Trump’s impact on ACA enrollment: What you need to know

Despite efforts of the Trump administration and the majority of the Republican Congress to repeal the ACA in 2017, it is still the law of the land. These politicians were successful, however, in eliminating one of the act’s mandates via Trump’s Tax Cuts and Jobs Act that became law on December 22. The act states that beginning in 2019, individuals will no longer be required to pay a monetary penalty at tax time if they can’t prove that they have health insurance.

“With the tax penalty eliminated, some younger individuals without health issues are likely to drop coverage or continue to avoid exchange-based coverage,” says Harry Nelson, managing partner, Nelson Hardiman, LLP, a healthcare law firm. “The underlying concept of the insurance exchanges was that coverage would be affordable by forcing the younger, healthier population to buy insurance as a result of the tax penalty and thereby subsidizing the cost for the more expensive and sicker population-although the concept has never been proven.”

Christopher Metzler, PhD, JD, president and CEO, Metzler Enterprises, a global healthcare corporation, says that removing the mandate will cause the Obamacare market to tilt even more toward sicker and older consumers. “That could make insurers think twice about participating in exchanges, especially since they would still be required to cover those with pre-existing conditions and not charge them more based on their medical history,” he surmises.

The Congressional Budget Office (CBO) estimates that eliminating this penalty would increase the number of uninsured individuals by 13 million by 2027, but less than half of that increase-five million-would come from people abandoning their individual and Obamacare plans, says Metzler. Another 5 million would drop their virtually free Medicaid coverage, and 2 million would choose to give up their employment-based coverage.

High enrollment persists

Despite attempts to eliminate the ACA, marketplace enrollment was almost as high for 2018 as it was for 2017. According to CMS, as of December 23, 2017, more than 8.7 million individuals had enrolled for 2018. That figure includes more than 2.4 million new enrollees. In 2017, enrollment was 9.2 million. In some states, consumers can enroll in the exchanges until January 31, 2018, so the total will likely increase.

There could be multiple reasons for high enrollment, experts say. “The debate about the future of the ACA over the course of 2017 generated massive public awareness of exchanges’ value,” Nelson says. “Americans watched nine Republican senators vote against their own party to block a Medicaid rollback, and then watched three vote to block the repeal. Many people who expressed opposition to Obamacare felt that the alternative was much worse, as some of their loved ones with health conditions might not be able to get necessary care. All of this led to a successful open enrollment.”

Metzler says the widespread availability of "zero dollar" Obamacare plans likely boosted enrollment for 2018. “Most people who buy coverage on an Obamacare exchange qualify for federal subsidies that reduce their premiums, and more people than ever were able to buy a plan that will personally cost them nothing in premiums this year because of that financial assistance,” he says.

CMS also took steps to encourage enrollment for 2018, which most likely played a role. According to CMS, while HealthCare.gov was scheduled for a total of 60 hours of regular maintenance during open enrollment, the site only used 21.5 hours-so there was little interruption for shoppers.

“Our goal was to empower patients across the healthcare delivery system and make sure that Americans who chose to enroll in the exchanges had a good customer experience while making enrollment more cost efficient, and the results show that we accomplished our goal,” said CMS Administrator Seema Verma, citing data from the call center showing that the consumer satisfaction rate remained at an all-time high-averaging 90%-throughout the entire open enrollment period. That’s up from 85% the previous year.

“Verma deserves credit for rising above politics and trying to let the system work,” Nelson concludes.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.