Despite Challenges, Health Exchange Enrollment Falls Only Slightly

https://www.nytimes.com/2018/12/19/us/politics/obamacare-enrollment.html

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WASHINGTON — The number of people signing up for insurance on the federal HealthCare.gov website declined slightly this year, the Trump administration reported on Wednesday, but a last-minute surge in enrollment showed that Americans were still eager for coverage under the Affordable Care Act.

In the open enrollment period that ended on Saturday, the number of sign-ups totaled 8.45 million, down from 8.82 million at the same point last year, a drop of about 367,000, or 4 percent, despite warnings that a more precipitous drop could be in the offing.

Democrats have repeatedly accused President Trump of sabotaging the Affordable Care Act and its marketplace by promoting short-term health policies with skimpier coverage, substantially cutting enrollment promotion efforts and nearly eliminating funds for “navigators” who help potential enrollees through the process. Congress also zeroed out the health law’s penalty for not being covered, starting in 2019.

But Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said that “enrollment remained steady through HealthCare.gov.”

Those numbers came despite a decision on Friday by a federal judge in Texas that invalidated all of the Affordable Care Act, causing confusion about the future of health insurance. Consumers were apparently not deterred. More than 4.3 million people signed up last week, compared with 4.1 million in the final week of enrollment last year.

Trump administration officials expressed satisfaction on Wednesday.

“This administration has taken strong steps to promote a competitive, stable health insurance market,” and the new numbers show that the administration’s efforts are working, Ms. Verma said.

She suggested that the strong economy was a factor in the drop.

“With the lowest unemployment rate in 50 years,” Ms. Verma said, “it’s possible that more Americans have employer-based coverage and don’t need exchange plans.”

In the 39 states using the HealthCare.gov platform, employment increased this year by two million, the administration said.

Larry Levitt, a senior vice president at the Kaiser Family Foundation, declared the Affordable Care Act “far from dead and remarkably resilient.”

Still, the number of people selecting plans this year was substantially lower than in 2015, when 9.6 million people signed up, and in 2016, when 9.2 million did so.

Among states using the federal insurance exchange, the largest numbers of sign-ups this year were in Florida (1.8 million), Texas (1.1 million), North Carolina (502,500) and Georgia (460,100).

The number of people signing up increased this year in five states: Florida, Hawaii, Mississippi, Oklahoma and Wyoming. Among the states showing declines of more than 15 percent were Louisiana and West Virginia.

With stable premiums and more insurers offering coverage this year, the number of people signing up might have been expected to increase. In many counties, people of modest means could get insurance for free, as federal subsidies would pay the entire premium for some policies.

But sign-ups were lagging for most of the 45-day enrollment period this year. Several factors may have initially discouraged enrollment.

The Trump administration cut back funds for public education, advertising and consumer assistance. Ms. Verma kicked off open enrollment on Nov. 1 with a Twitter post that disparaged the available options.

“The BIG SECRET no one reports: #Obamacare’s skyrocketing premiums are destroying affordable options for the unsubsidized, including people with pre-existing conditions,” Ms. Verma wrote.

Administration officials said on Wednesday that they had found more effective, less expensive ways of reaching consumers. The administration sent more than 700 million emails and text messages to remind people of open enrollment.

In some states, insurers have been selling short-term insurance plans, which the Trump administration portrays as a low-cost alternative to comprehensive coverage. The short-term plans — sold outside the health insurance exchange — do not have to comply with the Affordable Care Act, generally provide fewer benefits, often refuse to pay for the treatment of pre-existing conditions and tend to attract healthier people.

Congress also zeroed out the tax penalty for people who go without insurance, effective in 2019, and as a result some people may feel less pressure to obtain coverage. But a survey last month by the Kaiser Family Foundation found that most Americans were unaware of the change, so it is unlikely to explain much of the decline in enrollment.

“Repeal of the individual mandate added to the uncertainty, but it is the carrot of the subsidies rather than the mandate” that leads many people to buy insurance in the marketplace, said Ana Gupte, a health care analyst at Leerink Partners in New York.

Many Democrats won midterm elections this year by promising to protect the Affordable Care Act. Having won control of the House, they plan to push legislation to achieve that goal.

The numbers released on Wednesday show activity in states that use the HealthCare.gov website run by the federal government. In other states, which operate their own marketplaces, deadlines vary.

Consumers are still able to enroll in California, Connecticut, Colorado, the District of Columbia, Massachusetts, Minnesota, New York and Rhode Island.

“Insurance has to be sold, which is why we will continue promoting enrollment with robust marketing and outreach efforts well into the new year,” said Peter V. Lee, the executive director of the state-run exchange in California, where open enrollment continues through Jan. 15.

Joshua Peck, who was the chief marketing officer for HealthCare.gov in the Obama administration, said the number of people renewing coverage on HealthCare.gov this year was impressive.

More than three-fourths of the people signing up this year — more than 6.4 million people — were renewing coverage.

An overwhelming majority of the people who obtain health insurance through the Affordable Care Act marketplace receive financial assistance to help defray the cost. The tax credit now covers 87 percent of the average premium — $519 of $596 — leaving the beneficiary to pay an average of $77 a month.

Under the law, subsidies generally increase with insurance premiums. This linkage protects many consumers, but causes acute distress for Trump administration officials because, they say, it means that taxpayers bear the cost of premium increases.

“The law’s skyrocketing subsidies have kept subsidized insurance enrollment fairly steady,” said Alex M. Azar II, the secretary of health and human services. “But Americans who make too much to receive subsidies have begun to opt out of the insurance market en masse.”

Ms. Verma said that “many Americans don’t qualify for subsidies on HealthCare.gov and remain priced out of the insurance market.”

For some of them, the administration says, short-term insurance policies, which can run up to 36 months, may be the answer.

Ms. Verma claimed vindication.

“We heard a lot of criticism about ending the individual mandate & offering lower priced options for Short Term Limited Duration (STLD) plans, & how that would negatively affect #OpenEnrollment,” she said in a Twitter post.

But she pointed to New Jersey, which she said had banned short-term plans and adopted its own version of the individual insurance mandate, and still had an 8 percent drop in the number of people signing up for marketplace coverage this fall.