Signing Up for Obamacare After Trump Proclaims It 'Dead'

The difficult job of an insurance-enrollment counselor in a time of tight budgets and confusion

For the six weeks leading up to December 15, the work calendar of Laura Holdrege, a health-care navigator in Salt Lake City, Utah, was booked solid. She and her colleagues at the Utah Health Policy Project worked overtime helping people sign up for insurance on Healthcare.gov.

Because of cuts imposed by the Trump administration, other navigator organizations in the state had reduced their ranks and were sending their clients to Holdrege and her team. She warned some that she could squeeze them in, but they would have to share their appointment with someone else. Toward the end, she ran out of appointment slots and began simply referring people to Healthcare.gov.

When they did sit down for their appointments, some people would ask, “Obamacare is gone, right?”

So went the first full Obamacare open enrollment under President Trump. It was surprisingly strong, with 8.8 million people signing up during the six-week period that ended last week. That’s 96 percent of the total during last year’s open enrollment, which was twice as long.

“These numbers debunk that theory that people don’t want it, that it’s not a good product,” said Emily Barson, a senior adviser with the national group Get America Covered, which assisted the cash-strapped navigators in spreading the word about open enrollment.

It’s also somewhat surprising, given the Trump administration’s many efforts to undermine and besmirch the law that’s named after the president’s predecessor. It slashed funding for advertising about the open-enrollment period and cut grants to navigators. It also halved the enrollment period and shut down Healthcare.gov, the site people use to buy insurance, on several Sundays during open enrollment.

In October, Trump announced he would end payments to insurers, the so-called cost-sharing reductions, that help cover expenses for low-income customers. Without them, some insurers threatened to raise their rates or pull out of the Obamacare marketplaces. That same day, he signed an executive order encouraging the sales of skimpier insurance plans, which could undercut the more robust plans sold by Obamacare.

“Obamacare is finished. It’s dead. It's gone,” Trump said in October—just weeks before open enrollment for Obamacare began.

“That kind of misinformation is very difficult to combat in a state where most people voted for the president and tend to believe the president first,” said Shelli Quenga, the director of programs at a South Carolina navigator organization called the Palmetto Project. To persuade people that Obamacare was not quite dead yet, she would gently walk them through the “window shopping” feature of Healthcare.gov, where they could see plans that were available.

But with half as many navigators as the Palmetto Project could afford in past years, it was tough. Quenga and her colleagues simply couldn’t reach some rural parts of the state. “It makes you sad for people who need information and you know just aren’t going to get it based on where they live,” she said.

Interviews with health-care navigators across eight states this week revealed a frenzied time in which navigators were forced to do more with less. People came in confused about whether their insurance would be cut off midyear. Some received letters quoting premiums that were much higher than they turned out to be. Still, almost all said they saw enrollment figures that were better than expected. (Eleven states have extended deadlines for enrolling; none of the navigators I interviewed were based in those states.)

Before open enrollment starts, navigators go to community events and phone bank to raise awareness about the Affordable Care Act. In some places, they also place radio, TV, and social-media ads. Much of that advertising effort was reduced this year, some said, because of the cuts to their grants.

Holdrege, in Utah, doubled down: She and her colleagues made flyers and spent part of September calling back past clients to tell them to come in during the new, 45-day period.

Others simply pared down the number of counties they worked in, or laid off staff. This year, the Utah Health Policy Project’s budget was cut by 60 percent just a few weeks before the start of open enrollment. “It’s a school superintendent looking at the school year, and not knowing how many teachers he can hire,” Matt Slonaker, the director of the Utah Health Policy Project, said. He said they were told their budgets were cut because of performance, which he found puzzling because they thought they had been performing well. They ended up cutting their navigator ranks in half.

I asked one director of a Missouri program, Catherine Edwards, why her organization opted to remain in the navigator program this year, despite seeing a 62 percent budget cut and the attendant layoffs and gutted social-media presence. Her organization, which otherwise focuses on senior citizens, could have simply sat out open enrollment.

“I tell you what,” she said. “Our case managers and outreach workers are dedicated to helping people in their community live better lives. If we could give people more access to health care, hopefully when they do age, they’ll age more healthily.”

After enrollment starts, navigators guide people through the process of signing up for health insurance, either through in-person appointments or on the phone.

Livbier Pearson, a navigator in Arizona, saw a smaller budget cut, but her team nevertheless worked Monday through Saturday, from 8:30 a.m. to 7 p.m. on some days. Her phones had 50 or so voicemails almost the entire six weeks, she said. She and several navigators said they ultimately couldn’t fit in everyone who needed in-person help.

Some people mistook Trump’s ending of the cost-sharing reductions as an end to the tax credits that individuals receive for buying health insurance. Meanwhile, because of a strange quirk in how the law works, the end of the cost-sharing reductions actually made the more generous “gold” plans cheaper this year than skimpier “silver” plans, in some parts of the country.

Leslie Bachurski, a director with the navigator group Consumer Health Coalition in Pittsburgh, had explained to her enrollees that the different metal-tiered plans are like rings—a gold ring is nicer than a silver ring. But she then struggled to explain why something better might cost less than something worse. She settled on, “just for this year, the gold ring is on sale!”

Several navigators said insurers had sent letters to customers quoting them wildly high prices for renewing their policies, potentially because they had overcompensated for the end of the cost-sharing reductions. For some, this created a chilling effect—a needless one, since the prices some of these individuals ultimately paid were much lower.

Sandy Dimick, the director of Get Covered Tennessee in Nashville, forwarded me a letter quoting a woman a monthly premium of $1,242. She said the woman actually paid nothing for her plan when she entered her information into Healthcare.gov. Another letter quoted $1,045 for a policy. That person got a silver plan whose actual premium was also $0, with a $20 deductible.

There was also confusion among people who fell into the Medicaid gap—a salary range, in states that didn’t expand Medicaid, in which people qualify for neither Medicaid nor tax credits to buy insurance. Navigators would try to problem-solve with them, Quenga said, asking if they could visit a low-income clinic or ask someone else to claim them as a dependent.

Though news coverage of the Affordable Care Act throughout the year often made repeal seem like Lazarus—rising from the dead over and over again—it also seemed to inadvertently publicize the law. Slonaker, in Utah, said that if open enrollment had been longer, his organization likely could have enrolled more people. “All this talk about health care made people interested in finding out what the alternatives were,” he said.

Even before the enrollment figures came out, navigators said their phones were ringing off the hook. They said most customers were happy with their plans and their cost, likely because they were getting hefty tax credits to buy them. (Many of those who didn’t qualify for the tax credits faced “a terrible reality,” one Iowa navigator told me, of premiums above $1,000 a month.)

Dimick, in Tennessee, said some of the navigators worked six- and seven-day weeks. One navigator was packing up his desk at a public library, where he had been enrolling customers, late at night on the final day of open enrollment. A woman came running in. She had been driving by the library when an NPR report about open enrollment came on.

“She thought she still had until the end of January,” Dimick said. He enrolled her in a plan with a very low premium. “She started crying and said, ‘Oh my gosh, to think that I almost missed this.’”