In some cases, state insurance regulators urged insurers to raise premiums in order to remain financially solvent. “For example,” reported the Commonwealth Fund in a recent paper on premiums,  "in approving final 2016 rates, the Oregon Insurance Division required some carriers to increase their rates. Tennessee's state insurance commissioner also suggested that a requested average increase of 32.6 percent by Community Health Alliance might not be sufficient to make the nonprofit co-op financially sustainable."

But other analysts say that because most of the sick people are already signed up, those who will join in the future will be healthier and use less care, which argues for lower premiums, or at least smaller increases. "The industry has unanimously and reasonably expressed the view that the least healthy people would sign up first – i.e. in 2014 – thus necessarily resulting in a healthier and less expensive pool of enrollees in 2015 and 2016," wrote Jay Angoff, a former Missouri insurance commissioner and former federal official, in comments opposing CareFirst of Maryland’s proposed increases. "Nevertheless, (CareFirst) has assumed that its 2016 enrollees as a group will have worse health status and higher claims costs than its 2014 enrollees did. Even modestly more reasonable assumptions in this area could reduce (CareFirst’s) proposed rate increase to single digits."

Angoff, now a lawyer in private practice, was representing the Maryland Women's Coalition for Health Care Reform and Consumers Union.

Some plans also appear to be trying to increase premiums for 2016 to protect against losses in 2017. That's when special programs included in the ACA to protect insurers from very high risks will expire. The Obama administration has been trying to reassure health plans that enroll unexpectedly expensive patients that not only does it have enough money to continue the programs through 2016, but that plans would get even more than they expected in some of these special payments.

A fundamental problem, though, says Laszewski, is that too many consumers don't see the value in the plans available to them and would prefer to simply pay the tax penalty. "The products suck, nobody's buying them," he says bluntly. "The reason we’ve got these big increases is because we only have a 40 percent take-up rate." He says to succeed plans will need to sign up at least 70 percent of those eligible.

But time is working on that problem, too. The penalties for not having insurance are increasing year by year. In 2016 those who are uninsured and don't fall into one of the categories of people who are exempt will have to pay the greater of $695 or 2.5 percent of their income. In 2014, when the penalties were only $95 or one percent of income, an estimated 7.5 million Americans paid $1.5 billion in penalties.

As of March 31, an estimated 10.2 million Americans were signed up through a health exchange; about 36 percent of the eligible population, according to the Kaiser Family Foundation.

Kaiser Health News (KHN) is a nonprofit national health policy news service. 

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