In Indianapolis, the director of the state's largest organization helping people find Affordable Care Act insurance had to lay off nine of 13 staff members last month because the federal government had just taken away more than 80 percent of the grant that paid for their work.
In Atlanta, festivalgoers at the annual Pride weekend in mid-October were mystified that members of Insure Georgia had a table set up, because they thought President Trump had gotten rid of the health-care law.
And across Ohio, residents starting to phone a call center for appointments with coaches to renew their coverage are being told that the service no longer exists and that, for help, they should go to a website, a hotline, an insurance broker, a county health department or — if all else fails — their member of Congress.
In the countdown to the annual ACA enrollment season that starts Wednesday, such ground-level disruption suggests that the first sign-up period of the Trump era could be as daunting as any since the fall of 2013, when the federal website HealthCare.gov debuted with such serious defects that consumers trying to buy insurance were stymied for months.
In recent weeks, that website has been taken down for an unusual number of maintenance sessions. Its "window-shopping" version contained an error in calculating subsidies for certain family situations until Friday night, federal health officials confirmed. But the greatest challenges are a messy mix of higher prices and fewer options, plus less time to sign up, less assistance for doing so and far less government promotion of the opportunity to enroll.
The net effect is rampant public confusion, surveys show. And there is a broad expectation that when sign-ups end — on Dec. 15 in all but several states that run their own ACA marketplaces — fewer Americans will have gotten ACA coverage.
Unlike in each of the past four years, federal health officials have issued no forecast of the number of people who will be insured through the law during 2018. When asked whether such calculations have been made internally, they sidestepped the question. The Trump administration also did not provide an expected quarterly update last month on how many people were paying their premiums to keep their ACA plans in effect; the most recent figures available show that 10.3 million people were covered in March.
Outside experts think enrollment will dwindle significantly. Marilyn Tavenner, the president of America's Health Insurance Plans, a main industry trade group, recently predicted a drop of at least 1 million people nationwide from the 12.2 million who signed up for 2017 coverage. A Standard & Poors analysis predicts a drop of 800,000 to 1.6 million.
Whatever backsliding occurs will stem from actions and inactions by an administration whose posture toward the sprawling 2010 health-care law could not be farther from the cheerleading of its predecessor. While President Barack Obama appeared on the popular online comedy series "Between Two Ferns" to talk up the ACA and enlisted celebrities in the effort, Trump has erroneously claimed that the law's marketplaces are dead or "virtually dead."
A narrowed enrollment window — from three months to 45 days — was planned by the Obama administration for the approximately three dozen states that rely on the federal insurance exchange. But the change was to have begun for 2019 coverage; instead, the Health and Human Services Department announced in April that it would take effect for the sign-up period starting Nov. 1.
The other impediments are all Trump administration creations. One of the most significant was the president's long-threatened move this month to cut off billions of dollars in payments to ACA insurers to reimburse them for discounts the law requires them to give lower-income customers.
That action is driving a substantial increase in premiums for the most popular tier of coverage — 34 percent on average, according to an analysis by the consulting firm Avalere Health and 37 percent according to an analysis issued early Monday by HHS. A year ago, congressional Republicans and other opponents of the law expressed outrage over a 25 percent average jump in rates for such "silver" plans.
HHS's report contains a variety of figures that cast marketplace health plans' prices and availability in a negative light. It says that the average yearly insurance premium for 27-year-olds — a desirable age group because risk pools benefit from young, healthy customers — will be $4,932 for the most popular tier of coverage, nearly twice as much as in 2014 before taking federal subsidies into account. It also says that the premium subsidies for which more than 80 percent of ACA enrollees are eligible are increasing from $382 on average to $555, "chasing skyrocketing premiums."
"This data demonstrates just how rapidly Obamacare's exchanges are deteriorating," HHS press secretary Catlin Oakley said in the administration's latest bashing of the law.
Most people shopping for marketplace coverage, which is available to consumers who cannot get affordable health benefits through a job, will indeed qualify for larger federal subsidies to offset the higher prices. Yet many of those who earn too much for subsidies will face sticker shock. And of the states in the federal exchange, slightly more than half will have only one insurer participating — a 21 percent increase from 2016, Avalere found.
As prices have risen and options have shrunk, the administration has lowered the enrollment season's visibility. It slashed federal spending on advertising and other outreach efforts by 90 percent — to $10 million. Grants for "navigators," which guide consumers seeking coverage, plummeted by about 40 percent overall.
No state took a bigger hit than Indiana, which lost 82 percent of its anticipated funding from HHS's Centers for Medicare and Medicaid Services. That is why Julia Holloway, who directs Affiliated Service Providers of Indiana's navigator program, spent her birthday on Sept. 19 cutting the staff paid through that grant. It left her with one full-time and three part-time navigators, along with several funded through other federal programs, who will serve only Indianapolis and two nearby counties instead of the entire state.
At the Palmetto Project in South Carolina, which has cut 62 navigators to 30 and expects further reductions once the enrollment season ends, the residual staff will be working in 17 counties instead of statewide. In the past, navigators have spread the word at the 10-day Coastal Carolina Fair. They've canceled that appearance as well as others for the coming year, including at the "Hell Hole Swamp Festival."
"It's terribly scary," said Shelli Quenga, the project's program director, who is especially worried about what will happen in rural areas, where navigators no longer will be based. She now lacks money to pay mileage for her staff to drive into smaller communities.
Meanwhile, Insure Georgia has eliminated nearly 250 of more than 700 events it had scheduled for before and during the enrollment season. Though it has never done fundraising, the group is scrambling to solicit foundation donations to make up for some of its cut in federal money, from nearly $2.3 million last year to just $329,000. After laying off more than half of its 42 navigators, the group is also racing to train volunteer replacements.
To try to counteract the loss of federal advertising, others are stepping in. Several tech companies with a wide reach among freelance workers — including Fiverr, DoorDash, Care.com, Etsy and Postmates — aim to reach millions of people through in-app messages, proprietary email lists, blog posts and other social media, said Brent Messenger of Fiverr. "Basically, every communications tool these partners have, we're going to throw them at this problem," he said.
Alaska is also trying new approaches. Its Division of Insurance developed a grass-roots campaign with posters that anyone can print. The Juneau Arts and Humanities Council has pledged to place those posters on every public bulletin board it can find.
Across the country, the nonprofit Young Invincibles has broadened its focus beyond young adults. Filling part of the void created by the recent disbanding of another nonprofit group, Enroll America, it is operating an online "Get Covered Connector"for consumers to schedule appointments for help in finding ACA health plans. In addition, it is running digital advertising in 10 states.
The catch is whether people who see the ads or go to the online scheduler then will be able to find someone with whom to meet. The Ohio Association of Food Banks, the only navigator group working in all 88 of that state's counties, found out last month that its grant will shrink from $1.7 million to less than $500,000.
Deciding that "we can't deliver 365 days worth of services with only 29 percent of the funding," executive director Lisa Hamler-Fugitt said the group made the painful decision not to accept the grant. She is trying to persuade libraries to spread the word.
Ohio's only other navigator group had its funding cut by more than two-thirds. It will work just in Dayton and some nearby communities.
"It's sad," Hamler-Fugitt said. Some of the consumers who called for appointments "were pretty devastated. 'What am I going to do? You were always there to answer my questions.' "