As open enrollment for Affordable Care Act coverage nears the deadline of Dec. 15, and Florida once again leads all states using the federal exchange at healthcare.gov, Heidi and Richard Reiter sit at the kitchen table at their Davie home and struggle to piece together the family's health insurance for 2018.
The Reiters buy their own coverage, but they earn too much to qualify for financial aid to lower their monthly premiums. For 2017, they bought a plan off the exchange and paid $26,000 in premiums for family coverage, including their two sons, ages 21 and 17.
Keeping the same coverage for 2018 would have cost the Reiters $40,000 in premiums, a 54 percent increase. So they selected a lower-priced plan that covers less but costs $29,000 in premiums.
"That's more than a lot of people's mortgage payments," Richard Reiter said. "For me, it's a crisis situation."
More than a million Floridians have gained health insurance since the ACA exchange launched in 2014, and many more have seen their coverage improve as a result of the health law's benefit requirements.
But one group of Floridians is worse off.
As rates skyrocket, and uncertainty over the health law threatens to push premiums even higher, consumers who buy their own coverage and earn too much to qualify for financial aid are bearing the brunt of price increases.
"People have every right to be angry," said Sabrina Corlette, a researcher and professor at Georgetown University's Health Policy Institute.
Corlette said that going into 2017, health insurers on the ACA exchange raised rates to account for rising healthcare costs from prescription drugs and consumers who used more healthcare than anticipated. Other factors, including the expiration of an ACA program designed to stabilize premiums and the departure of insurers from the exchange, also contributed to the increases.
But, Corlette said, "Things started to turn around for the carriers in 2016 and then improved a lot in 2017. So the question becomes, 'If they did so well in 2017, then what's driving the premium increases for 2018?' "
Corlette said she read through actuarial reports filed by health insurers to justify their rate hikes for 2018 coverage and found a common theme: uncertainty about the future of the health law.
"Insurers do not like uncertainties," she said, "and the uncertainty swirling around the future of this market is going to cause them to hike the premiums."
The cause for uncertainty has been relentless, Corlette noted — from Congress' failed attempts to adopt legislation that would repeal and replace the ACA, to President Donald Trump's repeated remarks about the implosion of Obamacare, to executive actions that canceled a key subsidy for low-income Americans.
Like many ACA insurers, Florida Blue said it raised rates by 20 percent just to account for the president's canceling the subsidy that helps low-income consumers cover their out-of-pocket costs, such as deductibles and copayments.
And rates could spike even higher if Congress and the president repeal the individual mandate that requires eligible Americans to buy health insurance or pay a fine. The nonpartisan Congressional Budget Office reported that repealing the mandate would lead more people to drop coverage, resulting in higher premiums.
Corlette estimated that repealing the ACA's individual mandate could cause insurers to raise premiums by 10 percent.
In Florida, where ACA exchange rates for 2018 coverage rose by 45 percent on average, consumers like the Reiters are frustrated by the debate in Washington.
"The people in Congress need to understand what's going on," Reiter said. "I really think we're taking the brunt of a lot of unfortunate issues that are coming out."
About 7 million Americans who buy their own coverage but receive no financial aid could be facing the same challenges as the Reiters, according to estimates from Mark Farrah Associates, a publisher of healthcare industry analytics, and the nonprofit Kaiser Family Foundation, a health policy think tank.
In 2017, about 5.3 million Americans bought an ACA plan off the exchange, where financial aid is not available, according to the Kaiser and Mark Farrah analyses.
An additional 1.6 million consumers, including about 100,000 Floridians, Bought coverage on the ACA exchange in 2017 but earned too much to qualify for financial help, according to federal regulators at the Centers for Medicare and Medicaid Services.
Those consumers were more likely to cancel coverage, according to CMS estimates, which showed that about 1.5 million people dropped out of the ACA exchange between Jan. 31 and April 25. About 17 percent of those who canceled their ACA plans in that period cited their ineligibility for financial aid as the reason for dropping coverage, CMS reported.
Overall, though, most consumers signed up for coverage on the ACA exchange were protected from premium increases because the health law ensures that those who earn up to four times the federal poverty level — about $48,000 a year for an individual or $81,000 for a family of three — never pay more than 9.5 percent of their annual income for premiums.
But consumers like the Reiters do not have that protection, and they can't afford to take the risk of going without coverage.
The Reiters are early retirees. Richard, 63, stopped working in 2014 after a 38-year career as a certified public accountant; Heidi, 59, retired in 2008 from teaching in public schools.
They are in generally good health. Richard Reiter said he has had kidney stones in the past, and recently underwent surgery to repair hernias. He also takes medication to control his cholesterol. Heidi Reiter has had scoliosis, bone loss and allergies.
But it's their 17-year-old son, Daniel, whose coverage they worry about the most. He has Type 1 diabetes.
"We were concerned with having a plan that covers the diabetes supplies and insulin, which can be costly," Heidi Reiter said.
By switching to a lower-priced health plan for 2018, the Reiters will have a $12,800 family deductible for in-network coverage and a $13,800 out-of-pocket maximum.
Their benefits are also less generous. The Reiters will be responsible for 40 percent of their covered healthcare costs in 2018, and the plan does not include their preferred hospital and doctors at Cleveland Clinic Florida.
But Richard and Heidi Reiter have a strategy for keeping their doctors: They're going to pay for doctor visits on their own. Richard Reiter said he expects to receive a discount for paying his own way at Cleveland Clinic.
He calculates that the total should be less than the higher-priced health insurance plan that included Cleveland Clinic in its provider network, which would have cost the family an additional $11,000 in 2018.
"I call it hybrid coverage," Richard Reiter said. "We certainly got a lot of room that it will be a savings over going with the higher-priced plan — as long as we hopefully stay healthy and don't have a need for greater services."