The Affordable Care Act was expected to be a boon for eHealth Inc., the nation’s largest online health insurance broker. After all, the law required most Americans to have coverage, provided government assistance to afford it and allowed Internet brokers to sell Obamacare policies.

But while the health law helped pump up profits and stock prices for many hospitals, insurers and other health companies, eHealth has taken a beating. The company last year lost thousands of customers to the health law’s online exchanges where consumers shop directly for plans and find out if they qualify for subsidies.

The number of individuals covered by health policies from which eHealth earns a commission fell from 796,000 in December 2013, the year before the health law exchanges policies began, to about 585,000 in March. The company swung from a $1.7 million profit in 2013 to a $16 million loss in 2014, and its share price swooned by more than 75 percent.

EHTH data by YCharts

But eHealth might get a boost if the Supreme Court in June strikes down government subsidies for consumers in the 34 states using the federal exchange. More than 8 million people–nearly 9 in 10 of the people who bought coverage on the health law’s exchanges this year–received subsidies. Without subsidies, consumers would have little reason to use the federal exchange.

“Folks who may not be able to get a subsidy may go back to eHealth,” said David Styblo, an analyst with Jefferies LLC in Nashville. But he notes Wall Street is not counting on that partly because there is so much uncertainty about how Congress and the Obama administration would react if the subsidies were invalidated. In addition, some analysts believe that if the subsidies were not restored through a political compromise, many people would go without coverage because they could no longer afford it.

In conference calls with investment analysts, eHealth officials have avoided making it appear that they want the court to strike down the subsidies, but they acknowledge the case could affect the company’s future. “We are thinking a lot about” the court case, CEO Gary Lauer told analysts in April, a month after the company eliminated 160 jobs, or 15 percent of its workforce.  Lauer refused requests for an interview.

EHealth, which is paid a commission by health plans for each policy it sells, is not the only online broker that’s faced new hurdles as a result of Obamacare. But because eHealth, which was founded in 1997, is the only publicly traded online health insurance broker, it’s the only one that must publicly report its performance.

Chini Krishnan, CEO of online broker GetInsured, which like eHealth is based in Mountain View, Calif., said since online brokers have to send consumers’ information through the state and federal exchanges to apply for subsidies, they cannot offer a seamless buying experience to customers. And when consumers think about buying insurance, www.healthcare.gov has become the most well known site.

“Healthcare.gov has a huge megaphone but not the best consumer experience,” Krishnan said.

Even if online brokers can offer an easier and quicker shopping experience, it may be too late. “Folks who are interested in buying coverage know they need to go to healthcare.gov,” Styblo said.

Krishnan does not buy that notion.  He said private industry can come up with better ways to sell and enroll people than the federal government.

Shane Cruz, chief technology officer for online broker GoHealth, says Obamacare has taken the industry on “a real roller coaster ride.” The law expanded the pool of people seeking coverage, but insurers responded by cutting their commission rates to agents. The Chicago-based firm said it sold nearly 500,000 Obamacare plans this year, double the amount it sold in the first year of enrollment. Realizing healthcare.gov is the first thing people will see when they search online for coverage, GoHealth has reached out to consumers by partnering with big box retailers and tax preparers, which are advising customers about the consequences of not meeting the law’s coverage mandate.

EHealth, meanwhile, has turned its focus to selling Medicare Advantage plans on its website. About 16 million of the 50 million people on Medicare are enrolled in the private plans, though most shop for them each year on the government’s www.medicare.gov site. But with 10,000 people a day turning 65, and gaining eligibility for Medicare, even grabbing a small piece of this market could be lucrative for eHealth, Styblo said. In addition to the Advantage plans, eHealth has been active in helping seniors find Medicare supplement plans. The company’s number of Medicare policyholders was 155,600 at end of March 2015, up from 111,700 a year ago.

“It’s a huge marketplace,” Lauer told analysts in April.

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

During a recent physical, Jeff Gordon’s doctor told him he may be pre-diabetic. It was a quick mention, mixed in with a review of blood pressure numbers, other vital statistics like his heart rate, height and weight, and details about his prescription for cholesterol medication. Normally, Gordon, 70, a food broker who lives in Washington, D.C., would have paid it little attention.

But his physician, who recently joined MedStar Health, uses the system’s Web portal that allows him to share his office notes with patients. For Gordon, seeing the word “pre-diabetic” in writing made it difficult to ignore, and he took action.

He contacted MedStar about joining a pre-diabetes clinical study. In the course of taking the tests required to participate, the otherwise healthy septuagenarian found out his blood sugar wasn’t elevated enough to qualify.

Still, the experience of seeing the term in his doctor’s notes was a “wake-up call,” inspiring him to pay more attention to his diet and exercise. “It’s harder to ignore when it’s in your face,” he said.

This kind of note-sharing got a kick-start five years ago when researchers from Harvard Medical School joined forces with the Pennsylvania-based Geisinger Health System and Harborview Medical Center in Seattle to launch a high-profile pilot program called Open Notes. The initiative focused on encouraging health care providers to give patients access to doctors’ office notes and then tracked what happened when patients read them. Even before the project, some providers had independently shared notes, but since the organized effort began, interest has grown.

Now, Open Notes estimates about 5 million people see physicians who share notes as part of the initiative, said Tom Delbanco, a professor at Harvard Medical School who has been with the project since it launched. That includes doctors from more than 20 institutions across the country, consisting of major academic medical centers and health systems ranging from the Cleveland Clinic to the Veterans Health Administration to Wellspan, in Maryland and Pennsylvania. And even beyond the project’s participants, there is a trend among physicians — such as Gordon’s doctor — to move in this direction, too.

It’s part of the health system’s growing focus on patient engagement – the idea that more informed people will take better care of themselves, improving their health while lowering costs. This emphasis is driven in part by the federal health law, which links Medicare payments to how well hospitals and doctors do at getting and keeping patients healthy.

The trend is also fueled, experts suggest, by components in the health law and the earlier financial stimulus law that set out financial incentives for doctors to use electronic health records and better connect with patients online.

Advocates say open notes could fundamentally shift the doctor-patient relationship by making it less paternalistic, putting patients in a position to catch mistakes and have more informed conversations with their physicians. But others worry the practice could curb honesty in what doctors write about their patients, or cause confusion if patients misinterpret what’s written.

What doctors write is hardly the stuff of state secrets. Some portions are technical to the point of dullness. Other portions offer clear, valuable advice.

In one note, shared by a patient who requested his name be withheld due to privacy reasons, a doctor wrote, in the context of a potential diagnosis of a hand deformity condition called Dupuytren’s contracture, that the patient’s “sensation is intact in the medial, ulnar and radial nerve distribution.” Hard to understand, yes, but still helpful to the patient for tracking the condition. Even more helpful, perhaps, is the physician’s summary of the condition: “It is very early, so we just need to monitor it.”

Some health care providers, though, worry patients might misuse the information – attempting to diagnose themselves or declining beneficial treatment because they misunderstand what’s written. That isn’t out of the question, said Jan Walker, a research associate at Harvard and Beth Israel Deaconess Medical Center, who also worked on the Open Notes project. “We certainly believe so far, the good far outweighs the bad,” she said.

Kenneth Burman, director of endocrinology at MedStar Washington Hospital Center, said he independently began sharing his notes with patients years ago, mailing them a private copy. When patients read their notes, he said, they can actually “understand the diagnosis and the recommendations.” Patients will look things up, he added, and occasionally correct references to things like family history, or add relevant details he might have missed.

Though he can’t document it, he said patients are generally better about following through with treatment if they get to read their notes. “It helps the patient understand the disease process and what the course of action should be,” Burman said.

How patients respond to this disclosure varies. Some use notes as helpful reminders while others use the information to challenge a physician’s recommendation and help rule out a diagnoses.

For Kent Snyder, 63, a lawyer from Portland, Ore., note-sharing was particularly helpful when he developed arthritis-like symptoms and vision trouble – part of an autoimmune condition doctors still haven’t been able to figure out.

Reading what his doctors had written, Snyder said, helped him focus conversations on “key salient issues” – for instance, correcting physicians about symptoms he’d actually experienced, which in turn allowed them to rule out potential diagnoses.

Looking at his notes, Snyder added, meant he better understood why doctors ordered certain procedures or treatments.

“It’s not just money – I don’t want to take an antibiotic unless I absolutely have to,” he said. “I don’t want to have a test if I don’t need it.”

Patients’ abilities to fix errors in their records could encourage providers to adopt note-sharing, especially if it could reduce the odds of doctor mistakes, said Steven Weinberger, CEO of the American College of Physicians, which represents internal medicine doctors.

But while doctors and patients said they knew anecdotally of patients finding and fixing mistakes when looking at their notes, Walker said there’s no research measuring how common it is and what effect it could have on patient outcomes or satisfaction.

Some physicians worry sharing notes could require them to change what they write so it’s easier for patients to understand, Weinberger said. Peter Elias, an Auburn, Maine-based doctor, said colleagues often worry they might have to omit things for fear of confusing or upsetting patients. But, he added, sharing notes makes him have important conversations he might otherwise have skipped.

When patients see what doctors write, he said, “it makes the difficult conversations essential. You can’t skip them anymore.”

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