From coast to coast, the fifth annual season for Americans to buy insurance under the Affordable Care Act opened on Wednesday with scattered reports of crowds, some technical difficulties and a public confused as never before by the political turmoil surrounding the law.
The federal website HealthCare.gov said "2018 Open Enrollment is here," as both it and state insurance marketplaces attracted the year's first customers. They came despite a 90-percent reduction in federal advertising about the sign-up window and a decision by the Trump administration to send advance emails about enrollment to millions fewer Americans than in past years.
The emails went only to people with current health plans through marketplaces created under the law, leaving out most of the names in a database of about 25 million consumers who once had such coverage or at some point explored the federal website HealthCare.gov.
A set of internal documents obtained by The Washington Post also shows a sharp change in the tone and content of the messaging. Absent from the emails is the theme of health plan affordability — which focus groups, surveys and other research during the Obama administration revealed is most powerful in motivating people to sign up.
Unlike the past four years, when the previous administration marked the arrival of each ACA enrollment period with considerable hoopla from the White House on down, the Health and Human Services Department limited its statements to two low-wattage tweets Tuesday afternoon and Wednesday morning.
For his part, President Trump ignored the opening day. His only reference to the health-care law was a tweet urging Congress to repeal an ACA centerpiece — the requirement that most American carry health coverage — as part of a federal tax-cut bill.
The administration's persistent determination to undercut the law's insurance marketplaces have prompted widespread predictions that fewer Americans will end up with coverage when the enrollment periods ends on Dec. 15 in most of the country.
Nonetheless, plenty of people in certain states appeared eager to register Wednesday at places still offering in-person assistance even though federal health officials slashed grants to the groups that provide such guidance.
Randy Lange, a goateed 63-year-old retired cowboy from Scott City, Mo., sat in a rhinestone-button shirt and mud-splattered boots across the desk from a veteran "navigator" named Gina Harper. Lange, who has long been uninsured, ignored stabbing chest pain while caring for his wife of nearly 20 years. After she died in February, he went to a free clinic screening where he found out that he had an aortic aneurysm.
"I don't want to get up in the morning," Lange told Harper, "but my buddies are on me like white on rice trying to get me to take care of this." Harper typed his income from Social Security and a small pension into HealthCare.gov to start his enrollment. "That's what buddies are for," she said.
In Maryland, dozens of people had been in line to enroll when the doors of a Silver Spring health office opened at 8:30 a.m. By noon, 145 had signed in for appointments, the downstairs waiting room was standing room only, and organizers were looking for more chairs. School bus driver Aneeta Malcolm, 54, of Takoma Park, was willing to wait several hours to enroll. She said she previously had ACA coverage through Kaiser Permanente but was kicked off in August over confusion about her federal subsidies and whether she had submitted the correct forms.
Malcolm, who has diabetes, has been cobbling medicine from friends and "trying everything to stay healthy," she said. "I couldn't wait for this day to come."
At Connect for Health Colorado, the staff had by midafternoon increased their projections of calls for the day from 2,700 to 4,000. The volume of calls was running ahead of the past two years, and the nearly 650 people who had created accounts on the federal website was already about one-third greater than for the entire first day last year.
And Access Health CT received nearly 5,000 calls by late afternoon and had roughly 1,000 people on its website at any given time, said Juliet Manalan, press secretary for Connecticut Lt. Gov. Nancy Wyman (D).
Other sites were quieter. At a table on the campus of the University of Southern Mississippi in Hattiesburg, a 32-year-old man with asthma who renewed his coverage in 15 minutes with a navigator was the only enrollee by the afternoon, though other people had picked up brochures.
Yet in at least three parts of the country, insurance seekers were thwarted by HealthCare.gov, which has largely worked well since the initial 2014 enrollment season when serious defects stymied consumers for months.
Elizabeth Alcorn, 56, of Charlottesville, was ready to fill out her first application for an ACA health plan since selling her dental practice this year because of worsening arthritis. But soon after she began, a box popped up on her computer screen saying her identify could not be verified. She made several phone calls for help and, in the end, was told the only way she could shop for plans was to mail two forms of identification for both her and her husband to an address in Kentucky. And then wait.
"I'm very nervous," Alcorn said. "I'm older, my husband is 61, insurance is costing us $2,000 a month, and it's killing us," she said. "I was really excited we could get something cheaper, and I really wanted to see the numbers."
In Houston, a 63-year-old retired chemical engineer named John May tried twice to start his application but got a screen saying, "Please wait." He eventually was locked out. "This is very familiar to someone who tried it during the terrible days of the initial rollout," he said.
In the absence of a robust federal promotion campaign, Democratic members of Congress, activists, local officials and several celebrities launched a major push Wednesday at events across the country. In Nashville, Mayor Megan Barry (D) was to join musicians Bill Lloyd, Ashley Cleveland, Gary Nicholson and Todd Sharp at a "Health Care Rocks" event. And nationwide, supporters of the law are tweeting with the hashtag #GetCoveredNow to spread the word that enrollment is underway.
Still, like many of her counterparts in the dozen states that run their own insurance marketplaces under the law, the head of the DC Health Benefit Exchange Authority keeps worrying over whether consumers will know to sign up.
In previous years, about half of its customers found their way to dchealthlink.com by first going to HealthCare.gov and being transferred once they typed in where they live. With so much less federal effort to generate attention, executive director Mila Kofman said, she is not sure that will again happen.
Moreover, administration officials have said that HealthCare.gov will not always be available on Sundays during the 45-day period. Late Wednesday, they announced four separate kinds of maintenance scheduled for between four and 12 hours this coming Sunday.
Tony Rehagen in Cape Giradeau, Mo., and Ashley Cusick in Hattiesburg, Miss., contributed this report.