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In this Oct. 6, 2015, file photo, the HealthCare.gov website, where people can buy health insurance, is displayed on a laptop screen. (AP Photo/Andrew Harnik, File)

When the Obamacare health insurance exchange opens for business at midnight Monday, tens of thousands of Tennesseans will be forced to find new insurance plans, and they will discover their choices are more limited and more expensive than in the three previous years of the program.

One major insurer has stopped participating, another has cut back its offerings significantly, and all three still offering plans in Tennessee won approval for double-digit rate hikes for 2017.

"People are having to scramble to make sure their doctors and hospitals and drugs they require are covered by the plan they have to move to," said Walter Davis, executive director of the Tennessee Health Care Campaign, a nonprofit group that lobbies for improved health insurance coverage. "The more difficult any health decision is for people, the less likely they are to make it. There is a tendency to lose people with coverage if we make the process too hard for them," he said.

Federal health officials say consumers will discover an improved Health care.gov website that is easier to understand and navigate, and premiums for most users will be only slightly higher than last year — providing they qualify for a government subsidy. But a small percentage of Tennesseans will see stiff jumps in their costs, and a majority of those using the exchange will have fewer places to buy a policy.

First, to be very clear: The current enrollment period does not apply to anyone who gets their insurance through their employer, through Medicare, or through Medicaid. Some 45 percent of all Tennesseans are covered through health insurance they buy at work; another 1.2 million who are 65 and older receive Medicare, and another 1.6 million, mainly low-income mothers and children, receive Medicaid.

Beyond that coverage, however, about 269,000 people in the state signed up on the Healthcare.gov website last year for insurance on what is commonly known as the Obamacare insurance exchange. They are the ones who now need to review that coverage, and many of them will need to shop for a new plan.

And tens of thousands of Tennesseans who have no health insurance and have not signed up for Obamacare will need to either find a plan or pay a penalty of at least $695.

About 172,000 of those who signed up for the health insurance exchange last year in Tennessee will be forced to find a new insurer this year because the two largest insurers dramatically reduced their offerings. United Healthcare, which only started offering insurance on the exchange last year, is leaving the market entirely, dropping 40,800 customers. BlueCross BlueShield, which had 69 percent of all of the policies on the exchange, decided to drop its offerings in the state's three largest cities, Memphis, Nashville and Knoxville, leaving 131,000 customers without coverage for 2017.

That means Tennesseans in 73 of the state's 95 counties who need to buy insurance on the exchange will have only one insurance company offering policies to choose from. While BlueCross BlueShield is available everywhere but in the Memphis, Nashville and Knoxville regions, Humana is only available in Memphis, Nashville and Knoxville. Cigna offers plans in Memphis, Nashville and in the Bristol-Johnson City area, where BlueCross BlueShield is also still selling coverage.

An analysis by The Associated Press and consulting firm Avalere Health found about one-third of U.S. counties will have only one health marketplace insurer next year. That's more than 1,000 counties in 26 states — roughly double the number of counties in 2014, the first year of coverage through the program.

Five states — Alaska, Alabama, Oklahoma, South Carolina and Wyoming — have one participating insurer across their entire jurisdictions. Only Wyoming and South Carolina had faced that predicament this year.

Another eight states — Arizona, Florida, Georgia, Missouri, Mississippi, North Carolina, Nevada and Tennessee — have only one participating insurer in a majority of counties.

And that applies to the Chattanooga area: Your only option is BlueCross BlueShield.

BlueCross BlueShield has shrunk its plans dramatically, offering only four options, down from 22 last year. There is one bronze-level plan (the least expensive), two silver-level plans, and one gold-level offering (the most expensive). The company no longer offers any platinum plans. The plans differ in cost depending on how large a deductible they require, what doctors are in their networks, how large a co-pay they require, and in the size of the maximum annual cap on payments.

In Chattanooga, however, BlueCross BlueShield's offerings all include access to its S network of doctors and hospitals, the most popular in the area and one that includes many local health care providers including Erlanger and CHI Memorial, according to Bobby Huffaker, CEO of the American Exchange, a Chattanooga-based health insurance broker.

If you want help figuring out what to do, there is free assistance. The GetCoveredTenn.org website offers information, but also a toll-free number (1-844-644-5443) that links to counselors who can walk you through your options.

Or Huffaker's American Exchange (www.americanexchange.com) has counselors to help both employers and consumers navigate the exchange, for a fee.

One thing is certain: premiums will be more expensive. Even before announcing they were pulling out of the state's three largest cities, BlueCross BlueShield asked for and received a 63 percent rate increase, claiming it needed the higher premiums to avoid losing money. BlueCross BlueShield said it has already lost nearly $500 million on the exchange because it underestimated how sick its new customers would be and underpriced its policies.

Of course BlueCross BlueShield's mistake was good for consumers. Tennesseans had among the lowest Obamacare rates in the nation for the first three years of the program.

And overall, the nation's insurers are doing very well indeed. The stock price of the top five health insurers — United­Health, Anthem, Aetna, Humana and Cigna — rose by between 80 and 165 percent since the Supreme Court ruled Obamacare constitutional in 2013.

For many people, the higher premiums will be offset by higher government subsidies to help afford them. The subsidy is based on the cost of the second-lowest silver-level plan available where you live. So when premiums get more expensive, the subsidy rises, as well.

The subsidies can make a huge difference in making monthly premiums more affordable. In a conference call Thursday sponsored by the Tennessee Hospital Association, BlueCross BlueShield officials pointed out that in the Chattanooga area, a 40-year-old nonsmoker earning around $30,000 a year would initially see a premium of $422 per month for coverage. But the subsidy would pay $397 of that, leaving an actual bill of only about $25. And even for a similar consumer earning nearly $50,000 per year, the monthly premium would only be about $200 with the subsidy.

While the increase in premiums is bad, "if you qualify for subsidies, you are going to have affordable options," American Exchange's Huffaker said.

Federal health officials estimate the average American who buys insurance on the exchange will pay about $113 a month, provided he or she qualifies for a subsidy.

In comparison, if you get your health insurance through your employer, the amount of money you pay from your paycheck for health insurance plus the size of your deductible has jumped significantly, from 6.5 percent of your salary in 2006, to 10.1 percent in 2015, while pay raises have not kept pace, according to a study released last week by the Commonwealth Fund.

While the increased subsidies for Obamacare mean federal taxpayers will have a larger bill to pay, the amount is less than anticipated because when Obamacare was adopted, the assumption was that some 21 million people would enroll in it by 2016. Instead, only some 13 million are enrolled, so the amount of money spent on subsidies is less than predicted.

But thousands of Tennesseans will not qualify for a subsidy, and they will be the ones hardest hit by the premium increase. Without a subsidy, the average premium for 2016 was estimated at $408, according to the federal Department of Health and Human Services. One bit of good news for those consumers in Tennessee: Aetna is offering coverage off the exchange statewide, to give Blue­Cross BlueShield competition. But since Aetna is not part of Obamacare, it has not yet revealed its rates or coverage plans for 2017.

About 93,000 Tennesseans fall into what is sometimes called the coverage gap, earning too much to qualify for poverty programs but not enough to earn an Obamacare subsidy. When Obamacare was designed, every state was required to expand its Medicaid offerings to include those making less than the poverty level. But the U.S. Supreme Court struck down that part of the law, and 19 states, including Tennessee, have not expanded Medicaid.

But since Obamacare assumed those earning less than the poverty level would be covered by an expanded Medicaid, those consumers were not covered by the subsidy program.

Whether or not they qualify for subsidies, consumers will find fewer choices this year. Some of the successful insurers on the Obamacare exchange — and there are some — offer a limited networks of doctors. That may mean giving up a family doctor in order to find a new one who is covered by the insurance policy.

Of course, those who have never had insurance may never have had a doctor anyway.

Cigna is focusing on those customers in expanding its coverage in the Memphis area.

"What we saw in entering this market was being able to make that connection, providing more of a primary care physician who can help improve the health for people who have never had that," company spokesman Joseph Mondy said. Mondy said Cigna hopes to expand its Obamacare offerings in the state. "Tennessee is one of the areas we have targeted for future growth," he said.

Consumers who decide not to sign up for health care for 2017 face a penalty of either 2.5 percent of household adjusted gross income or $695 per adult, whichever is larger. However, the total penalty cannot be larger than the cheapest bronze-level plan in your area, which in 2016 would have been about $2,676 for a single individual, and $13,380 for a family of five or more, according to the web site healthinsurance.org.

Obamacare supporters point out that several hundred thousand people in the state now have health insurance who never had it before, and as BlueCross BlueShield's losses confirm, many of them had significant health problems and benefited from the coverage. That is a key goal of the law, to protect consumers from catastrophic health care bills.

"They are not going to be excluded from insurance if they have a pre-existing condition," the Health Care Coalition's Davis said. "If they have cancer, they're not going bankrupt because the company cut them off at $100,000."

Young people also have benefited, because they can remain on their parents' policy until they are 26. But the program has not signed up as many healthy younger Tennesseans as the insurance companies had hoped, and there is concern that if rates continue to rise, many of them could decide it makes more sense to pay the penalty for not having insurance than to pay the premium.

As the Commonwealth Fund study found, the amount consumers pay for health care continues to rise faster than any increase in wages, pointing out the bigger underlying problem Obamacare was not designed to fix: Health care costs continue to rise.

But tackling that issue will be left for a new president and Congress to address.

Contact staff writer Steve Johnson at 423-757-6673, sjohnson@timesfreepress.com, on Twitter @stevejohnsonTFP, and on Facebook, www.facebook.com/noogahealth.

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