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MADISON, Wisconsin — At 9:30 on a Tuesday morning, Adam VanSpankeren settles into his desk at the Dane County Jobs Center.
In front of him is a laptop, an open can of Coke, and a long list of people who want to sign up for Obamacare. VanSpankeren usually skips lunch to accommodate his packed schedule.
“My typical day has five to six appointments back to back,” he says. “Last year it was a slow build. This year we started getting 20, 30, 40 phone calls each day, right away. It started with the momentum we usually have at the end of open enrollment.”
VanSpankeren is the lead health care navigator at Covering Wisconsin, a nonprofit that signs people up for the Affordable Care Act programs. Right now, he and thousands of others of navigators across the country are in the middle of their busiest time of year: Obamacare’s open enrollment period, which began November 1 and will end December 15.
While the White House attempts to sabotage the ACA, it’s clear that appetite for the law hasn’t collapsed. Obamacare sign-ups are up 22 percent from where they were at this point last year.
But Obamacare advocates aren’t celebrating — they’re panicking. They don’t think they can match last year’s enrollment numbers, because the Trump administration cut the sign-up period in half. So even though sign-ups are high now — and there are some clear reasons for that — there is simply less time for people to enroll.
“I’m very concerned about the final couple of weeks, because we’re not where we need to be to match where we were last year,” says Lori Lodes, executive director of Get Covered America. “The administration is not doing the things they need to to drive enrollment.”
In Wisconsin, VanSpankeren is energized by the high sign-ups but nervous about the next two weeks. The sign-up period ends on December 15. There isn’t much time left.
“It can be stressful because I worry we won’t be able to do enough,” he says. “If I have stress, it’s because there are people we’re not reaching. When I’m at home in the evenings, I feel like I should be doing more. The window is closing.”
How Trump inadvertently kept enrollment higher than expected
When analysts think about why Obamacare sign-ups are so robust this year, they often point to a decision by the Trump administration that had very unexpected consequences.
In September, the administration announced it would no longer pay Obamacare’s cost-sharing reduction subsidies, which lower deductibles and copayments for low-income Obamacare enrollees. This seemed, at the time, like blatant sabotage: cutting off a key source of health law funding.
But that decision set off a chain reaction that, on the whole, seems to have been good for millions of Obamacare enrollees. Counterintuitively, it actually made premiums cheaper.
“I think that decision backfired for Trump and what the administration was trying to accomplish,” Lodes says. “More people are finding coverage they can afford.”
Here’s what happened: When the Trump administration announced it would end cost-sharing reduction subsidies, insurance plans immediately jacked up premiums to offset the lost funding.
State regulators gave insurance plans explicit instructions on how to structure those rate increases. In 36 states, regulators told the plans to put the entire rate increase onto their midlevel silver plans. Other plans — like the more generous gold or less generous bronze — should be left untouched.
This idea was pioneered by California and quickly spread to other states. And it was strategic. The Affordable Care Act tethers the size of premium subsides — the amount that low- and middle-income Americans get to reduce their monthly payment — to the cost of the local silver plans. Higher-priced silver plans meant higher subsidies.
“They recognized that we were facing a lot of uncertainty, and this was a smart way to address this,” Paul Markovich, chief executive of Blue Shield California, told me of this approach earlier this year.
Obamacare enrollees can take those higher subsidies and, in many places, use them to buy a more robust gold-level plan for cheaper — or a bronze plan with a zero-dollar premium. An analysis by the Kaiser Family Foundation shows that there are 1,679 counties where a 40-year-old earning $25,000 can get a bronze plan for free because her subsidy increased so much.
And in some areas, Obamacare enrollees are even qualifying for zero-dollar premium gold-level plans. These plans are more generous and typically have lower deductibles. The health research firm Avalere estimates that 10 percent of low-income enrollees will be able to enroll in these plans with no monthly payment; their federal subsidy will cover the entire free.
This includes Jeffrey Barry, a 57-year-old who owns a small business making signs and trophies. He worked with VanSpankeren, the Obamacare enrollment counselor, to sign up for coverage last Tuesday.
He earns about $25,000 annually and received a $736 tax credit to help pay his premiums. That was enough to make the cheapest gold plan free. But after talking things over with VanSpankeren, he settled on a more expensive plan with a lower deductible.
“I feel good about it,” Barry says of his coverage. “I know I’m covered. I came in here expecting to pay, like, more than $300 a month. And I didn’t have to do that.”
“I worry we won’t be able to do enough. The window is closing.”
The problem with this year’s open enrollment is simple: There’s not enough time to get it all done.
“It’s math,” Donna Friedsam, the executive director of Covering Wisconsin, says. “If we have X number of navigators with X number of hours in the day, we can only do a certain number of appointments. You can’t add more hours to the day.”
It’s true that Obamacare sign-up numbers have so far outpaced last year’s. But it’s also true that this year’s open enrollment period is shorter and poorly funded compared to 2016.
Covering Wisconsin, for example, had its budget slashed 42 percent by the Trump administration. It reduced its number of Obamacare enrollment workers from 17 in 2016 to 11 this year. And it only covers 12 Wisconsin counties, instead of the 23 it worked in last year.
While Friedsam was able to secure some local grant funding, it didn't make up the difference. And fewer navigators means fewer appointments for people who want to sign up for Obamacare — especially in these final weeks, when most enrollees tend to get around to applying for coverage.
“In terms of the pace, we’re exceeding last year. But in terms of putting 12 weeks of enrollment into six weeks? I don’t think we’re going to get there,” Friedsam says.
Aviva Aron-Dine, a senior fellow at the Center on Budget and Policy Priorities, agrees. She served in the Department of Health and Human Services during the Obama administration, and she expects enrollment to decline.
Aron-Dine argues it’s important to focus on the new enrollees; those reenrolling in coverage typically will come back, but it’s those signing up for the first time who will make or break this sign-up period.
To match last year’s sign-up numbers, “new enrollments would have to be up a little more than 50 percent through December 15,” Aron-Dine says. “So far, the new enrollments are only up by about 40 percent.”
Many Trump administration decisions are expected to depress Obamacare sign-ups. The Trump administration has slashed Obamacare’s advertising budget by 90 percent and cut funding for in-person outreach by 70 percent. Unlike the Obama administration, the White House has not used the bully pulpit to publicize the enrollment period’s existence.
Meanwhile, the congressional debate threatens to depress sign-up numbers in the enrollment period’s final days. The Senate passed a bill repealing the individual mandate on December 1, two weeks before the Obamacare enrollment period ends.
That bill is expected to raise premiums and cause millions to lose coverage. And even though it hasn’t been signed into law — and if it were, it would not take effect until 2019 — experts worry that news of the bill could create confusion and depress enrollment.
“There’s the tax bill going on with the mandate being repealed, and there isn’t much advertising,” says Gary Claxton, who studies the Affordable Care Act marketplaces at the Kaiser Family Foundation. “It’s a confusing time, and that will probably mean lower enrollment even though there are a lot of good deals to be had.”
In Madison, sign-ups are moving at a swift pace. When Adam VanSpankeren finishes enrolling Jeffrey Barry — the enrollee who qualified for a zero-dollar gold plan — he turns to his voicemail. Yesterday it completely filled up with messages, and he wants to get back to those people before his next appointment.
“We only get six weeks, so we have this attitude like, ‘You can have all of our time for those six weeks,’” he says. “We want to feel like we did everything we possibly could to get people signed up for health insurance.”
National groups are planning to concentrate their sign-up efforts on the final two weeks of the enrollment period, from now through December 15. But they’re not sure it will break through the swirling news environment.
“We’re having this debate about the tax plan, and it feels like there is no oxygen to talk about open enrollment in the media,” says Lodes, of Get Covered America. “There is so much going [on,] I worry about people understanding that the deadline is almost here.”
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