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In just a few weeks, Jonathan Hope will have a birthday and a big decision to make. On Dec. 28, the Brigham Young University student will turn 26 and be dropped from his parents' health plan, leaving him uninsured for the first time.

Two days later, the Affordable Care Act (ACA) will take full effect, forcing the dietetics major to decide what to do about getting insurance. Passed in 2010, the ACA requires nearly every American to have health insurance or pay a tax penalty.

Although Hope said he rarely uses his current coverage, he already knows he doesn't want to be without a safety net. His wife of three years, Courtney, is already uninsured and the couple are thinking about starting a family.

"The thought of not having insurance scares me," Jonathan Hope said. "I just can't imagine going without."

The Hopes are among the more than 17 million uninsured young adults ages 18 to 34 across the U.S. — about 140,800 of them in Utah — weighing the requirements of the law against the financial and practical realities of their lives.

"It definitely worries me that I am uninsured," said Courtney Hope, who works as a special-education teacher's aide in the Provo School District. "If I needed surgery or had a serious illness, we would be in a lot of trouble. We would probably end up going into major debt because we do not have the money to pay for health care."

Jonathan Hope said he has "mixed feelings" about the ACA's mandate to buy health insurance.

"That always leaves a bad taste in people's mouths," he said. "Health insurance shouldn't be a luxury, in my opinion, but I also believe in personal responsibility. If [the cost] for us were about $150 a month or even a little bit more for us to have it, that's an investment I'm willing to make."

Are they in? • Experts say getting young Americans insured is critical to the success of the ACA. Those who are young and healthy reduce the risk in the insurance pool and balance the costs for older, less-healthy people.

Many speculate, however, that the so-called "young invincibles" won't rush to buy insurance — especially since the flawed federally run exchange is currently hard to use — because they don't think they need it.

It turns out, the opposite is true, said Christina Postolowski, a policy analyst for the advocacy group Young Invincibles, which is working to educate young adults about the law and get them enrolled in plans in all 50 states.

"What a lot of our polling found is that only about 5 percent of people don't have it because they think they don't need it," Postolowski said. "A much larger percentage don't have it because they can't afford it."

An August report from the Commonwealth Fund's Health Insurance Tracking Survey also found that a majority of 19 to 29-year-olds will get insurance if it's available and within their financial reach.

Massachusetts, where earlier reforms forced an insurance mandate, offers similar proof that young adults want to be insured, said Amanda Starc, an assistant professor of health care management at the Wharton School of Business.

An economist, Starc studies the use of that state's online marketplace and found individuals age 27 and older have shown a "somewhat annoyingly high" rate of compliance with the law. "It's 99-plus percent," Starc said.

So what are the options for Utah's young adults seeking coverage?

Hey mom, dad • The ACA allows Americans to add or keep their children on their health insurance policy, offering offspring coverage even after marriage, until age 26. Federal health officials estimate 26,000 young adults in Utah have gained coverage through the provision.

Covered at work • In 2012, nearly 62 percent of Utahns were covered by workplace insurance, according to the federal Current Population Survey. Most large employers offer health insurance to workers. Still, because young adults are often still in school, working unpaid internships or underemployed in part-time jobs without benefits, this won't be an option for some.

Courtney Hope once had access to insurance at work, but to skirt the upcoming ACA requirement to provide insurance to employees who work more than 30 hours a week, her school district cut the hours of part-time workers, her husband said. Jonathan Hope works on BYU's campus and is limited to 20 hours each week.

Making it to Medicaid • Currently in Utah only certain groups are entitled to the low-income health program, such as children, pregnant women and some disabled and elderly adults. The ACA was designed to stretch Medicaid to cover more uninsured, by basing eligibility solely on income. Should Utah decide to expand Medicaid, an estimated 71,000 uninsured young adults ages 18 to 34 would be eligible, the Young Invincibles data predict.

Utah Gov. Gary Herbert says he'll make a decision in 2014.

In states that don't expand, most working-age adults with incomes under 100 percent of the federal poverty level won't have access to Medicaid and won't qualify for subsidies to help with the costs of insurance.

Shop the exchange • Besides the bronze, silver, gold and platinum plans sold on the online marketplace, which offer increasing levels of coverage, young adults under 30 have an extra option: catastrophic health plans with cheap monthly premiums but very high deductibles.

These plans require consumers to pay all medical costs up to a certain amount, usually several thousands of dollars, which means they only cover worst-case scenarios, such as a serious accident or extended illness. But they fulfill the mandate for Americans to have coverage.

Support from subsidies • The Utah Health Policy Project estimates large numbers of young adults — as many as 25,000 in Utah County and 35,000 in Salt Lake County — may qualify for subsidies to help them buy private plans through the online marketplace, spokesman Jason Stevenson said.

To be eligible for a subsidy, consumers must have household incomes between 100 percent and 400 percent of the federal poverty level. They must also purchase at least a midlevel "silver" plan, which splits the cost of medical care with enrollees at a 70-30 rate.

The Urban Institute estimates that the majority of adults in their 20s will qualify for subsidies, according to the Associated Press.

Coverage at college • Brigham Young University, the University of Utah and Utah State University offer students health insurance coverage at costs that range from $74 to $145 a month.

Though most Utah institutions encourage U.S. students to have insurance and requires it for some, such as athletes or veterinary students, only BYU requires it for all undergraduates. International students are all required to have insurance.

Most Utah campuses, excluding Southern Utah University and Snow College, have a low-cost or free on-campus health center. Those facilities are generally supported by student fees rolled in with tuition — at USU, for example, it costs $40 a semester. At some schools, spouses and children can also use the clinics.

USU is preparing to shift its Health and Wellness Center to an insurance-billing system with the implementation of the ACA, said Jim Davis, USU executive director for student health, wellness and recreation.

"Lots of paperwork, means lots of administrative hours which, in themselves, are not billable," he wrote in an email.

Other schools, though, such as Dixie State University, don't plan to change their billing procedures.

"Our clinic is subsidized by modest student fees, and when combined with the per-visit co-pay and good fiscal management it currently meets our needs," wrote Dean of Students Del Beatty in an email.

Skip it • Many young adults Stevenson has spoken to have said they may wait to buy insurance and instead pay the tax penalty in 2015. Penalties will be low in the first year — about $95 — but go up rapidly in subsequent years.

In the long run, buying insurance will be both smarter and cheaper than a hefty hospital bill, he notes.

"I always tell them to remember that you can't buy Obamacare in the ambulance on the way to the hospital," Stevenson said.

The UHPP is planning outreach on Utah's campuses. The goal of its message "is to find some quintessential Utah snowboarder, or canyoneer, skateboarder or young family and say, 'This is how the ACA marketplace can help you,' " Stevenson said. "This could be your Mother's Day gift to your mom: Get health insurance, it's going to lower her blood pressure."

Tribune reporters Lindsay Whitehurst and Kirsten Stewart contributed to this report. —

TribTalk: Will young people buy into the Affordable Care Act?

About 30 percent of American young adults don't have health insurance, a fact that needs to change for Obamacare to work.

On Sept. 17, Trib Talk moderator Jennifer Napier-Pearce discussed the role young people will play in health reform and how to persuade them to sign up for a health plan with Christina Postolowski of Young Invincibles, a nonprofit dedicated to the public policy interests of 18- to 34-year-olds.

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