WASHINGTON - For most Americans, Monday is the deadline to sign up for health insurance that takes effect Jan. 1. It was supposed to be a turning point in the troubled history of the new health care law, the moment when the spotlight would shift from the federal governments Web marketplace to the insurance companies providing coverage to hundreds of thousands and eventually millions of people.
But as the date approaches, a series of decisions by the Obama administration to delay some of the laws most important provisions and to extend some deadlines has caused uncertainty among insurers and confusion among consumers.
Already the enrollment of young adults appears to be lagging behind the expectations of federal officials and insurers. And insurers, struggling with problems caused by the chaotic debut of the federal insurance exchange in October, have criticized the administrations last-minute changes, saying they could cause instability in the market.
The sudden shifts have sent a mixed message to consumers about the significance of the Monday deadline. They reduce the sense of urgency but not the need for coverage. Accordingly, federal and state officials said they were prepared for an increase in activity on their websites and at telephone call centers as uninsured consumers rushed to beat the deadline.
The Dec. 23 deadline is a huge milestone on the way to coverage that will provide relief and hope to a lot of people, said Andrea J. Routh, executive director of the Missouri Health Advocacy Alliance, a consumer group. For many, this will be the best Christmas gift theyve had in a long time.
Julie Bataille, a spokeswoman at the Centers for Medicare and Medicaid Services, said the agency was adding staff, training and outreach efforts across the country. People tend to have questions and act when they come up against deadlines, she said.
President Barack Obama said Friday that more than 1 million Americans have selected new health insurance plans through the federal and state marketplaces since they opened Oct. 1. The administration had hoped that 3.3 million would be signed up by the end of this month, according to a memo prepared by the Health and Human Services Department in early September.
States running their own exchanges, like California, Connecticut, Kentucky and New York, said they had seen a surge in demand in the last few weeks.
Momentum is growing, said Peter V. Lee, the executive director of the California insurance exchange. Friends are telling friends. Families are telling families.
Kevin J. Counihan, the chief executive of the Connecticut exchange, said that calls to its telephone call center had tripled in the last three weeks, to 6,000 a day. We are really bracing for Monday, Counihan said. The Connecticut exchange is increasing its call center staff to 114 from 63.
The White House and health policy experts have repeatedly said that the new insurance plans need to sign up large numbers of younger, healthier people to balance the financial risks of covering older Americans who require more medical care.
Federal officials have not disclosed demographic data on people buying insurance through the federal exchange, but early data from states suggest that people age 55 to 64 are overrepresented while those younger than 35 are underrepresented.
In Colorado, 43 percent of people signing up for private plans in the first couple of months were in the 55-to-64 age bracket. In Connecticut, Rhode Island and Washington, the share was 40 percent. And in California and Kentucky, the proportion was 35 percent. Nationally, about 12 percent of the population is 55 to 64.
Larry Levitt, a senior vice president of the Kaiser Family Foundation, said that people enrolling early included some with the greatest needs: people who had been locked out of the individual insurance market because of serious illnesses and those coming from federal and state programs for people with pre-existing conditions. Most of those programs, known as high-risk pools, are scheduled to end next year.
Many people who bought insurance on their own have received notices saying their policies were being canceled or discontinued because the policies did not comply with coverage requirements of the new health care law. Those expecting high medical bills had the strongest motivation to overcome the obstacles to buying insurance on the federal exchange.
The mix of enrollment is much more important than the total number, Levitt said. Those figures are not unrelated. If you assume that sicker individuals are likely to come in first, then a smaller pool is likely to be a sicker pool. The best guarantee of a diverse pool is a big pool, because that means you are probably reaching younger and healthier people.
The enrollment period for people seeking individual insurance continues through March 31. To be sure of coverage in January, people are supposed to pick plans by Monday and pay the first months premium by Dec. 31.
The White House has encouraged insurers to relax those deadlines and provide coverage retroactive to Jan. 1 for people who sign up or pay later in the month. Americas Health Insurance Plans, the industrys largest trade group, said its members would give consumers more time, to Jan. 10, to pay the first months premium, provided they choose plans by Monday night.
Our biggest concern is whether people will have the coverage they need next month, said Sandy Praeger, the insurance commissioner of Kansas. The concern, she said, is acute for people in the middle of a course of treatment, like cancer therapy, and those coming into the exchange from high-risk pools.
Jessica F. Waltman, a senior vice president of the National Association of Health Underwriters, which represents 100,000 agents and brokers, said that people trying to sign up should be aware that rates and benefits for some plans had been displayed inaccurately on the federal website, while some plans in some counties were not showing up at all.
Daniel J. Schwartzer, the deputy insurance commissioner in Wisconsin, said that such errors and omissions could affect thousands of people in his state, leading them to believe incorrectly that they would not be responsible for co-payments for doctors services or prescription drugs.
These glitches are creating consumer protection nightmares, Schwartzer said. If companies display wrong information, we make them pay for it, we make the consumer whole. I dont know how we make the consumer whole when the problem is the fault of the federal government.
Gary M. Cohen, an Obama administration official supervising the federal exchange, said that such errors should not happen and added, We want to fix things that are not working right.
The deadlines, which once seemed firm, are now somewhat flexible. Some state exchanges have enrollment and payment deadlines that differ by a few days from those of the federal exchange. Some insurers will provide retroactive coverage; others will not.
For a patient who receives hospital care early next month, before paying the January premium, those differences could have a big impact. An insurer who made coverage retroactive to Jan. 1 could pay most of the hospital bill, while patients in another health plan might have to pay it all themselves.