.

Yet the companies and brokers selling these plans often do not make that clear — in fact, they seem to purposely attract marketplace shoppers with ads that are often hard to distinguish from the government’s website.

“There are websites that are designed to confuse people — or at least they seem designed to confuse,” said Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.

To make matters worse, the administration has slashed the ACA’s public outreach budget, leaving healthcare.gov no way to counter with ads of its own.

House Democrats pushed through a package of health-care bills that would reverse the Trump administration’s expansion of short-term health plans and restore funding for groups that help people enroll in healthcare.gov. Senate Democrats followed with a companion bill addressing short-term plans.

But with a split Congress, the task of protecting consumers has fallen to the states, which have varying restrictions on limited-benefit plans and little ability to wrangle websites that operate seamlessly across state lines through the internet and are the Federal Trade Commission’s responsibility to regulate.

In the meantime, consumers are left in a difficult-to-navigate insurance market, where one wrong click can land them in an insurance plan with thin benefits and significant exposure to high medical costs.

Millions spent on ads

Google healthcare.gov and the first three to five results that show up above the federal government’s marketplace website are ads, mostly for insurance quote websites with official-sounding names.

Websites bid for their ad to show up when people search for certain keywords.

Between 2014 and 2017, more than 2,800 advertisers spent $46.6 million sponsoring about two dozen ACA-related search keywords, according to analysis by Kantar, a data and market research company.

Six websites outspent the federal government, which put $1.4 million into Google ads for healthcare.gov in 2017, according to Kantar.

Screenshot of a Google search for "healthcare.gov" on May 7, 2019.
Sarah Gantz
Screenshot of a Google search for "healthcare.gov" on May 7, 2019.

All Web Leads, an Austin, Texas-based lead-generation company, was the second-biggest spender that year, shelling out $3.2 million to attach its website, affordable-health-insurance-plans.org, to heavily searched ACA keywords.

A majority of the people who visit the website, which predates the ACA, can’t afford marketplace plans and are looking for something cheaper, said Bill Daniel, CEO of All Web Leads.

Yet the hyperlinked text in its Google ad says HealthCare.gov. The homepage advertises “Obamacare Plans from $9/wk” and notes that all of the plans agents sell meet federal standards under the ACA. That’s true, but not very meaningful, because short-term plans are exempt from the law’s coverage requirements for major medical insurance.

The site’s ACA branding attracts shoppers during the government marketplaces’ fall open enrollment. That’s when many of All Web Leads’ customers — brokers and insurers — sell plans that meet ACA standards for full health insurance, Daniel said.

He doesn’t think many people have trouble distinguishing full coverage from skimpy coverage.

“I don’t think that’s a significant problem, based on what we hear from consumers," Daniel said. "They do contact us if they’re not happy with the connection we’ve made for them.”

Designed to confuse

Insurance quote websites note on their homepages — usually in tiny type — that they’re not affiliated with the government, but even people with decades of health-policy experience can’t always tell the difference.

Every year, Ezekiel Emanuel, chair of the University of Pennsylvania’s department of medical ethics and health policy, assigns his students to shop for health insurance using the government marketplaces. One year he did the exercise, too.

“It took me about 15 minutes to realize I wasn’t at healthcare.gov or a state exchange,” Emanuel said. “Unless you know what the right place looks like, what the offers are, they’ve done a very good job of making it look like it’s the [government] health insurance site.”

Although Emanuel’s error was merely a class exercise, consumers who make the same mistake often discover the plan’s shortcomings only when they have a medical issue.

Allen realized her mistake when she checked her plan’s coverage for a specialist visit she wanted to schedule.

The plan she thought was conventional health insurance was actually an indemnity plan, which pays a set rate for a select list of services and is designed as an add-on to real health insurance. In her case, the plan would pay nothing for that specialist visit.

United States Fire Insurance Co., the plan’s underwriter, did not respond to a request for comment.

According to Pennsylvania’s directory of licensed insurance brokers, the agent who sold her the plan has agent privileges with three insurance companies, including USFIC — none of which sell major medical health plans.

“I was like, oh, my God, I have been completely scammed,” Allen said.

With help from a local professional, Allen has since enrolled in a full insurance plan. But she recalls how overwhelmed she felt at her initial discovery.

“I just put my head down on my computer and started to cry. I didn’t know what to do,” she said.

She hasn’t been able to get her money back, yet.

Discreet ad labels

In the early 2000s, Google ads appeared in hard-to-miss colored boxes. Now they’re marked by a tiny white label with a green outline.

Search engines are regulated by the FTC and the issue of ad clarity has been on the agency’s radar for years. In a 2017 report, the FTC recommended that search engines use bigger, brighter ad labels at the very top of a listing, and easily understood phrases such as paid content, but stopped short of making the changes mandatory.

Google has on a few occasions banned ads criticized for targeting vulnerable individuals, such as ads for alcohol and drug rehab and payday lending.

Vetting millions of ads would be difficult because knowing whether an ad is misleading requires understanding the industry, said Megan Gray, general counsel for the Paoli-based search engine DuckDuckGo and former consumer protection attorney for the FTC.

Still, she said, "for a company with the gargantuan size and influence of Google they should have some moral responsibility that they are not misdirecting users.”

DuckDuckGo uses a white ad label similar to Google’s, but lists just one ad above organic search results and includes a button to report bad ads.

Yahoo lists about five ads separated from search results by a thin horizontal line.

Bing’s ad label is smaller than Google’s and outlined in light gray.

Google did not respond to a request for comment.

Others say the only way to truly protect consumers is to rein in the plans themselves.

“While I absolutely think it is wrong for companies selling these junk policies to take advantage of unsuspecting consumers, we should not have to rely upon platforms, like Google, to take on the role of a regulator,” Sen. Bob Casey (D., Pa.) said in a statement.

The Senate’s bill to reverse Trump’s policy on short-term plans builds on the House’s legislation, which also restores $100 million in funding for “navigator” groups that help individuals sign up for marketplace plans. All but a handful of Republicans voted against the House measure.

In the meantime, states can regulate short-term plans, though rules vary — New Jersey bans them, while Pennsylvania has some of the loosest restrictions.

Slippery websites and ads are much harder to pin down.

"It’s whack-a-mole. You take one down and another pops up," Palanker said.

It can be hard to tell the difference between major medical insurance and skimpier health plans, so it’s important to know what to look for and what questions to ask your broker. Here are some tips:

Check the URL

The best way to know you’re in the right place is to double (triple!) check the URL, which is the website address. The federal marketplace website is healthcare.gov.

Search engine ads often use healthcare.gov in the hyperlinked text people click on to get to the website, but look closely at the URL just below to see the actual website address.

All government websites are “.gov” domains, while private websites use .com, .org. or .net. Many companies have scooped up websites people might land on if they miss a letter typing or use the wrong domain.

Check for a disclosure

Insurance quote websites are required to note that they are not affiliated with the government, though this detail is often in small print at the bottom of the page. The privacy statement at the bottom will give more information about who owns the website.

Did you have to answer health questions?

The ACA prohibits comprehensive health plans from basing coverage on your health status, which means if you had to answer questions about whether you smoke or have ever been pregnant, you’re on an insurance quote website where at least some of the plans are allowed to underwrite (denying coverage or charging higher prices) for health conditions.

Can you window-shop?

Government marketplace websites allow consumers to compare plans without creating an account or submitting any contact information.

Did you give out your phone number?

Healthcare.gov doesn’t ask for your phone number on its homepage so that an agent can call you. If an agent calls to help you sign up for insurance, it is a private broker.

Get good help

Healthcare.gov has a search tool to help you find navigators (groups that receive federal funding to assist with enrollment) and brokers licensed to sell comprehensive, ACA-compliant plans.

Research the agent

Search by name in Pennsylvania’s insurance broker registry to see whether your agent’s license is up to date. Once on an agent’s license number page, click “appointments” to see which insurance carriers he or she has relationships with. If none of them are major medical insurance companies, your agent won’t be selling you comprehensive health insurance.

Research the plan

Write down the plan name and carrier, and check its status with the state Insurance Department online or by calling 717-787-2735. If the agent is reluctant to give you this information, that may be a sign he or she hasn’t been upfront about the plan’s coverage.

Get it in writing

All major medical plans have a summary of benefits document that outlines exactly what is covered under the plan and how services are paid for. Look closely for wording about exemptions and limitations, especially if the document you receive looks more like a glossy brochure than a boring legal document.

Think on it

Brokers selling insurance over the phone can be convincing and pushy — but you’re not obligated to hand over your credit card number right away. Insist on having the contract agreement emailed or mailed to you, to review carefully, before signing.