The Affordable Care Act (ACA) appears to have survived last year’s bumpy road, obtaining enrollment figures close to what it had the previous year.
However, it’s unclear whether Obamacare can sail through this year’s choppy seas and achieve the same level of enrollment for 2019.
Among other things, the individual mandate is now gone, and Republicans are talking about getting rid of the employer mandate, too.
In addition, there are concerns that insurance companies will drop out of the ACA marketplaces later this year, leaving fewer insurers for consumers to choose from next year.
And there’s the unrelenting criticism of Obamacare that comes from the White House.
“I think next year could be a coin toss,” Kurt Mosley, vice president of strategic alliances for Merritt Hawkins, a health consultant, told Healthline. “But this year showed that Obamacare is not dead.”
“I think the enrollment shows this is an important program people want,” added Dr. Parveen Parmar, the California field director for Doctors for America. “However, I am concerned that the numbers will be down in 2019.”
What 2018 numbers show
The final ACA enrollment figures for 2018 won’t be known until the Department of Health and Human Services (HHS) releases its final report in March.
However, analysts at the National Academy of State Health Policy last week unveiled their preliminary estimates based on state reports.
Those numbers show that almost 11.8 million Americans signed up for health insurance programs using the ACA marketplaces.
That was down about 3 percent from the 12.2 million who signed up in 2017.
Enrollment in the 39 states that use the federal government’s ACA website declined about 5 percent, while the marketplaces run by individual states were up about 0.2 percent from 2017.
An HHS representative told Healthline the relative stability in the marketplaces was due in part to the “cost-effective and smooth experience for consumers” who used this year’s ACA website.
Representatives of the health industry said the enrollment shows the importance of having coverage.
“Americans should have coverage they value and these results show that people recognize how important coverage is for their health and financial stability,” Kristine Grow, a spokesperson for America’s Health Insurance Plans, told Healthline in a statement.
The academy analysts noted that about two-thirds of the state-run marketplaces showed increases in enrollment.
The states that marketed their plans the most aggressively saw the biggest increase.
Among them were Washington at 7 percent and Rhode Island at 12 percent, the highest increase in the nation.
HealthSource Rhode Island director Zachary Sherman told the Los Angeles Times that the state’s success was due to its ability to manage its own market as well as working with insurers to control premiums.
California actually saw a 2 percent drop, but it still has the highest enrollment in the country with 1.7 million participants.
State officials told the Times they were pleased with the number of new enrollees as well as the mix of participants.
“It’s all about marketing,” said Mosley. “The states marketed the product better.”
What lies ahead this year
While Obamacare supporters breathed a sigh of relief at this year’s numbers, there are a number of obstacles facing the system this year that could make it difficult to match these figures again in 2019.
The first is the elimination of the individual mandate, a provision that was included in the Republican tax overhaul approved in late December.
Experts have told Healthline that eliminating this requirement — that everyone purchase health insurance — dilutes the pool of ACA participants.
They said without a mandate, healthier individuals may not sign up for insurance coverage, leaving insurers with a larger percentage of less healthy, more costly customers.
Mosley noted that the ACA pool really should be closer to 30 million to make it function properly.
“The pool needs to be that to make it work and we’re not getting there,” he said.
Mosley and Parmar said they fear that a lopsided pool could persuade insurers to drop out of the ACA markets.
Mosley said insurers will probably be checking the ACA market every quarter to see if it’s worth staying in.
There might be one incentive to stay coming from, of all places, the White House.
In his proposed budget, President Trump has included $812 million in fiscal year 2019 for so-called “risk corridor payments.” These are reimbursements to insurance companies participating in the ACA marketplaces.
In addition, some Republicans are now talking about eliminating the Obamacare employer mandate, which requires larger companies to provide specific minimum health insurance to their workers.
Rep. Kevin Brady (R-Texas), chairman of the House Committee on Ways and Means, said he’d like to either delay or repeal this mandate so companies don’t face fines and other penalties.
States are also making attempts to get around some Obamacare requirements.
One of them is Idaho, where the Republican governor has issued an executive order that allows insurance companies to sell plans that don’t meet ACA requirements.
However, HHS Secretary Alex Azar told Congress this week that he’d enforce Obamacare regulations in any state that was violating the law.
All this uncertainty does make for a shaky future for Obamacare.
Parmar, who works at Los Angeles County Hospital, said facilities such as public hospitals and emergency rooms will be the first places to feel the impact of fewer people having insurance.
Mosley said the uncertainty may persuade more people to start health savings accounts.
He added, however, that unless Republicans come up with other options, consumers may keep returning to the ACA marketplace.
“Unless there is an alternative,” Mosley said, “people are going to need coverage.”