As the health law’s second open enrollment season barrels to a close on Sunday, nearly a million Texans have purchased or applied for health insurance. This time around, insurance brokers are aggressively marketing themselves to shoppers – it’s a big change for the brokers who have had an uneasy relationship with the health law for years.

Bart Franco is one customer who sought help from a broker this time. He is the pastor of a tiny community church that he founded in a garage behind his house near downtown Houston where he spends hours every day in prayer.

Franco, 65, is retired and covered by Medicare, so he needed to buy insurance for his wife and son. When he tried to enroll them in an Affordable Care Act plan last year, he got nowhere.

“First, I called the 1-800 number and I was on hold for 40 minutes and just hung up, gave up. I’m not going to put up with that,” he recalled.

Franco missed the 2014 deadline to get a plan on the federal marketplace exchange. He later called Blue Cross Blue Shield directly and succeeded in purchasing a short-term catastrophic plan for his family. But he felt the process was rushed, and he was uncomfortable with the plan’s high deductible.

“They just give you insurance and [say that] it costs this much, and you only pay $146 (a month) that sounds good, doesn’t it? OK, fine. You’re hooked, and you don’t even know what you have.”

So this year, when enrollment began again for 2015 plans, he turned to Jo Middleton, a licensed insurance broker who had advertised in the local paper.

“She connected us on the computer. She showed us everything, showed us a deduction, why we didn’t want this and why we didn’t want that. So she explained everything,” Franco said.

Franco’s rough experience last year was common, says Middleton, who is also president of the Houston Association of Health Underwriters. People struggled to pick plans on their own, using the healthcare.gov website. Many learned later they couldn’t afford the deductible. Others discovered that a favorite doctor or hospital wasn’t accepting a particular plan.

“Buying an insurance policy is not like going online and buying a vacation,” Middleton said. “It’s much more complicated. There are a lot more nuances.”

Some shoppers did turn to government-funded navigators for help, but there are fewer than 500 of them in Texas, compared to more than 190,000 health insurance agents.

From the beginning, brokers felt left out of the law because the federal marketing focuses on the navigators and the website.

Last year, Houston brokers worked on their own to help consumers. But now they’re uniting to assert their expertise and market themselves. Middleton has organized two enrollment events featuring brokers from the Houston Association of Health Underwriters.

Brokers across Texas are trying multiple strategies: holding events with hospitals and community groups, putting up fliers and even buying TV ads.

Middleton said brokers have to become more visible, because the Affordable Care Act was written in a way that sidelined brokers and what they could offer.

“There has been a deep-rooted thought process that agents and brokers are superfluous. That we are not necessary, that we are an added expense,” she said.

Brokers say the health law’s impact on them is mixed.

Theoretically, the law created a whole new market of potential customers and agents get paid a commission every time they sign one of those people up for a new health policy.

But they also say their commissions have been cut.  That’s because of the law itself – it dictates how much money insurance companies can set aside for profit and overhead, and some companies have dealt with that by cutting the agents’ commissions.

Marcy Buckner of the National Association of Health Underwriters in Washington, D.C. says, “This has just kind of devastated the agent community, and has been in place for several years.”

The association is backing efforts in Congress that would help insurance agents and brokers by changing the rules on commissions.

In the meantime, Buckner says brokers have had to adjust.

“We’ve seen some agents who have been able to really work the new opportunities that they’ve had in the marketplace, and have continued to grow their business, and have succeeded very well, while the others have still been struggling under this cut in commissions, ” she says.

And some brokers have to switch their focus to Medicare policies or health plans for small businesses.

It’s too early for any exact numbers on how many brokers stayed in the game, or how many people they signed up.  What is clear is that more than nine million people have signed up or re-enrolled this year, with a few days left still before the deadline.  And about one in ten of those people is from Texas.

This story is part of a reporting partnership that includes Houston Public Media, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

When Wendy Swanson started out as a pediatrician eight years ago, it never crossed her mind to bring up the option of intrauterine devices – an insertable form of long-acting contraception – when she had her regular birth-control discussions with teenage patients who were sexually active.

“The patch had been the thing,” she said, referring to a small, band-aid-like plastic patch that transmits hormones through the skin to prevent unwanted pregnancies.

But Swanson’s approach changed after a casual conversation with her sister-in-law. This relative wasn’t a doctor, but she worked at the Adolescent Pregnancy Prevention Campaign of North Carolina, and she told Swanson that the devices could be used as a first choice of contraception for teenagers. Now Swanson regularly discusses IUDs, which are more than 99 percent effective, in her Seattle practice.

“I thought, ‘I can’t believe I don’t know this and no one else in my office knew’ ” that IUDs could be a good choice for some patients, she said.

Yet some pediatricians and other doctors worry they aren’t properly prepared to make this form of birth control available, because their training did not cover insertion of the devices. Experts say this has to change, starting during medical residencies, especially among pediatricians who will treat teenagers.

Serious medical problems reported with the use of the Dalkon Shield in the 1970s frightened many women away from IUDs, and the extra cost associated with their insertion often stopped women from using them. But the devices have become increasingly popular. IUDs, which use copper or hormones to block sperm from fertilizing eggs, are considered safe in part because they do not use the problematic strings that were part of the Dalkon Shield, and a number of physician groups recommend them. And under the 2010 health law, women with insurance are eligible for IUDs without paying out-of-pocket costs.

Almost 12 percent of women who used birth control between 2011 and 2013 chose IUDs, a rate surpassed only by contraceptive pills and condoms, according to a recent analysis by the Guttmacher Institute.

Last fall, the American Academy of Pediatrics for the first time recommended IUDs as a first-line form of contraception for adolescents who have sex, though condoms and the pill are also accepted options. This recommendation builds on support from the American College of Obstetricians and Gynecologists, which in 2011 termed it the most effective form of birth control and noted that it posed minimal risks. A year later, the group recommended it specifically for teens. Rare problems reported include disruption of menstrual cycles and, in rarer instances, perforation of the uterus. The IUD also can occasionally be
expelled by a woman’s body, meaning it no longer prevents pregnancy.

Once inserted, IUDs – which last for years before they need to be removed or replaced – don’t require daily attention. This makes them easier to manage than options such as condoms or daily birth control pills, which teenagers must remember to use or, in the pill’s case, take on a daily basis. Unlike condoms but like the pill, the IUD doesn’t prevent sexually transmitted diseases. Though the patch is about as effective as an IUD, it requires weekly maintenance and has attracted scrutiny in recent years for potential side effects such as strokes and blood clots.

“So many kids never pick up the pills, or pick up the pills and don’t take them right,” said Melanie Gold, medical director of Columbia University’s School-Based Health Centers. “Clearly, an IUD is a better choice.”

But even with this relatively recent buzz, a December editorial in the Journal of the American Medical Association Pediatrics asserted that pediatricians often aren’t trained in the procedure – making it, experts said, harder for teenage girls to access this form of birth control, unlike adult women, who are more likely to see a gynecologist.

Pediatric residents typically spend only a month studying “adolescent medicine,” which includes contraception.

Julia Potter, a doctor based in New York-Presbyterian Hospital’s pediatric department and a co-author of the editorial, said the instructors who teach the adolescent medicine often aren’t themselves trained in IUD insertion procedure. Medical residents then may not pick up the skills they would need to provide this birth control option once they start practicing.

If residents are exposed to the procedure – something that depends heavily on the patients they happen to see during that month-long rotation – that time frame is “certainly not enough time to learn how to put in an IUD,” said Jane McGrath, chief of adolescent medicine at the University of New Mexico.

Doctors offered different thoughts on how many times would be enough to become competent in inserting IUDs, but Gold suggested it might take 10 insertions before a physician would feel comfortable administering it.

Pediatricians also may be less comfortable offering IUDs to patients than are other doctors, suggests a 2013 survey published in the Journal of Adolescent Health. The study found that 26 percent of doctors practicing pediatrics or internal medicine provided IUDs or other long-acting contraception – compared with 88 percent of those identified as OB/GYNs or family medicine providers.

Those who do bring it up often refer patients interested in IUDs to other providers, such as gynecologists, said Annie Hoopes, a pediatrician and adolescent medicine fellow at Seattle’s Children’s Hospital. But for teens, such referrals can get complicated.

Privacy can be an issue, said Swanson, who doesn’t do the insertion procedure in her office. A teenager may not want her parents to know she’s receiving the birth control, but “if she goes in and sees a gynecologist and the visit is billed,” it’s impossible for the pediatrician to guarantee that won’t appear on an insurance statement.

In those situations, Swanson said, she will send patients to Planned Parenthood or a similar provider, where the visit doesn’t get billed to a parent’s insurance plan.

Teens also don’t always act on the referral, said Marissa Raymond-Flesch, an adolescent and young adult medicine fellow at the University of California at San Francisco.

“They may have limited control over their time – particularly if they’re trying to come to receive services confidentially,” she said. That fear of attrition, she added, is a reason her practice has moved to offer IUD insertions in-house. Otherwise, “adolescents could be lost to follow up.”

And in places where a provider is harder to reach, geography could pose another barrier to teens who don’t get the IUD from their regular doctor.

Meanwhile, conversations with patients and their parents have changed “dramatically” since she began discussing IUDs, Swanson said. Initially, parents would be nervous about IUDs – suggesting, for instance, that they might cause infertility for their daughters. Now, by contrast, both teens and parents seem “very open to” long-acting contraception, she said, and teenage girls are more likely to ask about IUDs without prompting.

Swanson added that, though parents sometimes bring up birth control issues, she personally waits to raise the subject until the one-on-one portion of a teenager’s visit, when parents are required to leave the room.

It’s still unclear whether and how residency curricula might change to incorporate IUDs and similar forms of contraception. If they become more popular, residents – especially those with an emphasis on adolescent medicine – might come to demand such training in medical school.

But it’s hard to know when or how this might happen, said Mandy Coles, another co-author of the JAMA editorial and an adolescent medicine physician and assistant professor of pediatrics at Boston University School of Medicine.

“The bottom line is this is going to take more time and advocacy and research to improve training,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Thinking about enrolling in an insurance plan under the health law? It’s not too late, but you’d better get moving fast. Open enrollment ends Sunday.

“If you or someone you know needs health insurance, now is the time to act!” Sylvia M. Burwell, secretary of the Department of Health and Human Services, wrote in a blog post Tuesday. “The Open Enrollment deadline is February 15, and there is less than a week left to sign up.”

If you who don’t get coverage at work or are otherwise uninsured, you may qualify for financial assistance for coverage purchased on the exchanges, or marketplaces.  You can compare plans and prices at the federal website, healthcare.gov, or, if your state has its own exchange, shop there to find out which coverage is best for you.  If your state has expanded Medicaid, the federal-state program for low-income people, you might also qualify for coverage there.

And remember, if you don’t have coverage, you may pay a penalty at tax time.

Among consumers in the 37 states where the federal government is running the exchange, 8 in 10 could pick a plan with monthly premiums of $100 or less after tax credits, according to HHS. Eighty-seven percent of individuals who signed up for coverage through healthcare.gov qualify for financial help, HHS said. This year, 25 percent more insurers are offering plans in the marketplace, giving consumers have an average of 40 plans to choose from, the agency said.

For those of you who have waited until the last minute, here’s a revised version of the Kaiser Health News five things to keep in mind as you shop for coverage: 

– I Don’t Have Much Time. How Do I Do This?:  You’ll need several documents before you start the process, such as Social Security numbers for everyone in your household, employer and income information like pay stubs or W-2 forms and your best estimate of what your household income will be in 2015. Healthcare.gov features a complete list of items you’ll need.  Also think about the particular physicians, hospitals and other health care providers you prefer so you can determine if they’re in a health plan’s network before you enroll.

While people can sign up for coverage online or over the phone, “last year we saw that consumers who got in-person help were nearly twice as likely to successfully complete the enrollment process,” said Andrew Dupuy, regional communications director for Enroll America, a nonprofit group that is working to enroll people in the health law. “We think it’s important that consumers know that free, local, in-person assistance is available because it can really help people navigate the process in the final week.” Consumers can schedule an appointment in their community with Enroll America’s Get Covered Connector tool or by attending a local enrollment event. 

– Do I Have To Buy Health Insurance? No but if you don’t you might have to pay a fine. People who skipped coverage last year will have to pay a penalty that is the greater of a flat $95 per adult and $47.50 per child under age 18, up to a maximum of $285 per family, or 1 percent of your family’s modified adjusted gross income over $10,150 for an individual, $13,050 for a head of household and $20,300 for a married couple filing jointly. This year, the penalty increases to $325 per adult or 2 percent of income. The requirement to have health insurance applies to both adults and children, but there are exemptions for certain groups of people and those who are experiencing financial hardship. 

– Find Out If You Qualify For Financial Help: Enter your most up-to-date income information on healthcare.gov or with your state exchange to see if you are entitled to receive a tax credit toward the cost of your health insurance. Even if you received a subsidy in 2014, update your income to make sure you get the correct amount. This is important because if you get too much of a subsidy, you’ll have to repay it when you file your 2015 taxes. 

– Know All Costs: It’s not just the monthly premium that will cost you. Understand a policy’s out-of-pocket costs, things like co-pays, co-insurance and deductibles, before you enroll. The health law allows out-of-pocket maximum caps of $6,600 for an individual policy and $13,200 for a family policy in 2015 but some of your health care expenses – including out-of-network care – might not be included in that cap. 

– Get Help If You Need It: Confused? There are several ways to get help. Work with a local insurance agent or broker. Find one of the law’s trained navigators or assisters. Or call the federal consumer assistance center at 800-318-2596 for extra help or to find out if you eligible for a subsidy. Folks there can also help you enroll in a health plan or if you qualify, Medicaid. Federal officials have said that they expect the website and consumer phone lines to be busy this week, so be patient. They have bolstered staffing but you may experience some delays.  As was the case last year, consumers who have started the enrollment process and are in line to finish their application when the Sunday deadline arrives will be able to complete the process, according to HHS.

For most consumers, if they don’t enroll by the deadline, they’ll have to wait until the next open enrollment unless they qualify for a special enrollment period or an exemption. People can apply for coverage under Medicaid or the Children’s Health Insurance Program at any time during the year.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.