ObamaCare made it through nearly 10 months of repeal attempts with Republicans in full control of Washington.
It now faces another crucial period starting Wednesday.
It’s the first test of how the Trump administration will handle enrollment under the law it claims is “imploding.” With the president making no secret of his desire to kill the law completely, Democrats accuse the administration of "sabotage" and say the number of new enrollees is likely to drop as a result.
That would lift the uninsured rate, which has fallen dramatically since the law went into effect, and could hurt ObamaCare’s sustainability by leaving a smaller, sicker and costlier pool of enrollees.
“There’s a renewed urgency that I haven’t seen in the past couple of years,” said Lori Lodes, a former Obama administration health official who runs Get America Covered, a group working with local officials to fill the gap left by the Trump administration’s cuts.
Since Trump came into office, he has taken a series of actions that could undermine the law. He signed an executive order that instructed agencies to loosen ObamaCare rules, slashed advertising and outreach dollars, cut enrollment staff and earlier this month cut off payments to insurers that reimburse them for giving discounts to low-income enrollees.
One influential analyst predicts confusion from these actions will lead enrollment to drop several million compared to last year. Charles Gaba projects the numbers could drop to between 9.5 and 10 million people this year, down from 12.2 million last year, though he notes it is hard to predict.
Josh Peck, a former Obama administration health official, has estimated that the new administration’s cutbacks to outreach alone will lead to 1.1 million fewer people signing up for coverage this year.
Gallup found this month that the uninsured rate has already started to tick back up this year after a sharp decline when ObamaCare went into effect in 2014. Since the law went into full effect, the number of uninsured has dropped from around 45 million to 28 million.
The Trump administration will also not put out an enrollment goal this year, in a break with the practice under Obama.
The administration faces a difficult balancing act in overseeing a law it opposes but that is still on the books. Department of Health and Human Services (HHS) officials pushed back on the idea they are sabotaging the law, arguing that ObamaCare was already flawed.
The administration says it will still be carrying out many functions, like a call center and email alerts to consumers. Asked if the administration wants the sign-up period to go smoothly, an HHS official said “absolutely.”
However, the administration slashed funding for advertising and outreach by 90 percent and cut funding to outside groups, known as navigators, that help people enroll.
More broadly, experts say the several near-misses in Congress to repeal the law this year could leave consumers wondering if ObamaCare is even still in effect.
President Trump’s recent comments that the law is “dead” are not helping, according to Ceci Connolly, CEO of the Alliance of Community Health Plans.
“Some folks might hear that and think either, ‘I don’t have to sign up for insurance anymore,’ or maybe ‘my insurance isn’t available,’ ” said Connolly, whose group includes community-based health insurers, many of which participate in the ObamaCare markets.
Trump’s decision to cut off the payments to insurers has also led to some premium spikes as insurers try to compensate for the loss.
Connolly said that her insurer group had “no heads up whatsoever” before Trump's move earlier this month.
An official with America’s Health Insurance Plans (AHIP) said that she is “hopeful” that the ObamaCare markets will continue to stabilize but that uncertainty from the administration and Congress has been an obstacle.
“The uncertainty has certainly been challenging this year and we're hoping to get on some more level footing next year,” said Kelley Turek, AHIP's executive director of employer and commercial policy.
She added that insurers are “trying to step up to the plate a little bit more” in their outreach efforts to consumers to fill the gap left by the administration’s cutbacks.
The enrollment period is about half as long this year, ending Dec. 15, another focus of messaging.
The Trump administration pushed back on the idea that its cuts are part of an effort to sabotage the law.
“It’s important to remember that ObamaCare enrollment was in decline before President Trump took office,” said HHS spokesman Matt Lloyd. Enrollment dropped from 12.7 million in 2016 to 12.2 million in 2017, though Democrats argue that Trump administration cutbacks in January played a role.
“The previous administration inflicted heavy damage on the individual market — premiums doubled, insurers dropped out of the individual market in droves, millions of Americans saw their plans cancelled because Washington didn’t approve of them, and millions more paid billions in fines to avoid the kind of coverage ObamaCare dictated,” he added. “That’s not evidence of a healthy, competitive market nor one that is best serving individuals and families.”
If enrollment falls significantly short this year, it could hurt the stability of the law, given that the people most likely to remain are the sickest enrollees who most need health insurance and are the costliest.
“If enrollment drops and healthy people drop out the effect would be destabilizing,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation. “In this political environment what happens during open enrollment will be really important both symbolically and practically.”
But experts emphasize that the law is still on the books and financial assistance is still available to help people afford coverage.
“We're really trying to make sure that consumers are aware of the fact that things aren’t really changing that much,” Turek said.