In Kentucky, a Glimpse of Health Insurance Help

Luke Sharrett for The New York Times

LOUISVILLE, Ky. - Jennifer Albrecht lost her job after being given a diagnosis of multiple sclerosis last year - a turn of events that her husband, Hugh, described as feeling like 'a building fell on us.' She stretches out her medicine because she cannot afford the refills, suffering worse flare-ups as a result. But last month, after seeking the help of a 'kynector' - one of Kentucky's counselors certified to help people sign up for insurance under the federal health care law - Ms. Albrecht found she qualified for Medicaid. Her coverage will take effect at the beginning of 2014.

'I know that starting Jan. 1 there's some hope, there's some relief there,' she said.

Ms. Albrecht, 42, is among the roughly 1,000 people a day who are signing up for coverage through Kentucky's online insurance marketplace, or exchange, a volume that state officials say has far exceeded their expectations. The success of the exchange, known as Kynect, contrasts sharply with the technical failures of the federally run exchange serving 36 states. Even some state-run exchanges, including those in Maryland and Oregon, have struggled so far.

But to watch the sign-up process last month in Louisville, a city of 600,000, was to get a glimpse of how the rollout of the exchanges was supposed to work from coast to coast.

There are caveats. Most enrollments in Kentucky - about 85 percent - have been in Medicaid, the government program that provides health care to the poor, which is expanding under the law. The rest have been in private health plans offered through the exchange, with many applicants qualifying for federal subsidies to help cover the cost. If only the sickest people end up buying private coverage, the cost of premiums could rise and the exchange could fail. And if Medicaid enrollment under the expansion exceeds projections, the state could be on the hook for higher costs than it expected.

It is the job of people like Samantha Davis - the kynector who helped Ms. Albrecht sign up for Medicaid - to reach as many uninsured Kentuckians as possible over the coming months. Ms. Davis spends most of her time enrolling patients at Family Health Centers, a network of clinics here that serves thousands of uninsured residents. The organization used a $300,000 federal grant to hire Ms. Davis, eight other kynectors and an enrollment coordinator.

But Ms. Davis also helps out at community sign-up events, including one where she met Mrs. Albrecht on Oct. 1 and another where she met Patricia Bond, a breast cancer survivor whose daughter had pressed her to attend. Ms. Bond, 62, said she was paying $837 a month for health insurance, a cost that had leapt since her diagnosis.

'It's been really hard to come up with that,' Ms. Bond, a seamstress, said. 'I mean, that's higher than my house payment.'

With Ms. Davis's help, she found that she would qualify for a premium subsidy of $377 a month if she bought an exchange plan. 'That's the highest I've ever seen,' Ms. Davis said of the amount. Of the 24 plans that the exchange offered her, the most expensive would be a silver plan for $263 a month after the subsidy, with an $800 deductible. She went home to study her options, planning to meet with Ms. Davis again once she had narrowed them down.

Not every shopping experience on Kynect is so painless. Elaine Osborne, 57, who works at a discount store that does not offer her insurance, qualified for $212 in premium assistance when she applied with the help of Kelli Cauley, another kynector. She gasped when she saw that the plan with the lowest premium - $97 a month, including her subsidy - had an annual deductible of $6,300.

Donald Mucci, an insurance agent who is certified to enroll people in health plans through Kynect, said most people needed a lot of help understanding the different costs and deciding which amounts were right for them. He also said he worried that people signing up on their own would choose a plan without checking whether it covered their preferred doctors and hospitals.

'They have to make educated decisions about what they're signing up for,' Mr. Mucci said, 'and we need to help them do it.'