Other lingering misconceptions could feed Republican attacks through the midterms. ACA's next obstacle: Confused users

Obama administration officials hoping to exhale after the big finish to Obamacare’s first enrollment season may need to hold their breath a while longer.

All the confusion and mixed messages out there are bound to combust if people decide they were misled — an echo of the “you can keep your plan if you like it” fiasco.


“If there’s been a failing with the Obama administration [communication], it’s the failure to adequately plan for that kind of extensive, repeated interaction with people at the community level,” said Larry Jacobs, an expert on health politics at the University of Minnesota. Successful outreach doesn’t depend on just one jingle, he stressed. “It’s repeated and unceasing outreach at multiple levels.”

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Some of the missed points and mixed-up details could bite the administration almost immediately as people start using their new plans and blame surprises on the White House. Other lingering public misconceptions could feed Republican attacks through the November midterm elections.

Here are six big danger points.

1. I’m sick! Why can’t I get covered?

Coverage of pre-existing conditions was a big selling point of the law, but not everyone realizes that they can’t just sign up the minute a condition is diagnosed. The regular dates and deadlines for enrolling still apply, no matter when you get appendicitis.

Yet 6 in 10 uninsured Americans didn’t know March 31 was the cutoff for getting 2014 coverage, according to a Kaiser Family Foundation poll last month. They didn’t know that missing the deadline meant they’d be locked out until November (unless they’re eligible for Medicaid, which has no such restriction.)

“Since they don’t even know that there’s a deadline, I don’t think that they could know the next step, which is that they can’t enroll for the rest of the year,” said Mollyann Brodie, executive director of public opinion and survey research at Kaiser.

“It’s going to be a shock, and we are going to be fielding a lot of calls,” said Michael Mahoney, a senior vice president with the online insurance broker GoHealth. “But there’s not much you can do to help.”

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One reason for the confusion might have been all those delays and extensions. Just before March 31, the administration granted people with special circumstances or sign-up difficulties a bit more time.

“There’s almost an assumption that there’s never a real deadline on anything,” said Tom Miller, a fellow at the American Enterprise Institute and a critic of the law.

The risk: Anyone who gets sick and thinks they can just waltz in and get insurance is in for a shock. They just might blame it on Obamacare — or President Barack Obama. And then when they get hit with a penalty for not having insurance, they’ll be even angrier.

2. The $95 mandate myth

Most people know there’s a penalty for being uncovered. But they are wrong about the amount.

“You have to pause and say, ‘It’s not one Ben Franklin, it’s probably closer to three,’” said Brian Haile, senior vice president for health policy at Jackson Hewitt Tax Service Inc. Customers constantly walked in and declared that they were going to forgo coverage and cough up the $95 penalty, he said. Then they’d learn that it was actually $95 or 1 percent of income, whichever is greater. In 2016, the amount increases to $695 or 2.5 percent of income.

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“They say, ‘Well, that’s a lot more than what my congressman told me, or what I read in the newspaper or heard on television,’” Haile said. “They’re sort of flummoxed.”

The government didn’t stress the penalty during much of the outreach. “I have a strong feeling that the kind of vagueness about the mandate and penalty was deliberate,” said Jacobs, the political scientist. “It’s better to attract people with the benefit than threaten them the IRS is going after them.”

Ceci Connolly, managing director of the Health Research Institute at PricewaterhouseCoopers, said she’s not sure that was a smart strategy. Her research found that Massachusetts’s emphasis on a penalty when its own health reform law took effect motivated people to sign up.

Of course, Obamacare won’t hit anyone with a fine until Americans start to do their 2014 taxes next year. That means it comes due in 2015 — after the November midterms but in time for the 2016 presidential campaign.

The risk: a delayed but nasty surprise at tax time.

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3. I can’t afford Obamacare

Four in 10 uninsured Americans still don’t know that the Affordable Care Act offers financial assistance to low- and moderate-income individuals, according to that Kaiser poll. Plus, many of the GOP attacks on the law that people hear are about its cost.

Enroll America found that perception of high costs was the single biggest barrier to enrollment in this first season. Over the course of the enrollment period, the group fine-tuned its messaging to stress the availability of financial help and interest soared. “Once the connection is made, the likelihood of those people enrolling goes through the roof,” Enroll’s field director John Gilbert said.

But sometimes people who knew generally about the assistance didn’t realize that they themselves might qualify, said Christine Barber, a senior policy analyst at Community Catalyst. “People are really surprised that they can get financial help and that the law can benefit them,” she said.

And subsidies don’t prevent sticker shock for everyone; the aid gets “thinner” as people move up the sliding income scale. “That will be off-putting for some,” said Karen Pollitz, a senior fellow at Kaiser.

It’s impossible to know how many people never applied for coverage — or sidestepped an exchange and bought a policy elsewhere at full cost — because they didn’t understand how much help was available.

The risk: People who learn that they missed out on a good (or a better) deal will want to blame someone — and it probably won’t be themselves.

4. “Sort of a bait and switch”

People who end up making more than they anticipated during the year, and don’t realize that they should report it, may have to pay back some of their tax credit when they file their taxes. But for many people, matching up what they got versus what they should have gotten is going to be “highly problematic,” said Jackson Hewitt’s Haile.

Folks who suddenly find their tax refunds reduced may feel like the government has “raided their piggy bank” — forgetting, of course, that the piggy bank was bigger in the first place because of the financial help in purchasing health insurance. “You run the risk of it creating very negative perceptions of the marketplace. Sort of a bait and switch, if you will,” he said.

The risk: What do you mean I don’t get a tax refund? I want my piggy bank!

5. It’s not free?

Many people who signed up for Obamacare are insured for the first time — or the first time in a long time — and they are now confronting an array of befuddling terms. They don’t necessarily understand that a monthly premium isn’t the only bill they have to pay. The co-pays, deductibles and other costs they’ll encounter when they go see a provider could be a real shock.

“Messages get very simplified, and it sounds like, ‘enroll in the Affordable Care Act and your worries are over for medical bills,’” AEI’s Miller said.

Groups and programs that helped consumers choose a plan say they tried hard to explain it all. For instance, Jodi Ray, who oversees the navigator programs at the University of South Florida, said they were “careful about explaining deductibles, co-pays and premiums and when they’re used, when they’re needed, when they’re going to kick in, when they’re expected to pay them.” And they tried to connect people to an in-network physician. But it’s all still complicated.

The risk: EOB-alarm. Unhappy people who get one of those Explanation-of-Benefits statements for the first time.

6. The reality of costs

Remember that “save $2,500 on your insurance” promise that presidential candidate Obama made in 2008? It took a few different forms and was couched with different time frames. Sometimes it was promised by the end of Obama’s first term. But all the nuances of economic modeling and different cost-growth curves never made it into the sound bites. People with insurance heard promises of big savings and — except for some on the exchanges — they haven’t experienced that.

The overall rate of growth in national health spending including Medicare has slowed, Connolly noted. But for individuals? Neither premiums nor out-of-pocket spending has dropped — most certainly not by the $2,500 that people thought they were promised.

It’s little comfort that their costs might have been even higher without the health care law, if they even understand that.

And premiums could go up sharply next year in some or most states depending on who did get covered this year and how young, old, sick or healthy they are.

“That’s another possible premium shock,” Miller predicted. “I don’t think it will happen in all 50 states, but I think it’ll happen enough to be noticeable.”

The risk: an awful lot of GOP campaign ads blaring “Another Obamacare Broken Promise.”

Brett Norman contributed to this report.