The Ongoing, Quiet Repeal

When Obamacare became law, many people didn’t know how it worked. Eight years later that’s still the case. As of February, one-third of Americans were unaware that it was the same thing as the Affordable Care Act.

The effect was most pronounced among people under 30—which does not bode well for young people knowing how, when, and where to sign up for health care under the law.

People of all ages will sign up during open enrollment, which this year will take place between November 1 and December 15—a period that President Donald Trump’s administration cut in half compared with last year. Citizens are especially unlikely to know about this change, since the administration also cut the advertising budget for enrollment this year by 90 percent.

Instead, the Department of Health and Human Services has produced a series of YouTube videos that do just the opposite, warning people against the process. The series is called Families Burdened by Obamacare. In one, an exasperated man from Fort Worth, Texas, complains that HealthCare.gov is “wholly inadequate” and extremely difficult to use. “It was wholly frustrating to try to comply with the mandate from this government,” he continues. “All the while, I’m saying ‘What’s wrong with the free enterprise?’”

View counts in the 1,600 range suggest that these videos have not had significant viral impact, but defunding enrollment is potentially a big deal. The looming sign-up period will be the first to happen under leadership that has spent years insisting that the health-care system will “fail.” These new, quiet changes—relatively small on the scale of health-care spending—could determine the future of American health care. After the defeat of the fourth Republican health bill this week, the Affordable Care Act is here to stay, at least until 2018. And as attention turns to working within the current system, the word that keeps coming up among health advocates and policy experts is sabotage.

In addition to cutting this year’s open-enrollment period from 90 days down to 45, administrators from the Department of Health and Human Services (HHS) announced in a webinar Friday that there will be long service interruptions—“planned HealthCare.gov downtime”—for 12 hours on five of the six Sundays. This raised eyebrows among health advocates.

“This is outrageous,” wrote Brad Woodhouse, the campaign director for Protect Our Care. “It’s clear that even if Republicans continue to fail to repeal the Affordable Care Act, the Trump administration will go to any lengths to sabotage the law.”

Funding for in-person outreach has also been cut in half, from $62.5 million to $36 million. On Wednesday, BuzzFeed reported that HHS regional directors have been instructed not to participate in state-based events promoting open enrollment.

It does not require speculating about anyone’s motives to see a pattern emerging. If the object were to save money and develop a sustainable pool of insured people, enrollment would be a major priority. The more people who sign up, the lower the cost to everyone and the less likely for markets to enter the infamous “death spiral.” So money has always been invested in the sign-up process, namely via ads (radio, TV, social media) and in-person assistance. Officials estimated that the Obama administration spent $100 million on advertising last year, and this year HHS will decrease that to just $10 million. For comparison, that’s only one-fourth as much as Warner Bros. spent marketing the Entourage movie. And that objectively did not work.

HHS framed these cuts as money-saving ventures. Though in health-care dollars, the millions saved convert to almost zero: The federal health-care budget is over $1 trillion. What’s more, investing in enrollment is itself cost-saving. People who use a lot of health care are more likely to be vigilant about signing up, but getting younger, healthier people enrolled makes the system sustainable. That means getting in front of them and bombarding them with reminders—possibly even on Snapchat or using virtual reality, or wherever it’s best to reach listless millennials.

But instead the administration is disinvesting to such a degree that the only logical outcome will be a decrease in enrollment and a skewing of the participant pool toward costlier, sicker people. This means higher premiums and insurers leaving the marketplace—facts which Trump recites enthusiastically at his rallies. The more people who miss the deadline, the more end up using emergency departments as primary-care offices.

Officials from HHS responded to my inquiry as to why the changes to enrollment are happening with a link to a vague statement, and they’ve been similarly unclear in anonymous press briefings. In at least one of these briefings, they asked to be referred to as “Health and Human Service Officials one, two, and three.” Centers for Medicare and Medicaid Services spokesperson Nicole Black responded to me with a short email that included the following unattributed quote, which she said can be credited to “a CMS spokesperson”: “Maintenance outages are regularly scheduled on HealthCare.gov every year during open enrollment. This year is no different.” (We didn’t agree beforehand that I would withhold names or receive information “on background,” a term which typically means a journalist won’t directly cite the source of information.)

This year does seem different. If the site is indeed down for hours on those five Sundays—outages that would make up 6 percent of the enrollment period—that would mean an increase from 0.1 percent downtime the year prior, according to a 2016 report to Congress by the U.S. Digital Service.

Black offered the caveat: “On background/not a direct quote: The duration of the outages that were listed in the notice are the maximum amount of time allowed for the maintenance; actual outage times could be shorter.” I said it would look strange to attribute a quote like that to an anonymous source and asked if anyone in the department could put their name on it, since it’s not a guarantee of anything. She said no.

The implicit philosophy conveyed by the changes so far is consistent with the lack of transparency in conveying them. And both seem designed to shore up the insistence by the president on many occasions that Obamacare is “failing,” and that “the best thing politically is to let Obamacare explode.”

(In that spirit, other changes could include HealthCare.gov changing its font to Wingdings. On Wednesdays and every other Thursday, it could be accessible only to people named Dave. HealthCare.gov could be outfitted with “retro 2013 functionality.”)

With Graham-Cassidy defeated, the administration does have the option to change its tack, acknowledge defeat, and unify to optimize the health-care system by getting people enrolled and making the law work. Though this would likely involve finding new ways of financing Republican reelection campaigns. The president indicated no such pivot this week, insisting that the law would be repealed. And in their concession statement on Tuesday, the authors of Graham-Cassidy said, “For the American people, when it comes to Obamacare, the worst is yet to come.”