The first draft was as mind-numbing as a tax form. On Tuesday the Obama administration unveiled simplified application forms for health insurance benefits under the federal health care overhaul.

The biggest change: a five-page short form that single people can fill out. That total includes a cover page with instructions, and an extra page to fill out if you want to designate someone to help you through the process.

But the application form for families still runs to 12 pages, although most households will not have to fill out each and every page. Finally, there's also a five-page form for households that do not want to apply for financial assistance with their premiums.

The paperwork takes on added importance because Americans remain confused about what President Barack Obama's health care overhaul will mean for them. A Kaiser Family Foundation poll released Tuesday found that 4 in 10 are unaware it's the law of the land. Some think it's been repealed by Congress, but in fact, it's still on track.

Consumers will start getting familiar with the new health insurance applications less than six months from now, on Oct. 1, when new insurance markets open in every state. Most people with job-based benefits will not have to bother with the new applications, only the uninsured.

Under the law, middle-class people who don't get coverage through their jobs will be able to purchase private insurance. Most will be able to get tax credits, based on their incomes, to make their premiums more affordable. Low-income uninsured people will be steered to government programs like Medicaid.

Benefits begin Jan. 1, and nearly 30 million uninsured Americans are eventually expected to get coverage.

While the old forms were widely panned, the new forms were seen as an improvement. Still, consumers must provide a snapshot of their finances to see if they qualify for help. That potentially includes multiple sources of income, from alimony to tips to regular paychecks.

"Given the amount of information necessary to determine eligibility, it's hard to see how the forms could be any shorter," said Robert Laszewski, a former insurance executive turned industry consultant.

Activist Ron Pollack, executive director of Families USA, is an administration ally who had openly criticized the first draft of the forms, worrying that consumers would get discouraged just trying to fill them out. He called the changes "very positive."

"There has got to be a balance to between getting adequate (financial) information to make sure everybody gets the help they're entitled to under the law, while at the same time trying to keep the process consumer-friendly," said Pollack.

Although the new forms are shorter, the administration wasn't able to get rid of all the complexity. Individuals will have to gather tax returns, pay stubs and other financial records before filling out the application.

Administration officials expect most consumers to apply online through the new insurance marketplaces in each state. A single application process will serve to route consumers to either private plans or the Medicaid program. Identification, citizenship and immigration status, as well as income details, are supposed to be verified in close to real time through a federal "data hub" that will involve pinging Social Security, Homeland Security and the Internal Revenue Service.

Currently, applying for health insurance individually entails filling out a lengthy questionnaire about your health. Under Obama's overhaul, insurers will no longer be able to turn away the sick, or charge them more. The health care questions will disappear, but they'll be replaced by questions about your income. Consumers who underestimate their incomes could be in for an unwelcome surprise later on in the form of smaller tax refunds.

"Consumers will have a simple, easy to understand way to apply for health coverage later this year," said Medicare chief Marilyn Tavenner, also overseeing the rollout of the health care law. She said the application is "significantly shorter than industry standards."

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Applying for benefits under President Barack Obama's health care overhaul could be as daunting as doing your taxes.

The government's draft application runs 15 pages for a three-person family. An outline of the online version has 21 steps, some with additional questions.

Seven months before the Oct. 1 start of enrollment season for millions of uninsured Americans, the idea that getting health insurance could be as easy as shopping online at Amazon or Travelocity is starting to look like wishful thinking.

At least three major federal agencies, including the IRS, will scrutinize your application. Checking your identity, income and citizenship is supposed to happen in real time, if you apply online.

That's just the first part of the process, which lets you know if you qualify for financial help. The government asks to see what you're making because Obama's Affordable Care Act is means-tested, with lower-income people getting the most generous help to pay premiums.

Once you're finished with the money part, actually picking a health plan will require additional steps, plus a basic understanding of insurance jargon.

And it's a mandate, not a suggestion. The law says virtually all Americans must carry health insurance starting next year, although most will just keep the coverage they now have through their jobs, Medicare or Medicaid.

Some are concerned that a lot of uninsured people will be overwhelmed and simply give up.

"This lengthy draft application will take a considerable amount of time to fill out and will be difficult for many people to be able to complete," said Ron Pollack, executive director of Families USA, an advocacy group supporting the health care law. "It does not get you to the selection of a plan."

"When you combine those two processes, it is enormously time consuming and complex," added Pollack. He's calling for the government to simplify the form and, more important, for an army of counselors to help uninsured people navigate the new system. It's unclear who would pay for these navigators.

Drafts of the paper application and a 60-page description of the online version were quietly posted online by the Health and Human Services Department, seeking feedback from industry and consumer groups. Those materials, along with a recent HHS presentation to insurers, run counter to the vision of simplicity promoted by administration officials.

"We are not just signing up for a dating service here," said Sam Karp, a vice president of the California HealthCare Foundation, who nonetheless gives the administration high marks for distilling it all into a workable form. Karp was part of an independent group that separately designed a model application.

The government estimates its online application will take a half hour to complete, on average. If you need a break, or have to gather supporting documents, you can save your work and come back later. The paper application is estimated to take an average of 45 minutes.

The new coverage starts next Jan. 1. Uninsured people will apply through new state-based markets, also called exchanges.

Middle-class people will be eligible for tax credits to help pay for private insurance plans, while low-income people will be steered to safety-net programs like Medicaid.

Because of opposition to the health care law in some states, the federal government will run the new insurance markets in about half the states. And states that reject the law's Medicaid expansion will be left with large numbers of poor people uninsured.

HHS estimates it will receive more than 4.3 million applications for financial assistance in 2014, with online applications accounting for about 80 percent of them. Because families can apply together, the government estimates 16 million people will be served.

Here are some pros and cons on how the system is shaping up:

— Pro: If you apply online, you're supposed to be able to get near-instantaneous verification of your identity, income, and citizenship or immigration status. An online government clearinghouse called the Data Services Hub will ping Social Security for birth records, IRS for income data and Homeland Security for immigration status. "That is a brand new thing in the world," said Karp.

— Con: If your household income has changed in the past year or so and you want help paying your premiums, be prepared to do some extra work. You're applying for help based on your expected income in 2014. But the latest tax return the IRS would have is for 2012. If you landed a better-paying job, got laid off, or your spouse went back to work, you'll have to provide added documentation.

— Pro: Even with all the complexity, the new system could still end up being simpler than what some people go through now to buy their own insurance. You won't have to fill out a medical questionnaire, although you do have to answer whether you have a disability. Even if you are disabled, you can still get coverage for the same premium a healthy person of your age would pay.

—Con: If anyone in your household is offered health insurance on the job but does not take it, be prepared for some particularly head-scratching questions. For example: "What's the name of the lowest cost self-only health plan the employee listed above could enroll in at this job?"

HHS spokeswoman Erin Shields Britt said in a statement the application is a work in progress, "being refined thanks to public input."

It will "help people make apples-to-apples comparisons of costs and coverage between health insurance plans and learn whether they can get a break in costs," she added.

But what if you just want to buy health insurance in your state's exchange, and you're not interested in getting any help from the government?

You'll still have to fill out an application, but it will be shorter.

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The new health care reform law is not going to provide health insurance for as many people, at least not as quickly, as the Obama administration had hoped, according to the latest look at the economy from the Congressional Budget Office.

That’s mostly because of the deal Congress made last month to keep the country from going over the fiscal cliff, the CBO says. About 8 million people who would have been insured by their employers will probably lose their coverage because of tax changes, the CBO projects.

It takes away some of the tax breaks that employers get for providing health insurance to workers and their families. The change “will lead to a greater reduction in such coverage and higher enrollment in insurance exchanges than previously estimated by CBO,” the report reads.

Some of those affected are likely to buy health insurance themselves on the new insurance marketplaces, called exchanges, that are supposed to be up and running by October, and some will become newly eligible for Medicaid, the joint state-federal health insurance plan for the low-income. The new law encourages states to expand Medicaid so more people can qualify -- subsidized by the federal government for the first few years.

But overall, instead of 32 million to 34 million new people getting health insurance by 2017, probably only about 27 million people will be covered by then, the CBO projects.

One of the main objectives of the 2010 Affordable Care Act was to get people signed up for health insurance. About 18 percent of Americans under the age of 65 don’t have health insurance, according to the non-profit Kaiser Family Foundation. That means they don't get medical care when they need it, instead waiting until they are really sick, and using emergency room and other last-minute services that cost far more than if they'd received routine care.

About 55 percent of Americans get health insurance provided by an employer. Others have Medicaid, Medicare, Tricare for military families, and other government insurance.

Starting in 2014, many more are supposed to buy their own health insurance on the exchanges, which will be heavily regulated to ensure they get good coverage.

The CBO projects that 26 million people will buy health insurance on the exchanges by 2022. And it predicts that 12 million people will become newly eligible for Medicaid in the states that choose to expand their offerings by 2022.

“In the current projection, the number of people gaining coverage through the exchanges rises from 7 million in 2014 to 24 million in 2016, and the number gaining coverage through Medicaid rises from 8 million in 2014 to 11 million in 2016,” the report reads.

There’s some good health care news for the administration in the CBO report. “In recent years, health care spending has grown much more slowly both nationally and for federal programs than historical rates would have indicated,” the CBO says.

So it’s made “technical adjustments” to how much Medicaid and Medicare will cost. “From the March 2010 baseline to the current baseline, such technical revisions have lowered estimates of federal spending for the two programs in 2020 by about $200 billion—by $126 billion for Medicare and by $78 billion for Medicaid, or by roughly 15 percent for each program,” the CBO says.

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The Obama administration has unveiled proposed rules spelling out how birth control expenses will be covered for employees of religious-affiliated groups opposed to contraception.

Here are some common questions and answers that help explain the administration’s contraceptive policy and the opposition.

Q. What does the new regulation require?

A. Under the rule, women employed by nonprofit religious organizations opposed to contraceptives, such as Catholic hospitals or colleges and student health plans, are entitled to get contraceptive services and products without a co-payment. But the organization is not required to bear the cost of the service.

In those workplaces, the employer must tell its insurer that it will not cover the costs, and the insurer automatically would notify workers that it will provide the coverage without cost sharing or other charges through separate individual health insurance policies, according to a fact sheet released by HHS.

In the rule, the administration says this procedure “would alleviate the need for the eligible organization to contract, arrange, pay, or refer for contraceptive coverage while providing contraceptive coverage to plan participants and beneficiaries at no additional cost.” It also says this should not increase costs for the insurer and may save money by eliminating some pregnancies.

The procedures will be a bit different for religious-affiliated workplaces that self-insure, which means the employer assumes the risk of the insurance but generally hires a private firm—often an insurer—to handle the administration of the coverage. In these plans, the administrator would “work with an insurer to arrange no-cost contraceptive coverage through separate individual health insurance policies,” the fact sheet says. The insurer could offset the costs of those policies through an “adjustment” in the fees that will be charged to insurers participating in the health marketplaces.

Q: What led to this proposal?

A: Last year, the administration announced that all insurance plans would be required to cover contraception as part of the list of free preventive services mandated by the 2010 federal health law. That regulation exempted houses of worship, like churches, from the requirement to provide contraceptive services at no cost to employees, but religious-affiliated institutions, such as universities and hospitals, would have to provide coverage for contraception.

Some religious groups, including the United States Conference of Catholic Bishops, objected on the basis that it violated their religious freedom. The resulting furor quickly engulfed the White House and even some Democrats and Catholic groups that had supported the health law, such as the Catholic Health Association, turned against the policy.

Last February, President Barack Obama said the administration would revise the policy to make sure that the religious-affiliated groups did not have to pay for the coverage. But while announcing a compromise, he also insisted that women working at those groups should have access to contraceptives without charge. "No woman's health should depend on who she is or where she works or how much money she makes," Obama said at the time.

Q. What was the nature of the opposition to the initial rule?

A. Catholic religious leaders and Republican politicians characterized the rule as an attack on religious liberty and an overreach by the Obama administration. The U.S. Conference of Catholic Bishops led the opposition, with dozens of bishops all over the country making statements against it. Several bishops said that they would have no choice but to stop insuring employees altogether if the contraception mandate goes into effect.

The Catholic opposition is rooted in belief that life begins at conception and, therefore, anything that prevents conception is a sin. Though surveys have shown that as many as 98 percent of Catholic women have used birth control at some point, a survey last year found that voters are split over the question of whether employers such as Catholic hospitals and universities should be required to provide contraceptive insurance coverage for employees.

Q: Wouldn't this mean that the religious institutions would still pay for birth control as part of the insurance they provide to their workers?

A: Administration officials say no. While birth control will be covered, by not requiring employers to pay anything additional or to tell employees how to get the services, the administration believes it has brokered a satisfactory compromise. White House officials said last year that actuaries they consulted said that covering contraceptive services would not increase costs for employers and could actually save insurers money by preventing pregnancy. They pointed to the Federal Employees Health Benefit plan, which had no increase in premiums after contraception coverage was added.

The trade association for insurers, America's Health Insurance Plans, issued this statement last year from Press Secretary Robert Zirkelbach: “Health plans have long offered contraceptive coverage to employers as part of comprehensive, preventive benefits that aim to improve patient health and reduce health care cost growth. We are concerned about the precedent this proposed rule would set. As we learn more about how this rule would be operationalized, we will provide comments through the regulatory process."

Q. How does the new federal rule and religious exemption compare with contraceptive coverage laws currently on the books in states?

A. The big difference is that under the federal rule birth control will be available without the employee being responsible for a copayment. That is currently true in just a handful of states. Some 28 states have mandated coverage of birth control, and 20 of those have some sort of exemption for religious employers. According to a report by the Guttmacher Institute, the state exemptions range from very narrow definitions, such as only for churches, to broader exemptions, including religious elementary and secondary schools. The most expansive state exemptions allow religious-affiliated colleges and hospitals not to provide birth control coverage.

The federal compromise cleaves closely to laws on the books in Hawaii, Connecticut and West Virginia. In all of those states, insurers must cover contraceptives for employees of institutions who choose not to do so for religious reasons. The federal rule, though, is unlike state laws that require the religious employers to tell workers where contraception coverage is available.

Q. What about the legal challenges to the plan?

The mandate to cover contraceptive care has inspired at least 44 lawsuits against the government, according to The Becket Fund for Religious Liberty, a legal organization fighting the mandate. The plaintiffs, who include private employers with strong religious views, generally argue that the contraception policy conflicts with the 1993 Religious Freedom Restoration Act, which prohibits the federal government from imposing a "substantial burden" on a person's "exercise of religion" unless it can prove that doing so is "the least restrictive means of furthering [a] compelling governmental interest." 

The administration contends that the mandate is only an indirect burden on religious employers. Courts around the country are taking up the cases and results have been mixed. Some scholars believe the issue could land eventually at the Supreme Court.

The proposed rule does not provide the non-religious businesses who are suing the same ability to avoid providing contraceptive coverage that is afforded religious-affiliated groups.

Getty Images stock

The White House has a new proposal aimed at helping employers with religious objections opt out of paying for birth control coverage.

The Obama administration is taking another stab at a compromise over the contentious issue of making employers pay for birth control, offering a way for women to get the coverage without forcing religiously affiliated organizations to pay for it.

The proposed new rule would have insurance companies provide the coverage free of charge through separate, individual health insurance policies. It’s not quite clear how much it would cost or who, exactly, would end up paying for it.

“Under the proposed accommodations, the eligible organizations would not have to contract, arrange, pay or refer for any contraceptive coverage to which they object on religious grounds," the Health and Human Services Department said in a statement.

The 2010 Affordable Care Act requires all health insurers to pay for a woman’s contraceptive care without charging her anything. Religious organizations such as the Catholic Church, which oppose artificial birth control, have objected strongly. While churches and other overtly religious organizations were always exempted, things were a little fuzzier for religiously affiliated organizations, such as universities, and private employers who said they had their own personal conscientious objections.

Some employers who don’t oppose birth control in general oppose the requirement that products such as emergency birth control, which they equate with abortion, be supplied.

At least 44 lawsuits have been filed against the government over the issue, The Becket Fund for Religious Liberty, a legal organization helping oppose the mandate, says. It has been a big thorn in the side for the Obama administration.

A year ago the White House came up with a compromise but it did not settle the matter. The new approach tweaks it a little, leaving almost all the responsibility for covering women whose employers object up to private health insurance companies.

Some employers are self-insured, meaning they pay all the costs of health insurance for their workers. Usually, they employ an insurance company to administer the plan. The new compromise leaves it to these third-party administrators to sort out which insurance company will pay for a woman’s birth control through a separate policy.

The insurance company would get a break on user fees that will be charged to join the state health insurance exchanges – the marketplaces where people can go buy health insurance starting in 2014 if they cannot get coverage through an employer, Medicare, Medicaid, Tricare or some other public policy.

The White House argues that it in fact saves money to provide contraception for free. It costs way more to pay for a pregnancy, the administration argues. The Institute of Medicine said in 2011 that it would save the country money and make medical sense to cover birth control for free, so more people would use it.

“Women who work or go to school at these organizations will have free contraceptive coverage and will no longer have to pay hundreds of dollars a year that could go to rent,” said Chiquita Brooks-LaSure, of the Health and Human Services Department’s Center for Consumer Information and Insurance Oversight.

Brooks admitted the administration doesn’t know how much the proposal would cost. “We have not estimated the cost. We certainly welcome comment on that,” she told reporters in a conference call.

Health insurers had no immediate comment. A spokesman for America's Health Insurance Plans, which represents the industry, said the group was studying the proposals.

The new rules also say religious organizations will be defined just as they are by the Internal Revenue Service.

Left-leaning and women's health groups welcomed the policy.  “As we go through this, we want to make sure that the details pan out, but it does seem as if it works,” Marcia Greenberger, Co-President of the National Women’s Law Center, told NBC News in a telephone interview. “Of course, women assume that contraception is part of their health care and it is widely accepted because it is almost universally used.”

"Today's draft regulation affirms yet again the Obama administration's commitment to fulfilling the full promise of its historic contraception policy," said Ilyse Hogue, president of NARAL Pro-Choice America.

“We know that Catholics in the pews support this position, as 98 percent of Catholic women use contraception and 58 percent of Catholics support insurance coverage for contraception,” said Louise Melling of the American Civil Liberties Union. “The ACLU will defend the health and religious liberty needs of employees and hopes the intense recent debate is now be behind us.”

The U.S. Conference of Catholic Bishops said it was studying the proposal. The Susan B. Anthony List, a political action committee that helps campaign for anti-abortion lawmakers, rejected the proposal.

“Once again, President Obama’s so-called ‘compromise’ is unacceptable – religious and moral freedom is not up for negotiation. There must be no religious ‘test’ by the government as to who, and what type of entities, are entitled to a conscience,” said the group’s Marjorie Dannenfelser. “The taking of human life is the antithesis of health care.”

The Family Research Council agreed. "The mandate continues to force religious non-profit institutions as well as companies guided by a well-articulated and longtime moral code, such as Hobby Lobby, to violate their faith, threatening serious fines in the millions of dollars if they refuse to comply," said Anna Higgins, director of the group's Center for Human Dignity.

“Regardless of whether insurance companies or third party administrators use their dollars for an employee’s free abortifacients and contraceptives, the provision of these drugs and devices still necessarily depends on the religious employer’s health insurance plan. They remain the gateway for drugs and services to which they object."

 HHS says 90 percent of American women use or have used birth control. The Centers for Disease Control and Prevention estimates that 10.7 million U.S. women use birth control pills. Despite this, CDC says nearly half of all pregnancies are unintended, which in turn can often lead to poor health for the mother and baby.

The proposals will be open for public comment for 60 days before they take effect.

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Health insurance exchanges will change the way people buy coverage and will help millions of uninsured people get a private plan. Nearly 49 million people are uninsured in the United States, but the numbers vary dramatically by state.

Exchanges will be the most visible part of President Barack Obama's health care overhaul law in everyday life. Open enrollment starts Oct. 1, less than 10 months away.

Some questions and answers on how the exchanges will work:

Q: What's a health insurance exchange?

A: "Exchange" is just another word for "marketplace." The plans sold in the new markets will start covering patients on Jan. 1, 2014. Each state will have its own exchange serving people who buy their health insurance directly, as well as a separate one for small businesses. The vast of majority of people now covered by employer plans will not see a change.

There will be three types of exchanges at the beginning: those run by states, those run by the federal government, and partnerships. Most Republican governors opposed to "Obamacare" are letting Washington run the exchanges in their states.

For consumers, the benefits should be the same no matter who runs the exchange.

Q: How will exchanges work?

A: Exchanges are supposed to have the feel of an online travel site — think Orbitz or Expedia. Middle-class people will be able to pick from a range of private insurance plans, and most people will be eligible for help from the government to pay their premiums.

Low-income people will be steered to safety-net programs for which they might qualify. This could be a problem in states that choose not to expand their Medicaid programs under a separate part of the health care law. In that case, many low-income residents in those states would remain uninsured.

Q: How will I know if I can get help with my health insurance premiums?

A: You'll disclose your income to the exchange at the time you apply for coverage and they'll let you know. Only legal residents of the United States can get financial assistance.

The health care law offers sliding-scale subsidies based on income for individuals and families making up to four times the federal poverty level, about $44,700 for singles, $92,200 for a family of four. But do yourself a favor and read the fine print because the government's help gets skimpier as household income increases.

For example, a family of four headed by a 40-year-old making $35,000 will get a $10,742 tax credit toward an annual premium of $12,130. They'd have to pay $1,388, about 4 percent of their income, or about $115 a month. A similar hypothetical family making $90,000 will get a much smaller tax credit, $3,580, meaning they'd have to pay $8,550 of the same $12,130 policy. That works out to more than 9 percent of their income, or about $710 a month.

The estimates were made using the nonpartisan Kaiser Family Foundation's online calculator. Some people will also be eligible for help with their copayments.

Final note: Though it's called a "tax credit" the government assistance goes directly to the insurer. You won't see a check.

Q: What will the benefits look like?

A: The coverage will be more comprehensive than what's now typically available in the individual health insurance market, dominated by bare-bones plans. It will be more like what an established, successful small business offers its employees. Premiums are likely to be higher for some people, but government assistance should mostly compensate for that.

Related: Buying health insurance will never be the same

All plans in the exchange will have to cover a standard set of "essential health benefits," including hospitalization, doctor visits, prescriptions, emergency room treatment, maternal and newborn care, and prevention. Insurers cannot turn away the sick or charge them more. Middle-aged and older adults can't be charged more than three times what young people pay. Insurers can impose penalties on smokers.

Because the benefits will be similar, the biggest difference among plans will be something called "actuarial value." A new term for consumers, it's the share of expected health care costs that the plan will cover.

There will be four levels of coverage, from "bronze," which will cover 60 percent of expected costs, to "platinum," which will cover 90 percent. "Silver" and "gold" are in between. Bronze plans will charge the lowest premiums, but they'll have the highest annual deductibles. Platinum plans will have the highest premiums and the lowest out-of-pocket cost sharing.

Here's a wrinkle: The government's subsidy will be tied to the premium for the second-lowest-cost plan at the silver coverage level that's available in your area. You could take it and buy a lower cost bronze plan, saving money on premiums. But you'd have to be prepared for the higher annual deductible and copayments.

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This fall, new insurance markets called exchanges will open in each state, marking the long-awaited and much-debated debut of President Barack Obama's health care overhaul.

The goal is quality coverage for millions of uninsured people in the United States. What the reality will look like is anybody's guess — from bureaucracy, confusion and indifference to seamless service and satisfied customers.

Exchanges will offer individuals and their families a choice of private health plans resembling what workers at major companies already get. The federal government will help many middle-class households pay their premiums, while low-income people will be referred to safety-net programs they might qualify for.

Most people will go online to pick a plan when open enrollment starts Oct. 1. Counselors will be available at call centers and in local communities, too. Some areas will get a storefront operation or kiosks at the mall. Translation to Spanish and other languages spoken by immigrants will be provided.

When you pick a plan, you'll no longer have to worry about getting turned down or charged more because of a medical problem. If you're a woman, you can't be charged a higher premium because of gender. Middle-aged people and those nearing retirement will get a price break: They can't be charged more than three times what younger customers pay, compared with six times or seven times today for most private plans.

If all this sounds too good to be true, remember that nothing in life is free and change isn't easy.

Starting Jan. 1, 2014, when coverage takes effect in the exchanges, virtually everyone in the country will be required by law to have health insurance or risk fines. The mandate is meant to get everybody paying into the insurance pool.

Obama's law is called the Affordable Care Act, but some people in the new markets might experience sticker shock over their premiums. Smokers will face a financial penalty. Younger, well-to-do people who haven't seen the need for health insurance may not be eligible for income-based assistance with their premiums.

Many people, even if they get government help, will find that health insurance still doesn't come cheaply. Monthly premiums will be less than the mortgage or rent, but maybe more than a car loan. The coverage, however, will be more robust than most individual plans currently sold.

Consider a hypothetical family of four with $60,000 in income and headed by a 40-year-old. They'll be eligible for a government tax credit of $7,193 toward their annual premium of $12,130. But they'd still have to pay $4,937, about 8 percent of their income or $410 a month.

A lower-income family would get a better deal from the government's sliding-scale subsidies.

Consider a similar four-person family making $35,000. They'd get a $10,742 tax credit toward the $12,130 annual premium. They'd have to pay $1,388, about 4 percent of their income, or about $115 a month.

The figures come from the nonpartisan Kaiser Family Foundation's online Health Reform Subsidy Calculator. But while the government assistance is called a tax credit and computed through the income tax system, the money doesn't come to you in a refund. It goes directly to insurers.

The Affordable Care Act is the biggest thing that's happened to health care since Medicare and Medicaid in the 1960s. But with open enrollment for exchange plans less than 10 months away, there's a dearth of consumer information. It's as if the consumer angle got drowned out by the political world's dispute over "Obamacare," the dismissive label coined by Republican foes.

Yet exchanges are coming to every state, even those led by staunch GOP opponents of the overhaul, such as Govs. Rick Perry of Texas and Nikki Haley of South Carolina. In their states and close to 20 others that are objecting, the exchanges will be operated by the federal government, over state opposition. Health and Human Services Secretary Kathleen Sebelius has pledged that every citizen will have access to an exchange come next Jan. 1, and few doubt her word.

But what's starting to dawn on Obama administration officials, activists, and important players in the health care industry is that the lack of consumer involvement, unless reversed, could turn the big health care launch into a dud. What if Obama cut the ribbon and nobody cared?

"The people who stand to benefit the most are the least aware of the changes that are coming," said Rachel Klein, executive director of Enroll America, a nonprofit that's trying to generate consumer enthusiasm.

"My biggest fear is that we get to Oct. 1 and people haven't heard there is help coming, and they won't benefit from it as soon as they can," she added. "I think it is a realistic fear."

Even the term "exchange" could be a stumbling block. It was invented by policy nerds. Although the law calls them "American Health Benefit Exchanges," Sebelius is starting to use the term "marketplaces" instead.

Polls underscore the concerns. A national survey last October found that only 37 percent of the uninsured said they would personally be better off because of the health care law. Twenty-three percent said they would be worse off in the Kaiser poll, while 31 percent said it would make no difference to them.

Insurers, hospitals, drug companies and other businesses that stand to benefit from the hundreds of billions of dollars the government will pump in to subsidize coverage aren't waiting for Washington to educate the public.

Blue Cross and Blue Shield plans, for example, are trying to carve out a new role for themselves as explainers of the exchanges. Somewhere around 12 million people now purchase coverage individually, but the size of the market could double or triple with the new approach, and taxpayers will underwrite it.

"Consumers are expecting their health insurance provider to be a helpful navigator to them," said Maureen Sullivan, a senior vice president for the Blues' national association. "We see 2013 as a huge year for education."

One goal is to help consumers master the "metals," the four levels of coverage that will be available through exchange plans — bronze, silver, gold, and platinum.

Blue Cross is also working with tax preparer H&R Block, which is offering its customers a health insurance checkup at no additional charge this tax season. Returns filed this year for 2012 will be used by the government to help determine premium subsidies for 2014.

"This tax season is one of historical significance," said Meg Sutton, senior adviser for tax and health care at H&R Block. "The tax return you are filing is going to be key to determining your health care benefits on the exchange."

Only one state, Massachusetts, now has an exchange resembling what the administration wants to see around the country. With six years in business, the Health Connector enrolls about 240,000 Massachusetts residents. It was created under the health overhaul plan passed by former Republican Gov. Mitt Romney and has gotten generally positive reviews.

Connector customer Robert Schultz is a Boston area startup business consultant who got his MBA in 2008, when the economy was tanking. Yet he was able to find coverage when he graduated and hang on to his insurance through job changes since. Schultz says that's freed him to pursue his ambition of becoming a successful entrepreneur — a job creator instead of an employee.

"It's being portrayed by opponents as being socialistic," Schultz said. "It is only socialistic in the sense of making sure that everybody in society is covered, because the cost of making sure everybody is covered in advance is much less than the cost of putting out fires."

The Connector's executive director, Glen Shor, said his state has proven the concept works and he's confident other states can succeed on their own terms.

"There is no backing away from all the challenges associated with expanding coverage," Shor said. "We are proud in Massachusetts that we overcame what had been years of policy paralysis."

Some questions and answers on how the exchanges will work

Related stories:

• States get more time for health exchange plans
• Feds look set to run more state health insurance markets
• More Americans got health insurance in 2011

When Marie D'Orsaneo's rheumatoid arthritis worsened three years ago, her doctor prescribed Rituxan, an expensive injectable drug that her employer-sponsored health plan had to sign off on first.

In the four weeks D'Orsaneo waited for that approval, the 41-year-old physician's assistant says her health deteriorated so rapidly she had to leave her job, move in with relatives and was eventually hospitalized.

"I couldn't afford to pay for the drug on my own," says D'Orsaneo, who lives in Philadelphia and estimates Rituxan costs about $7,000 per month plus facility costs. "But waiting came with a huge cost of its own."

Fewer and fewer consumers today can count on their prescription drug benefits to cover all the medications they take with no restrictions. Overall prescription drug costs have fallen, thanks to greater use of generics. The exception is specialty drugs, typically biologics, for which there are currently no substitutes. In addition to rheumatoid arthritis, these medications often treat difficult-to-manage conditions including multiple sclerosis, chronic pain, HIV and cancer.

Approximately 57 million Americans rely on specialty drugs, according to the Independent Specialty Pharmacy Coalition. The cost is high — averaging $1,766 per prescription in 2011, according to prescription benefits manager Express Scripts. Traditional drugs cost $53.97 per prescription on average.

The number of patients who could benefit from these more sophisticated therapies will only continue to grow, in some cases by 15 percent annually. "By 2016, seven of the top-selling drugs are going to be specialty drugs," says Adam J. Fein of Pembroke Consulting, whose clients are pharmaceutical manufacturers.

Employers are struggling to contain costs. Many have adopted tiered prescription benefit plans, with specialty drugs in the fourth tier, which has the highest cost-sharing either through co-payments or co-insurance. Plus, only about half of employees have any annual cap on how much co-insurance they'll pay on fourth-tier prescriptions, according to the 2012 Kaiser/HRET Employer Health Benefits Survey.

Also common is requiring prior approval for a particular drug or "step therapy" where a patient must try a number of cheaper drugs before they will cover certain prescriptions. Other prescription plans mandate where pharmacy members must purchase specialty drugs. A new trend limits the quantity of medication dispensed to cover 30 days in order to prove it is effective first, according to a recent survey by drugmaker EMC Serono Inc.

The issue, patient advocates say, is that any cost-savings must be weighed against severe health consequences like D'Orsaneo's. "For rheumatoid arthritis, for instance, waiting for prior authorization or trying an ineffective drug first can mean the loss of a joint. How do you price losing the use of your thumb?" says Seth Ginsberg of the New York-based non-profit Global Healthy Living Foundation.

Several states, including California, New York and New Jersey, are now considering legislation that would ban so-called "fail first" policies, Ginsberg says. "Insurance plans should not come between the patient and the doctor who is right there with them, deciding what the best course of treatment is."

Some relief is in sight. Starting in 2014, the Affordable Care Act will require insurers to restrict out-of-pocket costs, including for prescription drugs. The cap for an individual will be about $6,000 and $12,000 for families.

There are steps a patient can take now to help ease the path to the medication they need. Here are few tips: 

• Contact the drug manufacturer directly. Fein recommends doing this before ever reaching out to your health plan because most have a group that assists patients in navigating the insurance approval process as quickly as possible.

  You may qualify for the drugmaker's patient assistance program, which can bring down the price dramatically. Seven out of 10 biologic makers, for instance, have programs to offset co-pays, according to a September survey by Zitter Group, a life-sciences research firm.

  Drugmaker Amgen's copay offset program for Enbrel, a rheumatoid arthritis and psoriasis treatment, for example, saved patients, on average, $180.82 per prescription in copays during the first three quarters of 2012, according to the Zitter Group research. Patients paid no co-pay at all for the first six months on treatment, and $10 per refill for the next six months.

• Charm your doctor's office administrator. Health plans often require prior authorizations to be faxed in triplicate. That's why one of the biggest hurdles to treatment can be the paperwork alone, necessitating a great deal of patience from your doctor's staff. Being polite and persistent goes a long way.
• Work with your doctor to document your health history. Maintaining an on-going record of what therapies you've tried in the past can head off some questions in a prior approval process upfront.

  "We've had clients whose insurance companies will make them go back and try medicines they've already failed on years before," says Brittany Allen, a staff attorney for the group Advocacy for Patients with Chronic Illness. "But some allow a look-back period that will grandfather them in."

  Doctors can also help find creative solutions. When Pat Killingsworth was diagnosed in 2007 with multiple myeloma, a bone marrow cancer, his doctors at Mayo Clinic prescribed Revlimid, an oral chemotherapy drug. But his health insurer, Blue Cross/Blue Shield, refused to pay, saying the FDA had not approved Revlimid for newly diagnosed patients and insisting he try an older therapy first.

  With the help of his doctors and nurses, Killingsworth found a loophole -- he'd previously had radiation therapy -- and his insurance appeal was granted. "It wasn't what the insurance company originally wanted, but they accepted it anyway," Killingsworth, now a patient advocate living in Weeki Wachee, Florida.

• Ask your employer for help. Three in five workers are in a self-insured health plan, according to the Kaiser 2012 survey. That means their employer has assumed the financial risk of enrollees' medical claims, even if a third-party firm administers them.

  Going to your employer directly then can sometimes speed up the approval process, Allen says, especially if you have been with the company for several years. Although rare, self-insured employers may also be willing to overrule their health plan in the case of a denial.

• Appeal plan decisions. The worst-case scenario is that a request for a treatment is turned down. Every decision, however, can be appealed, a process that your insurer should provide instructions on in its denial letter. In Allen's experience, about 80 percent of appeals have led to a denial being overturned. Here again, however, maintaining comprehensive medical records is important.
• Pay attention to deadlines. "If you miss one, you don't get another chance," Allen adds.

Want more health news? Don't miss these stories on NBCNews.com

Injecting a rare shot of bipartisanship in the nation's contentious health care overhaul, the Obama administration cleared four Republican-led states to build their own consumer-friendly insurance markets on Thursday.

With open enrollment for millions of uninsured Americans just nine months away — Oct. 1, 2013 — the four GOP-led states joined 17 states plus Washington, D.C., that have gotten an initial go-ahead to build and run insurance exchanges. Seven were approved Thursday.

Significantly, the list also included California, which has nearly 7.5 million uninsured residents. Democratic-led California was an early supporter of President Barack Obama's health care law and had been working diligently on its plan.

Insurance exchanges are not something consumers are familiar with.

"Most people don't really know what those words mean, but that's OK," said Rachel Klein, executive director of Enroll America, a nonprofit trying to educate the public about new benefits under the federal health care law. "What they really need to know is that there's going to be a new way to buy health insurance."

The new marketplaces are supposed to take the confusion and anxiety out of buying private health insurance for individuals and families who buy their coverage directly. Exchanges are meant to have the feel of an online travel sitean Expedia or Orbitz.

Exchanges will also offer some relief from sticker shock. Under the new law, about eight in 10 customers in the new marketplaces will be eligible for income-based federal aid to help pay their premiums.

Small businesses will have separate access to their own exchanges.

The approvals announced Thursday are provisional; administration officials said more work remains to be done before they'll issue final sign-offs.

The GOP-led states conditionally approved are Idaho, Nevada, New Mexico, and Utah. Idaho and Utah have Republican governors and legislatures. Nevada and New Mexico have GOP governors, but Democrats control their legislatures.

"We're on track for Idaho having a say over how this process works, instead of having the federal government dictate all of it," said Jon Hanian, spokesman for Republican Gov. C.L. "Butch" Otter. The legislature still has to weigh in.

A fifth Republican-led state, Mississippi, may yet win approval. However, the administration's decision is complicated by a legal dispute between Republican state officials. The governor does not want to participate, while the insurance commissioner does.

The federal government will set up and run the new marketplaces in states that opt out of playing any role, and 19 Republican-led states have taken that route. The rest of the states are either pursuing partnerships with Washington or still mulling their options.

Two states, Arkansas and Delaware, have been approved for partnerships. That means a state will handle consumer issues and oversee health plans while Washington takes on the back-office tasks of enrolling consumers and determining subsidies.

Right now, exchanges exist in only a couple of states, although some large private employers are also experimenting with them.

Originally a Republican idea, exchanges won bipartisan support, only to be abandoned by many in the GOP once they were incorporated into Obama's health care law.

The basic concept is that setting up a marketplace with clear-cut rules would benefit consumers and encourage insurance companies to compete, helping keep costs in check. Former Massachusetts Gov. Mitt Romney set up an exchange in that state under his 2006 health care overhaul law. And Utah has already launched one that caters to small businesses.

Under Obama's law, plans in the new marketplaces will have to cover a set of "essential" benefits, including hospitalization, doctor visits, prescriptions, prevention and care for pregnant women and young children. Cost to the consumer will be the main difference among plans, with four levels of coverage: bronze, silver, gold, and platinum. A consumer with a bronze plan will pay lower monthly premiums, but would face higher cost sharing for medical care.

Exchanges will also steer low-income people to state Medicaid programs. The law gives states the option to expand Medicaid to cover more of their low-income residents, with the federal government picking up about 90 cents of every dollar in added costs.

Coverage through exchange plans will begin on Jan. 1, 2014.

Related stories:

Health reform a winner in November elections

Federal government releases long-awaited health rules

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Two-thirds of Americans who sign on to buy health insurance using new state marketplaces will actually be getting a federally administered plan, a health consultancy firm projected Thursday.

Only 17 states, plus Washington, D.C, have said they will run their own health insurance exchanges or share responsibility with the federal government.

“These states are expected to enroll 2.8 million individuals out of a total of 8.2 million people nationwide who will buy coverage through exchanges in 2014,” Avaleere said in its report.

The rest have either said they’ll leave it up to the federal government, or are leaning that way.

Friday is the deadline for states to say for sure what they plan to do and just three states – Florida, North Dakota and Indiana – have failed to give an answer so far. But all three have governors who have indicated they won’t be setting up exchanges.

On Wednesday, Pa. Gov. Tom Corbett said his state would leave it up to the federal government.

Republicans who control the House Energy and Commerce Committee’s health subcommittee held a hearing on Thursday to highlight state reluctance to take part in the exchanges, even though they got their deadline extended by a month.

But the Health and Human Services Department said it didn’t matter – people will be able to sign up to buy health insurance on the exchanges as scheduled, in October 2013. Their coverage will start on the first day of 2014 under the 2010 health reform law.

“I am confident that sates and the federal government will be ready in 10 months," Gary Cohen, director of the Center for Consumer Information and Insurance Oversight, which is in charge of the new exchanges, told the hearing.

HHS said earlier this week that six states -- Colorado, Connecticut, Massachusetts, Maryland, Oregon, and Washington – are on track to have their health insurance exchanges approved. California, Hawaii, Vermont, Mississippi, Kentucky, Minnesota, New York and Rhode Island are also on board to run their own, Cohen said. Delaware, Illinois, Iowa and North Carolina want federal-state partnerships.

One of the main goals of the 2010 Affordable Care Act is to get more Americans covered by health insurance. About 15 percent of the population currently goes without, and most experts agree that people without health coverage delay routine medical care until they develop expensive-to-treat conditions. Hospitals and taxpayers often end up footing their bills.

The main way the health care law will get these people covered is on the exchanges. They’re designed to be a kind of online marketplace where people and small businesses can compare different insurance plans available in their states, choose a level of coverage, and find out if they are eligible for federal government subsidies to pay the premiums.

Cohen said HHS is on track to make this as easy as possible. “For example, we are building a website with interactive capabilities and a call center. Consumers will be able to use this to compare qualified health plans, check their eligibility for affordability programs, and enroll in a qualified health plan,” he said at the hearing.

Even if the federal government runs the exchanges, they’ll be subject to state-by-state variation. That’s because state law still determines which insurance companies can sell products within a state’s borders. States also can decide whether to expand Medicaid, the state-federal health insurance plan that now covers mostly the very poor and pregnant women without insurance.

But representatives from several states said the process has been far too confusing and they fear HHS will make an already complicated process even more complex.

“In all my years of public service, I have yet to witness a law so vast with such breathtaking scope, demands on state resources, and lack of federal guidance,” Gary Alexander, Pennsylvania's secretary of public welfare, told the hearing.

“I have hundreds of policy, operational, and technical staffers working to implement this health-care reform law, and yet, we realized early on that we do not have the capacity or the financial resources to address all of the provisions and requirements of this complicated law.”

Bruce Greenstein, Louisiana’s health secretary, echoed this. “We have repeatedly shared our concerns regarding its policy implications, lack of sufficient guidance and unreasonable timelines for implementation,” he said.

Cindy Mann, deputy administrator at the Center for Medicare and Medicaid Services, said HHS had held constant briefings to help guide states. “We are on the phone literally every day with people form the states, helping them, answering their questions,” she told the hearing.

Dr. Joshua Scharfstein, who heads Maryland’s health department, agreed. “We have had a terrific interaction,” he told the hearing, saying he has been “really impressed” with Cohen’s and Mann’s departments.

Democrats on the subcommittee accused Republicans of playing politics and said critics of the health reform law were still trying to undermine it, even though the U.S. Supreme Court ruled it constitutional in June.

“Many of us fear is the purpose of this hearing is to show we can’t move forward,” said California Democrat Henry Waxman. “That’s flat-out wrong. It seems to me it’s just the latest attempt to repeal the Affordable Care Act.”

 Related stories:

• Report: Americans paying more for health insurance
• Who falls through the cracks if states don't expand Medicaid
• States decide future of health reform