The enrollment period on HealthCare.gov was half as long this fall as in previous years, and the Trump administration slashed funds for advertising and outreach. The president also often publicly referred to Obamacare as "dead" or "over."
"Obamacare is finished. It's dead. It's gone," Trump declared on the eve of the 2018 open enrollment period, which began Nov. 1.
Many of the federal moves were not helpful, said Heather Korbulic, executive director of Nevada Health Link, which is operated by the state but uses the federal Health care.gov website.
Korbulic credited the state's Republican governor, Brian Sandoval, with helping to stabilize a shaky market even as insurers stopped selling plans in the state and threatened to leave consumers in some rural areas with no choice of plans. Nevada, in the end, saw a 2.2 percent increase in enrollment this year.
In neighboring Arizona, which also has experienced significant turmoil in its insurance market, enrollment fell 15.6 percent in 2018, one of the largest drop-offs in the country. Arizona relied on the federal government to operate its marketplace.
The marketplaces have primarily served low- and moderate-income Americans who don't get health benefits through an employer or a government program such as Medicare or Medicaid.
They have been buffeted for much of the last year by uncertainty over their future, with insurers in some areas raising rates steeply or exiting markets altogether.
That has been particularly tough for consumers who make too much to qualify for federal insurance subsidies through the health care law.
The law offers subsidies to Americans making between 100 percent and 400 percent of the federal poverty line, or between $12,060 and $48,240 a year.
Those subsidies likely mean that millions of low- and moderate-income Americans will continue to be able to find relatively low-cost health plans on marketplaces in future years as well.
But continued uncertainty about the markets and the disappearance in 2019 of a penalty for not having coverage could push up rates for consumers who don't qualify for aid.
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