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Health insurance customers are holding on to their ACA plans

M.L. Simone isn't averse to risk. You might remember Simone, the self-proclaimed "most-educated coffee pourer in Philadelphia," who has a business degree and an art administration degree, and who first shared her insurance story here in December.

M.L. Simone isn't averse to risk.

You might remember Simone, the self-proclaimed "most-educated coffee pourer in Philadelphia," who has a business degree and an art administration degree, and who first shared her insurance story here in December.

She opened Hinge Cafe, a coffee bar/art gallery in Port Richmond when it was still a Maxwell House Coffee-drinking, blue-collar neighborhood.

In Hinge's early years, Simone also risked not having health insurance. Starting a business put health insurance low on her list of priorities, not to mention that she couldn't afford it. But when her daughter was born five years ago, Simone jumped into the pre-Affordable Care Act individual health insurance market, paying a $600 monthly premium.

She sat out the ACA's first open enrollment in 2013. But in December, she switched to a marketplace plan, buying Independence Blue Cross' Silver Proactive tier policy. Truth be told, Simone isn't thrilled with the plan, even though with her subsidy she's paying just $150 a month.

"I'm getting hit with very big co-pays and co-insurance and other things not being covered," she says.

Many people opposed to the ACA foresaw situations like Simone's leading to the law's eventual downfall. Anti-ACA pundits predicted people would enroll and never even make their first payments or would stop paying when they found the premiums unaffordable.

But that is not what appears to be happening - either to Simone or to marketplace enrollees nationwide.

According to an April 13 Gallup poll, the uninsured rate among adult Americans for the first quarter of 2015 was 11.9 percent, a 5.2 percent decrease since shortly before the ACA went into effect.

The poll doesn't include people who bought marketplace plans during the March 15 through April 30 special enrollment period.

An improving economy with lower unemployment and the expansion of Medicaid in several states - including Pennsylvania and New Jersey - can explain some of the increase in the number of people insured, but Gallup thinks the ACA also deserves credit.

"However, the uninsured rate is significantly lower than it was in early 2008, before the depths of the economic recession, suggesting that the recent decline is due to more than just an improving economy," the survey says.

In Pennsylvania, nearly half the potential pool of residents - 427,454 total - are enrolled in a marketplace plan, according to Kaiser Family Foundation. In New Jersey, 35 percent of potential enrollees - 208,467 people - have a marketplace plan.

Locally, Independence added 40,000 customers during the last open enrollment, bringing its total book of business to 173,000 people. When the 2014 marketplace closed, Independence had a first-payment rate of 87 percent, well above the national average of 80 percent.

This year, the first-payment rate was 94 percent. And 97 percent of those people have continued making their monthly premium payments.

"This year, I think people were more thoughtful," says Paula Sunshine, Independence vice president for consumer affairs. "It was the second year, and they understood more about what was happening. And the people who were entering the marketplace in the second year were more intent on having insurance."

It wasn't only customers who had a better understanding of the marketplace. Sunshine says Independence had a better understanding of how it could help its customers.

In addition to the letters it sent last year welcoming people to their plans and asking them to call with questions, the company made more outreach calls and sent text messages to remind people of a forthcoming premium payment.

"Once open enrollment closed, we took some of those resources and redirected them to do outreach to customers," she says.

Like last year, the tiered Proactive plan was again the company's best seller for both new sales and renewals.

The Proactive plan is the first of its kind for individual consumers in the Philadelphia market. Boiled down, it is an HMO plan that uses a tiered system; members can go to any facility in the Blue Cross network. The internal tiers - Preferred (lowest cost), Enhanced (middle), and Standard (most expensive) - represent rising levels of out-of-pocket payments. Consumers pay more to go to academic hospitals and less for community hospitals.

"A large percentage of people who switched policies during the renewal process switched into the Proactive plan," she says. "So I think people were beginning to understand that tiered networks could be very beneficial to them.

There is still plenty that people don't understand about the marketplace and buying health insurance. But two years in, the marketplace is running more smoothly. With more insurers joining the marketplace, consumers will have a wider selection of plans to choose from. But it will take time - some experts say five years - to smooth out all the kinks in the law. (At press time, the U.S. Supreme Court had not yet ruled in a case that could determine the future of insurance subsidies in states that lack their own exchanges - including Pennsylvania and New Jersey - potentially throwing the ACA and the individual insurance market into turmoil.)

In the meantime, Simone is going to "reevaluate" her plan when the marketplace reopens in November. Until then, she will pay her monthly premium.

"I just have to figure out what's best financially now that I am a little better educated," she says. "I have to stay insured, no ifs, ands, or buts."