Much of healthcare journalism is about policy choices and the debates that shape them. The full implementation of Obamacare, however, calls for something different—old-fashioned consumer reporting. Many features of the Affordable Care Act are already in place, but now comes its central pillar: the requirement for most Americans to carry health insurance, starting January 1, or face tax penalties. Most people—insured through their employer or through Medicare or the military—won’t see much change. Some with low incomes will be able to get benefits for the first time through Medicaid, at least in the 26 states that have currently agreed to expand that program. But those who buy their own insurance—about 15 million Americans already and maybe another 9 million or so who may buy it for the first time—will need help.

These people can buy coverage via the new health insurance exchanges that are being set up in each state—some by the states themselves, some through state/federal partnerships, and some by the feds alone (in states where the legislature chose not to take part). How the exchanges will function is anyone’s guess. So is the question of affordability. Some people will receive government subsidies to help them pay for coverage; others won’t.
Critics and backers alike agree that implementing a vast and complex program that affects family budgets and family health will be fraught. Readers and viewers will be forever grateful if journalists help them find their way through the confusion of the liftoff. Here is a case study that illustrates some themes for journalists to consider, and a down payment on what they need to know.

Carol’s story: One woman tries to navigate the insurance jungle

A Pennsylvania woman we’ll call Carol contacted me not long ago with a vexing problem. She is 59, “a self-employed individual buyer of Aetna health insurance,” which “just raised my rates by $100 per month,” she wrote. Aetna told her that her premium—for its HMO 30 plan, a managed-care policy with what the company calls “moderate” premiums—would increase 17 percent, from $604 to $704 a month. That’s $1,200 a year, bringing her annual insurance outlay to nearly $8,500. These days, such increases are not uncommon in the individual insurance market.

Aetna’s Dear Customer letter gave a rationale: higher medical costs plus Obamacare. “I live in Pennsylvania,” Carol protested, “so I don’t understand why Obamacare would cause my rates to go up, because our governor has not opted into Obamacare.”

For starters, Carol had a misperception about the law, one that’s often heard in states that have chosen not to operate their own healthcare exchange. The state may not be taking part, but the federal law still applies—whether the state, the federal government, or a joint partnership between the two operates the exchange. Carol has the option of continuing with her existing policy for another year or trying to do better by shopping in her exchange, which in Pennsylvania will be run by the feds, and for which she is eligible. She could also decline insurance and pay a tax penalty. She says she won’t do that.

Meanwhile, Carol’s premium is already going up. “I think they are gouging me,” she said, and set out to find out why, though she didn’t expect to find answers. “I feel powerless,” she told me.

Many of the 15 million people who, like Carol, buy insurance on their own, without the help of an employer making decisions about price and coverage, feel just as powerless. They will soon be joined by another 9 million or so who are currently uninsured and who will be turned loose in the uncharted insurance jungle starting October 1. Carol’s story is emblematic of all those people looking for answers.

She began her quest with Aetna, where a customer-service rep advised she would have to write to the carrier’s grievance-and-appeals department because it has no phone number. The Aetna rep also told her that the state of Pennsylvania had allowed the premium increases, so if she wanted to appeal, she should contact state insurance regulators in Harrisburg.

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.