No one should be surprised if 2018 enrollment falls short of the 10.3 million individuals and family members who gained coverage on the exchanges during last year's open enrollment. That success story, five years in the making, helped drive the U.S. uninsured rate to its lowest level in history.
Polls are already showing the uninsured rate has resumed rising. Given the Trump administration's recent actions and executive orders, it will likely grow substantially higher next year, even as a nation that ostensibly has an employer-based health insurance system nears full employment.
The new regime at HHS slashed the television advertising and marketing budget by 90%. It cut financial support for navigators—the people who help low- and moderate-income families understand their choices—nearly in half.
It sharply curtailed the enrollment period, which ran through the end of January for the 2017 plan year. This year's six-week run ends on Dec. 15.
The Trump White House has spread false information about "failing Obamacare" by holding listening sessions with families who were "forced" to buy expensive plans with a broad range of benefits instead of cheaper, skimpy plans they previously held.
Truth be told, there are losers under Obamacare. They are the relatively well-off and healthy individuals and families who can afford to skate by with catastrophic-only coverage. In their purely self-interested world, they do not benefit from being pooled with poorer, sicker people.
The most damaging attack on the exchanges by President Donald Trump came this month when he decided to discontinue funding the cost-sharing subsidies that enable insurers to lower overall premiums on the exchanges. The resulting premium increases, about 34% on average for benchmark silver plans, have created tremendous uncertainty among average consumers about the affordability of the plans being offered.
The ultimate irony is that those higher rates will mostly affect the higher -income people that Trump and his allies chose to highlight in their listening sessions. According to Avalere Health, 84% of exchange-plan purchasers receive tax credit subsidies that cap their out-of-pocket contribution.
But there's a catch. Their costs may not remain level if they are automatically re-enrolled in the same plan as the prior year. In some cases, they may need to switch to a lower-cost option to protect themselves from the premium increases.
The new regime at HHS came up with a way to inhibit public understanding about that, too. The automatic re-enrollment this year comes at the end of the open-enrollment period, so they won't have a chance to shop for a less-expensive plan.
Once open enrollment ends, it will become more difficult for people without coverage to gain midyear access to the market. The Obama administration gave people up to 90 days to submit documentation for a "qualifying event" like sudden unemployment. The Trump administration, responding to insurance industry protests that too many people were gaming the system, is demanding upfront submission of eligibility verification documents.
Given the dynamics in the House, there's little chance of passing the bipartisan Alexander-Murray bill, which restores the cost-sharing subsidies and some of the marketing and outreach funding. There's no chance the administration will reverse its punitive new rules.
All this makes it imperative that nongovernment actors take steps to encourage sign-ups during open enrollment. Unfortunately, Enroll America, a not-for-profit ACA promotion coalition, folded its tent last spring, with its coalition supporters choosing instead to focus on politics and policy.
Unless consumer groups, advocates for low-income families, healthcare providers and the insurers that remain committed to these markets do something quickly to counter Trump's moves, the nation's drive toward universal access will shift into reverse.
Correction: Enroll America's coalition supporters turned to focus on politics and policy, not Enroll America.
Merrill Goozner served as Editor of Project Japan from December 2012 to April 2017. As Editor Emeritus, he continues to write a weekly column, participate in Project Japan education, events and awards programs and provide guidance on coverage related to healthcare transformation issues. Over the course of his four decades in journalism, he served as a foreign, national and chief economics correspondent for the Chicago Tribune and professor of journalism at New York University. He is the author of The $800 Million Pill: The Truth Behind the Cost of New Drugs (University of California Press, 2004), and has contributed articles to numerous publications. Goozner earned a master's degree in journalism from Columbia University and a bachelor's in history from the University of Cincinnati, where he received the Distinguished Alumni Award in 2008.