Trump says Obamacare is dead. Here's how states are keeping it going

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Myles Ma, CPFCSenior ReporterMyles Ma, CPFC, is a certified personal finance counselor and former senior reporter at Policygenius, where he covered insurance and personal finance. His expertise has been featured in The Washington Post, PBS, CNBC, CBS News, USA Today, HuffPost, Salon, Inc. Magazine, MarketWatch, and elsewhere.

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New York should have been well insulated from the political cloud hanging over the Affordable Care Act (ACA). The state runs its own marketplace (NY State of Health) and, in the wake of deep cuts at the federal level, elected to maintain its advertising spend at around $14 million.

That advertising campaign, which includes TV, radio in some areas, print, digital and social media, sends the message the marketplace is open for business, despite what people may hear on the news, said Donna Frescatore, executive director of NY State of Health.

The state is also putting plenty of boots on the ground: Before and during open enrollment, 5,500 navigators are heading to supermarkets, pharmacies, community festivals, food pantries and college campuses around the state to help residents sign up for healthcare.

Despite New York’s efforts, the uncertainty around the ACA has had an impact. Repeated attempts to repeal the ACA have put upward pressure on premiums, Frescatore said. While the state has 12 insurers offering individual plans, rates are increasing an average of 13.9%.

New York's experience is, in many ways, a mild version of the chaos insurance departments and marketplaces across the country have experienced as they try to carry out a law the controlling party and current administration in Washington do not support.

"Many of the insurers were leery of the efforts in D.C. to overturn the ACA, especially because of the uncertainty it created," said Stephanie Marquis, a spokeswoman for Washington state’s insurance commissioner Mike Kreidler. "It also doesn't help to have the president claiming the Affordable Care Act is gone or dead."

A long year

The ACA has faced political opposition since its inception. House Republicans voted to repeal or amend the law, also known as Obamacare, more than 50 times since it was passed in October 2009. But Donald Trump’s victory in the 2016 presidential election put the law’s future in serious jeopardy.

Many state health officials said the threat made insurance companies skittish about offering plans on the exchange. Republicans have tried (unsuccessfully) to repeal Obamacare five times since Trump took office in January. Meanwhile, the administration has steadily made decisions seemingly designed to hurt exchange signups, including shortening the open enrollment period and the cutting $90 million from the federal marketplace’s advertising budget.

NY State of Health is spending $14 million on ACA advertising.

Mackay Moore, chief insurance examiner for the life and health section of the Nevada Division of Insurance, fielded questions from insurers about what would happen if any of the proposals to pare down or eliminate the ACA came to pass. In response, Nevada Insurance Commissioner Barbara Richardson's stance has been that as long as the ACA remained law, the state would enforce it, Moore said.

The Department of Health and Human Services did not immediately respond to request for comment on whether Trump’s stance or actions on the ACA made it harder on states as they set up marketplaces for 2018.

But, a day ahead of the federal deadline for insurers to submit rates for, residents of 44 counties around the country were at risk of having no insurance plans available to them on the marketplace, according to the Kaiser Family Foundation. Twenty of the counties were in Ohio, where the federal government runs the exchange.

Restoring coverage was one of the largest challenges of the year, said Chris Brock, a spokesman for the Ohio Department of Insurance. In July and August, the department negotiated with five insurers who ultimately agreed to cover the 20 counties. The downside is rates in Ohio ended up an average of 34% higher in 2018 for individual plans.

Washington, like New York, fully embraced Obamacare. The state expanded Medicaid and created its own exchange. But it also faced the prospect of two bare counties for the first time this year.

"We worked really hard, reaching out to the insurers to see if one would be willing to pick up these counties," said Marquis, the spokeswoman for the state insurance commissioner. "Ultimately, we were successful — for this year. But we don't know what will happen next year — and insurers will file their plans for 2019 as soon as May."

An imperfect law

Not all states attribute their marketplace woes to the Trump administration and current political climate. Problems in some Obamacare marketplaces precede Trump’s year in office. In 2016, premiums were on the rise and health insurers were already leaving certain markets.

In April, when it looked as if Iowa would have no offerings on the individual market, the state filed for a waiver from Obamacare rules. The "Stopgap Measure" would have provided premium credits to residents based on age and income and a reinsurance program for high-cost policyholders. But Doug Ommen, insurance commissioner for Iowa, scrapped the plan after it seemed unlikely the Trump administration would approve it in time for enrollment.

"Unfortunately, Obamacare's waiver rules are so inflexible that the Stopgap cannot be approved under terms that would be workable for Iowa," he said, before urging Congress to repeal the law.

Montana Insurance Commissioner Matt Rosendale, too, said the ACA limits what states can do to keep insurance costs down.

A last-minute cut

This year has been a roller coaster ride for state insurance departments, who were thrown another curveball less than three weeks before open enrollment was set to begin: Trump announced plans to stop paying insurers cost-sharing reduction subsidies (CSRs). These subsidies help insurers give copay and deductible discounts to low-income people. It’s widely believed uncertainty over the payments — and their subsequent end — exacerbated rising Obamacare premiums. Trump had been threatening to end the payments for months, calling them a “bailout” for insurers.

Some state officials had anticipated the move. The New Jersey state insurance department, for example, told insurers to file with the assumption the CSRs would be cut, said Kevin McArdle, a spokesman for Horizon.

And, the day before Trump’s announcement, California’s state exchange announced it would require insurers to add a surcharge to premiums for silver-level plans. The value of premium tax credits is pegged to the cost of silver plans, so the rise in price actually meant many people received more help paying for individual plans.

Other states launched contingency plans. Leading up to open enrollment, Washington had asked insurers to file two separate sets of rates: one set assuming they would be cut, and one assuming they would continue.

"Now that President Trump has stopped the funding, we've directed insurers to use the higher set of rates," Marquis said. Officials also asked the companies to apply the higher rates only to silver plans, she added.

Pennsylvania also loaded increases on its silver plans, after discovering premiums were set to increase by an average of 30.6%. They would only have gone up 7.6% if the CSR payments continued, Acting Insurance Commissioner Jessica Altman said when she announced the rates.

“The president’s deliberate action and Congress’s failure to appropriate these funds despite repeated requests is forcing large rate increases on consumers in Pennsylvania and around the country, but my department is doing what we can to help our consumers understand their options and hopefully shield them from these rate increases,” she said.

Altman said increased tax credits may make more generous gold plans more affordable for people who normally buy lower-level plans. She also encouraged people who don't qualify for subsidies to shop off the exchange.

Montana’s Rosendale took insurers to task for raising rates in his state even though they had told him rates would stay steady if the payments stopped.

"The companies will now have to answer to their customers for their reversal in that assurance," he said.

Shopping for a health plan in 2018

Despite the slings and arrows the ACA has suffered this year, the exchanges open Nov. 1 for the fifth year running. With premiums rising and the IRS announcing a crackdown on people who don't sign up, it's especially important for people to be discerning shoppers this year.

If you don't get health insurance through your employer or another government program you should still shop the marketplace to see what options are available to cover you and your family. Premium tax credits are available to people who make between 100% and 400% of the federal poverty level and get a health plan through the marketplace. If you don’t qualify for a subsidy, it’s a good idea to check out plans off the exchanges. Insurers have more flexibility when it comes to structuring these plans so they might be more affordable.

Wondering where to get solid information on shopping for health insurance? We’ve got more resources on Obamacare 2018 in our HealthGenius section.

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