BIRMINGHAM, Alabama -- Doug Hoffman, who works statewide to help people sign up for benefits through the Affordable Care Act, just received a Blue Cross and Blue Shield of Alabama notice in the mail to find health insurance rates for his family have doubled.

And he's mad -- at Blue Cross.

"I just got my benefits renewal from Blue Cross for next year and they doubled my rate!" he wrote AL.com in an email. "I was paying $675 for a family premium (2 adults, one 22 yo dependent) with a $1,500 deducible. The new rate for a comparable plan is $1,360 with a $3,000 deductible. Basically they have doubled my costs."

"It appears as though Blue Cross is taking advantage of the ACA by hiking rates big time," said Hoffman, who is based in Birmingham with Enroll Alabama.

Others, who have received the notices from the state's dominant health insurer are mad as well -- at Obamacare.

"Obama thinks that he is making insurance affordable," wrote one reader to the Mobile Press Register Sound Off feature. "I just got a letter from my Blue Cross Blue Shield that if I want to keep their insurance it's going to cost me $300 more a month. I already pay $300 a month now and they're wanting right at $600 a month for this Affordable Care Act."

So who is right? Where should this righteous anger be directed?

Blue Cross, which has an 88-percent share of Alabama's health insurance market, posted a link to an explanation on their Facebook page in the wake of reaction to the rate hikes. The explanation is entitled "Affordable Care Act Brings Changes to Premium Calculation" and cites a variety of reasons that the law has an effect on premium prices.

In an emailed response to questions, Blue Cross elaborated on its several explanations as to why people are getting hit with sticker shock, including: there are more taxes and fees; there's a requirement to rate family members individually; and the law eliminated health underwriting and waiting periods for preexisting conditions.

The underwriting and preexisting condition explanations may be the most significant because now everyone can join the insurance pool, and actually are required or pay a penalty if they don't.

Before ACA, insurance companies in many states, such as Alabama, were allowed to offer younger, healthier individuals much lower rates than older sicker individuals.

"Alabama has allowed medical underwriting -- you're going to be quoted a high premium if you have something wrong with you," said Michael Morrisey, director of the University of Alabama at Birmingham Lister Hill Center for Health Policy. "The Affordable Care Act abolishes medical underwriting."

This means that those with expensive health problems will likely now jump in and buy coverage because it will be less expensive for them -- or if they already have coverage -- their rates will go down. But that also means rates will go up for everyone else as the insurer spreads that new cost around.

How this works can be illustrated by comparing Vermont and Alabama.

In a report earlier this year, the Society of Actuaries listed Vermont with an average per member health insurance claims cost before the Affordable Care Act at $587 per month. That's much higher than Alabama's pre-ACA average cost of $263.

The society predicted with the implementation of health reform, Vermont's average claims cost to the insurer would go down 12.5 percent to $514 by 2017. But Alabama, the society predicted Alabama's average claim cost would jump 60 percent to $422 by that year. The difference: Vermont had higher average rates because it had virtually eliminated underwriting as a state.

The Society of Actuaries points out that claims costs are a factor that goes into calculating premiums, but there are other factors involved. Premiums can vary based on age, gender and geography, among other things.

"So the ACA eliminates medical underwriting and requires everybody to buy coverage," Morrisey said. "In Alabama premiums go up a whole bunch because the older sicker folks join. In Vermont, younger, healthier people will presumably join disproportionately."

But Morrisey points out that Vermont-Alabama comparisons are projections and the results will ultimately depend on how many young healthy people there are, how many old, sick people there are, and what they decide to do.

Whether the elimination of medical underwriting is beneficial in terms of premiums depends on what group you are in.

"The thing that happens when you eliminate underwriting is that you lump dissimilar people together," Morrisey said. "When you combine groups, one group is better off and the other group is worse off" -- in terms of premium prices.

As a policy, the elimination of medical underwriting and preexisting condition clauses helps broaden access to health care coverage and that was the aim of its inclusion in the Affordable Care Act. Reformers say it eliminates insurers from "cherry-picking" and reduces uncompensated care.

Another factor in premium hikes Blue Cross said relates to how it assesses families.

In the past Blue Cross said it was able to offer one family premium, no matter the size.

"The ACA requires that each member on a policy be rated based on their age, address and tobacco use," spokeswoman Koko Mackin said in an email. "Then all of these individual rates are added together to determine the family premium. As a result, larger families may experience higher premiums."

She also said the new law limits how much insurers can vary premiums based on age. There used to be five levels of age insurers could offer variable rates for -- now there are three.

"The result is older consumers have new protections against premium increases, but younger individuals may see premium increases," Mackin said.

There is no lack of frustration out there among those who have been getting the news.

One commenter on the Blue Cross Facebook page wrote:

"I vote you replace the faces of the smiling people in your banner with the faces of the ones who just got their 2014 renewal rates in the mail."

(Story updated 10:09 a.m., Oct. 11, to correct that the Society of Actuaries study reflected claims costs to the insurer -- a key factor in calculating premiums -- but not the premium prices themselves.)

