NASHVILLE, Tenn. -- Zach Ryan's decision will help determine the success or failure of the Affordable Care Act.
He's not a powerful politician, a corporate executive or a federal judge. He's a 26-year-old without health insurance.
Whether he and millions of other young people buy coverage is crucial for the federal health law to reach the goal of making insurance affordable. Their participation is needed to offset the cost of guaranteed coverage for older people with pre-existing conditions. But with barely more than two weeks before enrollment begins on a newly created exchange for the uninsured, most young people know little or nothing about what's at stake for them, according to polls and surveys.
"I can find the most obscure stuff on Google," Ryan said. "I mean stupid, obscure stuff. ... But I couldn't find how to get health care through the government. When you type in Obamacare, you would think it would come right up and have some clear instructions."
Obamacare - how many people refer to the federal health law - is not its official name. If Ryan had typed in Affordable Care Act, he might have gotten closer to the information he needed. The insurance exchange where people actually can sign up for coverage is the Health Insurance Marketplace. The website does not start taking applications until Oct. 1, but it does explain subsidies toward purchasing coverage and penalties for going without it.
The carrot can be sweet, bland or nonexistent, depending upon the subsidy amount, which is tied to income. The stick is tiny. With a penalty of only $95 or 1 percent of income for a single person, some young people will opt to forgo coverage next year.
"You need people in your 20s, your 30s and even early 40s to help balance out the costs of people in their late 40s, 50s and early 60s," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, an industry trade association.
Besides the small penalty for next year, it's also possible to game the system - to wait until sickness or injury occurs before buying a policy, as long as it's during an enrollment period. Enrollment does not end until March 31. That six-month window is a one-time deal. It will be only 53 days next time around.
How many young people won't bother with buying insurance is a guessing game, but a couple of reports give some insight.
A tracking survey commissioned by The Commonwealth Fund, a nonprofit that promotes better access to health care for the vulnerable, finds that affordability - not a sense of invincibility - is the key reason young people aren't enrolled in health plans. A poll commissioned by American Action Network, a conservative think tank that opposes the federal health law, determined that people between 18 and 40 who already have coverage are more likely to drop it as their premiums rise.
"What that report found was young people are extremely price-sensitive," Zirkelbach said.
In Tennessee, there aren't a whole lot of young people walking around with insurance cards or big checking accounts. Good jobs with generous benefits are hard to find. Many recent college graduates are making do with low-paying jobs outside their career fields. And those lucky enough to be under a parent's employer-based plan are aging past 26, when coverage ends.
That's what happened to David Carter of Hendersonville. He works as a grocer for a small business where he's without benefits. He's hopeful he will be able to afford insurance under the new rules.
"You might just break your leg walking down the road," he said. "You never know."
Austin Littrell, 28 of Nashville, also is without insurance. Although he disagrees with the law for making private insurers a legally designated part of the nation's health-care system, he said he would sign up just to avoid the hassle of paying a penalty.
"Between swinging multiple jobs and trying to make it in music and other things, there is not a lot of extra money lying around," Littrell said. "But at this point, it has gotten down to where you are either going to get it or pay the fines, so you might as well jump on board."
The Commonwealth Survey found that only 27 percent of people between the ages of 19 and 29 knew about opportunities to buy insurance with the help of subsidies.
"We've talked to the uninsured young adults all across Tennessee and we've heard over and over again that they value and want insurance, but need affordable options," said Carla Raynor, vice president of strategic marketing for Blue Cross Blue Shield of Tennessee. "They also told us they want help navigating the purchasing process and more education. That's why we launched our website, bcbst.com/knownow."
Another Tennessee insurance firm that is trying to close the information gap, Cowan Benefit Services, launched radio ads last week aimed at the young uninsured.
"We really think the young people who haven't gotten jobs with benefits over this last recessionary period and ... will need help in deciphering this health care morass that we're in," said Matt Cowan, president of the company.
Traditionally, the firm has operated on a business-to-business model, assisting employers in setting up health benefits. The Affordable Care Act offered the opportunity to do more sales to individuals.
"The consumer is more involved now in the buying decision of health care," Cowan said.
Besides being offered on a government website, the subsidized coverage can be purchased from an independent insurance broker without costing people any more money. The brokers make their compensation from commissions paid by the insurance companies.
Not all young people will be able to afford to buy coverage because a big chunk of them won't qualify for subsidies. Many will fall through the cracks because of states not expanding their Medicaid programs, The Commonwealth Fund survey concluded. Tennessee, at this point, is one of those states.
People earning less than $11,490 a year don't qualify for subsidies because states were supposed to provide them with Medicaid coverage, but the U.S. Supreme Court struck down the provision of the federal law that obligated states to do that.
The Commonwealth Fund determined that nearly 30 percent of young adults live in households that will be excluded from both Medicaid and subsidies to buy insurance.
Young people who make too much money, about $33,500 or more, won't receive subsidies either. And higher earners who already pay for their own coverage are likely to face heftier premiums than they owe now, according to the poll conducted for American Action Network.
The poll found that the more their premiums rise, the more likely they are to drop coverage.
Ryan, an East Nashville resident who works as a salesman at a boots store and a musician, said he could not think of a friend who had health benefits.
"It would be nice to know how to actually get it," he said.