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Obamacare signups are down, but the marketplaces are still healthy

The future of the Affordable Care Act exchanges is murky, with enrollment down so far this year and their fate wrapped up in court. But the marketplace remains strong, analysts have found, despite efforts to undermine it.

So far, more than 932,000 people have signed up for 2020 health insurance coverage through the marketplace exchanges set up under the Affordable Care Act, according to the latest figures released from the Centers for Medicare and Medicaid Services Wednesday. That’s down from over 1.1 million sign-ups this time last year. Early numbers released last week also showed enrollment in Affordable Care Act plans for 2020 off to a slow start.

Sabrina Corlette, a research professor who directs Georgetown University’s Center on Health Insurance Reforms said the marketplace has demonstrated “remarkable resiliency.”

The individual health insurance marketplace survived after the Republicans in Congress defanged the Affordable Care Act in 2017, wiping out the individual mandate. That rule had incentivized people to get health insurance by penalizing those who decided to forgo it.

But despite the repeal, enrollment for 2019 stayed steady with 11.4 million people signing up for health insurance on the exchanges, according to final numbers released by the federal government.

So far, “enrollment has stayed steady,” Corlette said. She noted that premiums have “settled out,” but remain high if people earn too much money to qualify for a subsidy.

Nationwide, 38 states participate in the health care exchanges, including the federally facilitated exchange. Open enrollment started Nov. 1 and people have until Dec. 15 to sign up for health insurance under the marketplace plans. Coverage kicks in on Jan. 1, 2020.

In October, the Centers for Medicare and Medicaid Services (CMS) announced that consumers would see lower premiums and an increase in the number of insurance provider choices. For example, the average premium for a 27-year-old buying a “silver” plan on the federal exchange is 4 percent lower this year, according to the agency.

Health and Human Services Secretary Alex Azar last month both hailed the developments and attacked the ACA as “still unaffordable for far too many.” Since President Donald Trump took office, his administration has publicly lambasted the landmark law established under former President Barack Obama, slashed the advertising budget around enrollment and encouraged efforts to repeal it.

So far this year, according to data from CMS, the vast majority — more than 128,000 people — were repeat customers. Another nearly 49,000 enrollees entered the system for the first time. Nationwide, the marketplace exchanges “look steady,” said Trish Riley, executive director for the nonpartisan National Academy for State Health Policy, but “it’s early to tell on this open enrollment.”

The PBS NewsHour asked health care policy experts about what, if anything, these early days may signal about the strengths of the insurance marketplace, the pillar of the ACA, and what challenges remain amid Trump administration-led efforts to diminish and dismantle it.

How the ACA marketplace has proved its strength

States have responded to Trump administration efforts to chip away at the law — including pressuring Republicans in Congress to repeal the ACA, along with executive orders such as one on short-term insurance — by shoring up their exchanges, said Riley of the National Academy for State Health Policy.

When the federal government shortened enrollment windows, some states stepped up to lengthen their own. When there were dramatic federal cuts in marketing for the sign-up period, Riley said states got creative, promoting sign-ups in night clubs, at movie theaters and on buses. Also, more states established state-based marketplaces, Riley said.

At the core of the debate around the Affordable Care Act and the marketplace health insurance model, Riley said, is one question: What do people want?

“I think people do want good coverage and what drives them is the cost,” she said. But the country hasn’t figured out how to control the factors that fuel those costs, including pharmaceutical pricing and hospital inefficiencies and waste.

How immigration policy could be affecting ACA sign-ups

As much as 15 percent of the health insurance exchange population are legal immigrants, Corlette said. And the cumulative effect of the Trump administration’s immigration policies may have translated to a chilling effect among those renewing or signing up for insurance on the exchanges, she said.

The administration’s public charge rule would deny a U.S. green card to a person who relies on one or more publicly funded social safety net benefits, such as Medicaid or food stamps. This rule has not been implemented because it is currently in litigation, but there’s still confusion following the administration’s announcement. Many people have expressed fear (unsupported by the law as written) that participating in any government services, even those they are legally entitled to receive, could jeopardize their status in the U.S.

With people already declining to get services, that apprehension could leave its mark on 2020 open enrollment numbers. Health policy experts have said immigrants were choosing to forgo health services or paying for those services out of pocket. The National WIC Association wrote that new mothers were uprooting themselves and their children from WIC because they did not want to be tied in any way to federal services and feared that could be used against them.

Why the ACA is still vulnerable

The health law has so far survived assaults by GOP lawmakers — but are marketplace plans out of the woods? In a word, no. Health care policy watchers are keeping an eye on the Fifth Circuit Court of Appeals in New Orleans, which is deliberating over Texas v. U.S. Several Republican state attorneys general are arguing that, because the individual mandate no longer exists, the Affordable Care Act is unconstitutional and should be zeroed out altogether.

No matter how the appellate court rules, Corlette said she expects the decision will be appealed and could very well be argued before the Supreme Court. One possibility, she added, is that the Fifth Circuit judges could agree that while the individual mandate should go, the Affordable Care Act offers redeeming qualities, like prohibiting discriminatory insurance coverage for preexisting conditions. Before Obamacare became law, those conditions ranged from pregnancy to prostate cancer.

The case’s influence over health care nationwide “is vastly overhyped” by people on both sides of the debate around the Affordable Care Act, said Thomas Miller, a senior research fellow with the American Enterprise Institute. But he conceded the decision could chip away at the health care law.

Looking ahead, Miller said he anticipates Republicans in office to propose health care plans that will be promoted as “customized” or “person-centric.” That means they will be cheaper, but you won’t get much coverage, he said.

At the state level, Riley foresees a rise in short-term health care plans that are less costly than those on the exchanges, but do not cover all essential benefits.

“The difficulty in making that political sale (of replacing Obamacare) is there are more people benefiting from extensive subsidies (under the current marketplace plans) who are getting better coverage than they would get otherwise, and they outnumber people who have been hurt,” Miller said.