Health Care

Administration policies may be contributing to a decline in sign-ups.

There has been a steep drop in Obamacare insurance numbers, halfway through the sign-up season for 2019, raising concerns that the Trump administration’s controversial policy changes are undermining the marketplaces.

The 9.2 percent drop to roughly 100,000 sign-ups per day has surprised close observers of the Obamacare markets, who expected the number of customers to remain fairly stable even after Republicans eliminated the unpopular individual mandate penalties for being uninsured. Premium hikes were fairly low in most states for 2019, and many parts of the country saw an increase in consumer choice as more health plans participated in what they now see as a more profitable, stabilizing market.

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Insurance experts say it’s unlikely that any one major cause is behind the enrollment dip compared with last year’s enrollment period. Instead, it’s likely a confluence of headwinds.

“It’s a little bit of this, a little bit of that,” said Duke University health policy researcher David Anderson, who has written extensively about the exchanges. “It’s very messy.”

One of the biggest challenges is probably ignorance: Hardly anyone knows that it’s open enrollment season. Just 1 in 4 Americans who buy their own health insurance or are uninsured are aware that the deadline for enrolling in coverage is Dec. 15, according to the latest polling data from the Kaiser Family Foundation.

In addition, barely 1 in 4 respondents reported seeing advertisements explaining how to enroll in Obamacare coverage. By comparison, more than half of respondents reported seeing such ads during the inaugural Affordable Care Act sign-up period, which ran from October 2013 through the following April.

One possible reason for this: President Donald Trump’s agencies are putting far less time and money into promoting the enrollment period than the Obama administration did.

A slow start doesn’t necessarily mean a slow end to the six-week season. A flood of sign-ups could arrive as the deadline prods the inevitable procrastinators to act. But ACA backers are worried. Enrollment nationwide peaked in 2016 at 12.7 million, according to Kaiser, and has ticked down each year since then, with 11.8 million sign-ups for the current year.

“This is affordable coverage that people need and want, but the reality is that the administration’s sabotaged open enrollment,” said Leslie Dach, chair of Support Our Care, a pro-Obamacare advocacy group, citing huge reductions in funding for outreach and marketing as particularly damaging. “The American people simply don’t know about the deadline and they’re not fully aware of how affordable health care is for them.”

Some people, particularly those who don’t get their premiums subsidized in the ACA markets, may be opting for the skimpier but cheaper plans the Trump administration is pushing as an Obamacare alternative. Some may be getting insured outside the exchanges, either in states that are finally expanding Medicaid or through employer-provided coverage in a booming job market.

The drop off applies to the 39 states that rely on the once troubled HealthCare.gov website for enrollments. Some states that run their own exchanges are seeing a more stable or improving environment. Covered California, the largest state-based marketplace, won’t release any enrollment figures until later this week. California committed to spending about $100 million on advertising and outreach this year — 10 times what the federal government is spending to drum up sign-ups for HealthCare.gov.

And there’s less of a spotlight on open enrollment compared to last year, when Republicans were still vowing to dismantle Obamacare, keeping it in the news.

“Last year the ACA received an incredible amount of free media,” Anderson said. “People were just aware of it.”

That attention may have blunted the effects of the decision to gut funding for Obamacare outreach and advertising. But this year the exchanges are likely feeling the full brunt.

Outreach groups that saw their funding slashed are focusing their limited budgets on re-enrolling existing clients rather than trying to reach new customers. The Dallas-based Community Council, for instance, eliminated advertising this year after the group lost its $1.8 million federal grant. Even though the group has managed to enroll roughly the same number of people as last year, CEO Ken Goodgames worries about the people they aren’t reaching.

“When you think about those that we serve, they are out of luck because they don’t know how to access the information or don’t speak English or don’t have technology,” Goodgames said.

Another likely reason for the decline is the removal of the individual mandate penalty, which Congress scrapped as part of its 2017 tax cut package. That’s likely spurring some people who don’t expect to need a lot of expensive medical care to take their chances by going without coverage. About 4 in 10 potential Obamacare customers indicated that they would choose to go without coverage after being told that the penalty for not buying insurance is being eliminated next year, according to Kaiser.

Also contributing is the Trump administration’s expansion of cheaper, often less robust, insurance plans that don’t meet the Affordable Care Act’s coverage requirements. The federal health law’s supporters have warned that such non-compliant plans will siphon off exchange customers, driving up costs for those who remain.

The spread of Medicaid expansion is also likely dampening ACA enrollments, since some exchange customers will be able to get free coverage. Most notably, Virginia is expected to add 400,000 residents to its Medicaid roles when expansion takes effect next year. In addition, Maine appears poised to move forward with expansion in the coming months, especially now that a Democratic governor is replacing stalwart expansion foe Paul LePage.

The booming economy is also likely depressing enrollments. The unemployment rate is down about half a percentage point since last year’s sign-up season, which means some individuals who were enrolled in Obamacare plans are likely now covered through their jobs.

The fluctuations in enrollment vary across the country. About 311,00 Texans signed up for ACA plans through the fourth week of open enrollment, compared with 334,328 over the same period last year.

“We’re certainly not panicking,” said Ken Janda, CEO of Community Health Choice. The Houston-based insurer’s seen a 15 percent dip in enrollments compared to this point a year ago, but Janda expects people who are insured to ultimately purchase plans. “What we continue to find is that once people have health insurance, they like it a lot.”

Enrollment in New York State is trending about 10 percent ahead of last year’s numbers, said Danielle Holahan, deputy director for the state’s exchange. Through Nov. 24, 870,000 people had renewed their plan and another 36,000 have enrolled. The increase comes despite the fact that prices for individual insurance rose an average of 8.6 percent this year.

Holahan attributed the success in part to the state’s commitment to Obamacare. New York still spends $14 million on advertising the exchange and $23 million on its outreach program.

Despite the sluggish enrollment, most close observers of the ACA markets aren’t sounding alarm bells about their long-term viability.

“It’s always going to be a little shaky in really low populations areas,” said Kathy Hempstead, who oversees coverage programs for the Robert Wood Johnson Foundation. “There is a point where you have a viability issue, but so far I don’t feel it’s being triggered.”

Renuka Rayasam, Dan Goldberg and Victoria Colliver contributed to this report.

congress

The longtime Democratic leader triumphs after meeting with some of her most vocal critics.

Nancy Pelosi is one step closer to a historic return to the speakership, having handily won her party’s nomination to lead the House in the 116th Congress.

The vote was 203 -32, with three blank ballots and one absent.

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The 78-year-old Pelosi will now try to return to the speaker’s chair for the first time since Democrats lost their majority in 2010. A final vote on the floor will take place on Jan. 3.

Reps. Steny Hoyer (D-Md.) and Jim Clyburn (D-S.C.) were unopposed for House majority leader and majority whip, putting the septuagenarian trio back in the same posts they held in the last Democratic majority.

In the hours leading up to Wednesday’s vote, Pelosi tried to lock down support. She cut a deal with the Problems Solvers Caucus over rules changes, sealing support from nine Democratic members of the group who had threatened to vote against her.

And Pelosi met with three of her most vocal critics — Reps. Seth Moulton (D-Mass.), Kathleen Rice (D-N.Y.), and Tim Ryan (D-Ohio ) — in a bid to win over hardcore opponents.

The anti-Pelosi group had held a private discussion on Tuesday evening, during which some lawmakers raised the possibility of backing Pelosi if she agreed to a transition timeline for new leadership, said the sources.

But the Wednesday gathering between Pelosi and her opponents did not lead to a truce.

“Moments ago we met with Leader Pelosi and tried to engage her in a reasonable conversation about leadership transition,” Rice said in a statement. “Unfortunately, our concerns were dismissed outright. We remain united behind our goal of new leadership and intend to vote against Leader Pelosi in Caucus and on the Floor of the House.”

Pelosi, was more successful in closing the deal with the Problem Solvers Caucus, a bipartisan group of lawmakers who want to rewrite House rules to make it easier to legislate.

The dual tracks to round up more votes took place just as Pelosi was on the verge of making history once again. The legendary Texas Democrat Sam Rayburn was the last lawmaker to lose the speaker’s gavel and then get it back, a feat the 78-year-old Pelosi is now trying to repeat.

Anti-Pelosi Democrats had been downplaying expectations heading into Wednesday’s closed-door meeting. They had hoped to get roughly 20 votes opposing Pelosi inside the Democratic Caucus.

Inside the caucus, Pelosi was nominated by Massachusetts Rep. Joe Kennedy, while a group of eight lawmakers — that includes incoming freshmen Angie Craig of Minnesota, Veronica Escobar of Texas, and Rep.-elect Katie Hill of California — seconded the nomination. Civil rights icon John Lewis of Georgia also spoke on Pelosi’s behalf.

Kennedy’s support for Pelosi is notable because another Massachusetts Democrat, Moulton, is one of her most outspoken critics inside the party.

Pelosi used the speaker ballot as something of a safety valve by allowing vulnerable Democrats to vote “no.” This enables Democrats who won races where Pelosi was an issue to say they opposed her return to the speaker’s chair, but now must back her since she has the overwhelming support of the Democratic Caucus.

Behind the scenes, Pelosi and other Democratic leaders were also dealing with other potential Democratic Caucus rules changes as they sought to lock down votes.

In the days leading up to the vote, Rep. Gerry Connolly (D-Va.) floated the idea of opening up the secret ballot election so that incoming freshmen who ran on a platform of opposing Pelosi or electing new leadership could show constituents they did.

But Pelosi instead opted to include “yes” and “no” checkboxes under her nomination to give members-elect the option of voting against her in caucus — with, of course, the notion that they would back her when she needs them most on the House floor on Jan. 3.

On that day, Pelosi needs half of the House — not merely half the Democrats. And she can only lose 17 votes.

Democrats predicted that incoming freshmen would likely snap pictures of their ballots showing their opposition to Pelosi in caucus. But that’s all part of a carefully crafted Pelosi plan to allow some incoming members to argue they opposed her even if they support her on the House floor.

Connolly predicted Pelosi would receive less opposition this year than previously, when she lost 63 Democrats to Ryan for minority leader.

“It was easy to cast a protest vote two years ago, and you had an opponent,” the Virginia Democrat said. “This is serious. This is now for speaker. And you have to really assess carefully what are the qualities, what are the skill sets and who has them. And I think that makes it harder frankly.”

Party leaders have also been fending off other potential Democratic Caucus rules changes. One would require the party’s speaker nominee get 218 votes, a shot at Pelosi. Another would limit the party leadership’s control over committee assignments.

Another rules change would require any lawmaker who is a part of the Democratic Congressional Campaign Committee hierarchy to back incumbents only. This is aimed at Rep. Jan Schakowsky (D-Ill.), who backed Rep. Dan Lipinski’s (D-Ill.) primary challenger.