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OPINION: Getting insurance under Obamacare like used-car shopping

On Oct. 1, millions of uninsured Americans —105,000 in South Dakota — suddenly got a new way to buy health insurance. They can now shop in the state insurance exchanges. Many of them had been shut out of the insurance market because they have pre-existing health conditions. In January, it will be illegal for insurers to turn away sick people.

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It’s expected that about 24 million people will find insurance coverage in the exchanges, and about 60 percent of them will be eligible for a subsidy to help them pay the premiums. For families with incomes hovering around the federal poverty level ($23,550 for a family of four; $11,490 for individuals) and somewhat above, subsidies will be large and might cover a good chunk of the premium. Families with higher incomes will get smaller subsidies and will have to pay most of the premium themselves. That could be a big chunk of the family budget if they choose a policy with good coverage.

Customers in the exchanges will mostly be those who have no coverage and those who now buy it in what’s called the individual market. If you have employer coverage, Medicare, Medicaid, or coverage from the military or the Indian Health Service, forget the exchanges. The law assumes you already have health coverage.

The poorest of the poor in the 26 states that have chosen not to expand their Medicaid programs, including South Dakota, cannot shop in them either.

They have incomes below the poverty level, and because their states have chosen not to expand, they have few options. Because of the way the law was written it was assumed that people with incomes below the poverty line would get Medicaid as well as those with incomes between 100 and 138 percent of poverty.

Because of the court decision, that meant those whose incomes were 99 percent of the poverty level are out of luck if their state has chosen not to expand.

Their incomes are too low for them to buy insurance on their own and unless their state offers benefits to childless adults (most don’t), they can’t get Medicaid either.

People who have coverage they’ve already bought in the individual market can also check out the exchange to see if they can get a better deal. That includes freelancers, retirees not yet old enough to get Medicare, people between jobs and families of workers whose employers provide insurance for employees but not for their spouses or kids.

A Hastings, Neb., woman who is disabled because of a medical error is one of those who will be looking for an insurance deal on the exchange. She and her husband already have insurance they bought in the individual market. She had heard about the new law and went online to do a bit of research. She left her name on the site of, and received calls from 15 agents eager to sign her up when the exchanges opened for business.

One from Florida told her if she didn’t sign up quickly her application would not be accepted. The woman told me the agent’s message was “if you don’t work with me on this, you’ve blown it, honey.”

That brings up the matter of where to go for help. One place to start is the website, the entry point for people in states like South Dakota. The federal government also runs the Marketplace Call Center 1-800-318-2596.

You can also look for a navigator, a real live person trained to help people enroll in a policy. They are supposed to be unbiased and can’t steer consumers to any particular policy. To find one in Hastings, I clicked on It gave me three choices: a hospital in Lexington, Community Action of Nebraska, and Planned Parenthood of the Heartland, both in Lincoln. Not exactly help around the corner.

Once you find your way to a list of insurance offerings either on a website or with a navigator’s help, the task becomes tricky. Choosing health insurance is never easy, whether you’re buying inside or outside an exchange.

You don’t have to rush into anything right now. Take your time and study the options. Coverage doesn’t begin until January (if you sign up by Dec. 15), and open enrollment doesn’t end until March 31. If you buy a cheap policy that doesn’t cover your needs when you’re sick, you may be stuck with it for months until the next open enrollment.

“It’s a like walking into a chasm of uncertainty,” the Hastings woman said. “It’s a little like shopping for a used car. You don’t know if you’re getting a lemon.”

-Trudy Lieberman is a contributing editor to the Columbia Journalism Review, where she blogs about health care and retirement.