Data: Centers for Medicare & Medicaid Services;
Chart: Andrew Witherspoon/Axios
December 14, 2018
The Affordable
Care Act is limping toward the end of what will likely be the worst enrollment
season in its history. That's partly because of the Trump administration's
policies, but there are also other reasons, and they may matter just as much.
Where it
stands: The window to purchase ACA coverage for 2019 closes on Saturday.
So far, the number of people signing up through HealthCare.gov, the main
enrollment portal, is down about 12% from the same time last year — and last
year was down slightly from the year before that.
Why now: The timing of
this enrollment drop has caught some experts by surprise. Yes, the Trump
administration has chipped away at the ACA, but a lot of that was baked into
the system a year ago, when premiums skyrocketed. Premiums are actually lower,
on average, this year, and many people have more plans to choose from.
Here’s why it’s
happening:
Coverage is
still really expensive. Yes, premiums went down this year
for many plans. But they’ve been going up, sometimes by double digits, every
year before that.
- “If you’re not sick or you can’t predict
your health care needs, and predict them to be high, there is not a ton of
incentive to purchase insurance at that cost,” said Chris Sloan, a manager
at the health care consulting firm Avalere.
Unemployment is
low. The ACA’s markets are mostly designed to serve people who don’t
get insurance through their jobs — and that pool shrinks when more people are
working. This probably isn’t a huge effect, Sloan said, but it’s “in there.”
Trump certainly
hasn’t helped, though some of the administration’s changes may not pack as much
punch as you might think.
- The Department of Health
and Human Services has slashed the budget for
advertising and enrollment outreach.
- It has also expanded
cheap, bare-bones “short-term” plans,
which don’t have to cover pre-existing conditions. That may be siphoning
some healthy people out of the ACA’s exchanges.
- Nullifying the individual mandate once
seemed like a death blow, but there’s a growing consensus among policy
wonks that the mandate just wasn’t very effective.
The big
picture: The market for ACA coverage has shrunk, but that shrunken
version is stable.
- Soaring premiums have
likely pushed out the vast majority of people aren’t eligible for help
paying their premiums, unless they’re truly desperate for coverage. People
who do receive those subsidies are largely insulated from premium hikes,
so the market still works just fine for them.
- The ACA is largely relegated now to the
poorest and/or sickest consumers. That slide didn’t start with Trump, but
his administration has leaned into it.
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