Dec. 15 is fast approaching for those who need to sign onto the Affordable Care Act.

As President Donald Trump makes it harder for people to buy their own health insurance, Oregonians must negotiate fewer and more difficult choices, and do so in the next three weeks — by Dec. 15.

Shrinking networks of doctors and hospitals covered by plans increasingly lurk as pitfalls in the individual market, which serves more than 200,000 Oregonians. And so does a landscape of premiums and subsidies that continues to shift.

These changes come as the Trump administration's newly compressed deadline leaves consumers half the time to do the research they need, increasing the likelihood of a costly wrong decision.

"If a consumer is not paying attention to the letters that they got from their carrier, or they're not making any changes or checking networks, they're going to have some big surprises," says Lisa Lettenmaier, who owns the Health Source NW brokerage in Tigard.

For the Affordable Care Act, this year could be a crucial test. Already, record enrollment rates this month on the national level have sparked experts to observe that Obamacare's demise may have been greatly exaggerated.

"I've had to start turning people away," Lettenmaier says. "We're slammed."

Obamacare evolution

In 2010, Congress approved the Patient Protection and Affordable Care Act, and it kicked in full bore in 2013-14. Commonly known as Obamacare, the law prohibited insurers from denying coverage to people with preexisting conditions, even some as easily treatable as hypertension.

That was great news for hundreds of thousands of Oregonians who won meaningful access to insurance. But it also meant a lot of sick people entered the individual market, adding medical costs that needed to be shared among all consumers.

The law came with an individual mandate — requiring all people to get coverage who were not subject to an exemption. But insurance executives and other analysts have said failing to enroll has not been accompanied by penalties high enough to compel healthy people to enroll. Without premiums from enough healthy people to balance out the costs of the sick, premiums have soared.

In recent months, Trump has sent mixed messages as to whether the existing mandate will be enforced, and Congress is currently mulling a proposal to eliminate the mandate entirely, which could result in health rates that are an estimated 10 percent higher on average in future years.

People buying their own policies need to do their homework, according to Lettenmaier, a past president of the Oregon chapter of The National Association of Insurance and Financial Advisors, who has tracked the implementation of the federal health law closely.

Double-check your network

In the early years of Obamacare, consumers in the individual market had choices that gave them broad freedom to choose providers without penalties.

But that is no longer the case. To cut costs,

carriers are more and more embracing the model of Kaiser Permanente, restricting member benefits to small networks of providers, except in cases of emergency.

But to ascertain how these changes affect you is not always obvious. For instance, though Regence BlueCross BlueShield and its affiliate, BridgeSpan Health, still sell insurance in the Portland area, their network is completely different, Lettenmaier says.

The two companies no longer use the Legacy network, meaning the number of providers available "is a lot smaller."

So consumers need to check with their provider, paying particular attention to the specific plan and network their provider is involved in. Different plans offered by a particular health insurer may offer different provider networks.

Consumers who relied on health coverage to fund Legacy providers as well as OHSU now must decide which is most important to them.

"They've got to pick and choose," says Lettenmaier, "It is going to create some major hardships for people if they are not paying attention."

Meanwhile, Portland-area customers of Providence Health will no longer be able to access its broadest provider network. Lettenmaier says that roughly a third of the time, she's finding that consumers who used Providence last year are finding that their doctor or other provider is no longer a part of the Portland-area provider network.

Many insurers, like Providence, either offer no coverage when you go out of network, or they include far greater penalties.

Check your rates

Each year, consumers in the individual market receive notices of their rate changes if they choose to stay with their current plan. But in October, rates for all "silver" plans — essentially health insurers' middle-of-the-road benefit plans — were boosted by 7.1 percent statewide — a change mandated by Oregon regulators to offset the Trump administration's decision to stop paying out Obamacare's cost-sharing subsidies.

The increase in rates will forestall massive losses to insurers, and also ensure that for those making less than 400 percent of the federal poverty level, significant subsidies remain available.

But the result is that a lot of people on silver plans may be better off shifting to the less-rich bronze plans, or even to gold-level plans.

On the plus side, the boost in silver rates actually helps households earning less than 400 percent of poverty level. Because the subsidized tax credits they obtain from are pegged to the cost of silver plans, richer benefits are now available for Oregonians whether they purchase a bronze, silver or gold plan.

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