The Trump Administration has announced initial enrollment numbers for the federally-run Healthcare.gov exchange, which provides individual and small group coverage for the 39 states that do not operate their own state-based exchange. Enrollment was significantly lower than last year—a total of 8.45 million people enrolled representing a drop of 4.2 percent from 2017’s level of 8.82 million and an aggregate drop of over 8 percent from 2016’s level of 9.2 million. This represents a significant blow to the financial security and health of America’s families. There is no evidence to suggest that people losing coverage on the exchange are gaining it elsewhere. Rather, these reductions indicate a significant increase in the number of uninsured Americans. They also represent a disturbing reversal of dramatic progress in reducing the number of Americans without health insurance prior to 2017.
The Trump Administration’s actions and actions of the 2017-2018 Republican Congress directly led to these coverage reductions. Based on what we are hearing from partner organizations and consumers, the following are the five biggest factors driving enrollment lower this year.
1) The Trump Administration Allowed Junk Insurance to Compete Directly with Real Health Insurance
This past August, the administration made it legal to sell “short-term insurance” plans for long periods of time that do not comply with the ACA’s consumer protections. The administration—in a maneuver that will be challenged in court —stretched a narrow exception from core insurance protections for “short term plans” under the ACA beyond all recognition. These plans were heavily marketed online and via telemarketing during open enrollment, and likely confused numerous consumers with seemingly low-cost junk coverage offers.
2) The Trump Administration Almost Eliminated Any Advertising of Open Enrollment:
Beginning last year and continuing this year, the Center for Medicare and Medicaid Services (CMS) and the White House made a highly partisan decision to almost eliminate any advertising of the six weeks that people had to sign up for coverage on Healthcare.gov. It’s hard for people to sign up for coverage they don’t even know about. In contrast, state-based marketplaces continued to advertise open enrollment and produced generally higher enrollment levels for 2019 than for 2018.
3) The Trump Administration Cut In-Person Enrollment Assistance by More Than 80%
Under the Affordable Care Act, the federal government has contracted every year to provide some level of in-person assistance with enrollment questions — “Navigator” services. These services provide a similar function to assistance from an HR department with health insurance questions for people who receive employer coverage. From 2017 until now the Trump administration slashed Navigator funding by 84 percent. Those services have been cut way back at the same time that—as described above—consumers have more trouble than ever distinguishing junk coverage “short-term” plans from regular health insurance coverage.
4) Repealing the ACA’s Individual Responsibility to have Coverage
The Republican tax bill passed in late 2017 ended the enforcement of the Individual responsibility requirement in the ACA that requires individuals to have insurance. This move was strongly opposed by the major national associations of actuaries, insurers, hospitals, and physicians, and criticized by the Congressional Budget Office (CBO) repeatedly. As the American Academy of Actuaries wrote in November 2017: “The ACA includes an individual mandate in order to make sure the young and healthy, as well as the old and sick, obtain coverage. Eliminating the mandate without implementing an alternative means to drive enrollment among healthy individuals would likely result in a deterioration of the risk pool due to lower coverage rates among lower-cost individuals.”
5) New Barriers for Immigrants to Enroll
Families USA heard repeatedly that immigrants were afraid to sign up for coverage because of the Administration’s actions around “public charge.” We heard this from consumer advocates and organizations that engage in enrollment assistance. About one million lawful immigrants apply for permanent residency every year, but their applications can be denied if they represent a “public charge.” In 2018 the Trump administration first leaked and then formally proposed a regulation that would count participation in any of numerous government services as a basis for denying these applications. In the leaked version of the rule—which was published in the Washington Post in April—receipt of premium tax credits on the marketplace was one of the services that would be the basis for denying permanent residency. Although the formally proposed rule did not include premium tax credits on the list of “public charge” grounds, it did include other health insurance programs like Medicaid, the Children’s Health Insurance Program (CHIP), and income-based subsidies in Parts B and D of Medicare. More broadly we are witnessing the beginning of a major chilling effect on lawful immigrant enrollment in health and social programs due to the Administration’s public charge proposal.
Our country is going in the wrong direction on health insurance, and the basic economic security that health insurance provides. And the fact that we are moving backwards is the predictable result of destructive policy choices made by the Administration and Congress over the last two years. These latest numbers on federal exchange enrollment for 2019 are further confirmation of this deeply concerning trend.