Health insurers heading into the 2018 Affordable Care Act enrollment season say they're staying laser focused on maximizing sign-ups, even as Republicans remain in disarray and even denial over the seven-year-old health-care law.
A big funding infusion that could help lower Obamacare premiums is in flux just 12 days before enrollment starts. President Trump sent mixed signals this week about whether he'd support legislation funding subsidies for lower-income Americans to get coverage. A compromise measure crafted by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) was embraced by two dozen Senate Democrats and Republicans on Thursday afternoon.
Adding to the array of possible outcomes, a federal judge could rule next week that the Trump administration is required by law to resume the payments known as cost-sharing reductions, in a court challenge filed by 19 states. The Department of Health and Human Services had cut them off last week, saying it didn't have constitutional authority to pay them without an appropriation from Congress.
Yet most insurers have already finalized plan offerings for the six-week enrollment period starting Nov. 1, when 11 million or so Americans are expected to shop on Healthcare.gov and state-run marketplaces. Insurers are more immediately worried about consumer confusion stemming from the debate over halting the CSRs, especially given the administration's recent cuts to outreach and advertising.
"They're focused on open enrollment and how do we ensure in this environment, where we've had so much uncertainty, that consumers know where to get their plans," said Kristine Grow, spokeswoman for America's Health Insurance Plans. "That's kind of job No.1 as we're standing here today."
Marketplace insurers, already struggling over the past several years with heavy losses, have been forced to operate in a deeply uncertain environment even after Republicans abandoned — for now — their efforts to repeal and replace the ACA. Republicans are now polarized over how to approach the health-care law as it remains standing. But they're still trying to attract customers.
Senate Health, Education, Pensions and Labor Chair Alexander has been trying to stack up enough support to pass a bipartisan measure hammered out with Murray, the panel's ranking Democrat. Their agreement would fund CSRs for two years and provide more flexibility to states seeking alternative marketplace approaches. But Trump appeared to tout an alternative reality this week, insisting on multiple occasions that Obamacare no longer even exists.
"It's dead. It's gone. It's no longer -- you shouldn't even mention. It's gone," Trump said in the Rose Garden on Monday.
At a Tuesday White House news conference, Trump called the ACA "virtually dead" and "in its final legs." "There's no such thing as Obamacare anymore," the president said.
The marketplaces certainly aren't dead, as Trump has claimed. But they're not as healthy as in prior years, either. Almost all of the big, publicly traded insurers have bailed under heavy losses, leaving the not-for-profit plans remaining, some of which are the only insurer in the more rural U.S. counties.
When the marketplaces first opened in 2014, three out of four shoppers had access to at least three plans, according to data from the Kaiser Family Foundation. Just six percent had only one plan to choose from. This year, just 58 percent of shoppers had at least three plans to choose from. More than one in five (21 percent) had only one option.
Trump's claims that Obamacare has collapsed -- coupled with months of headlines about dismantling the ACA and the possibility the administration would cut off the CSRs -- mean insurers are encountering even more consumer confusion than usual about their coverage options.
"Whenever our members hear in the media that these things are going away, their immediate thought is 'Oh my gosh, does this affect me now?'" said Melanie Coons, a spokeswoman for Premera Blue Cross, which participates in Alaska and Washington state's marketplaces.
"So we try to think from that perspective: what are our members going to do when all they hear is their subsidies are going away and their costs are going up?" Coons said.
Fortunately for Premera, it had already submitted to regulators a set of premium rates assuming the CSR payments would be cut off. Insurers have said they're generally raising premiums by 15 to 20 percent to account for the loss of the subsidies, which compensate them for discounting costs for the lowest-income marketplace enrollees.
So had many other insurers – including Piedmont Community Health Plan, which covers about 5,000 marketplace customers in Virginia. Neil Heller, the company's vice president of sales and marketing, acknowledged the possibility the payments could be restored, either through court order or congressional action. But present reality must govern the company's actions, given the political volatility, he said.
"Until we hear differently, that's really the only course of action that we can undertake," Heller said. "In the absence of any new information, we are executing on what has been approved and what are the current requirements."
The Trump administration has yet to release final rates and insurer participation for Healthcare.gov. So far, no insurers have decided to exit the marketplaces last-minute, even though they now appear to be losing the subsidies. But all the uncertainty could take its toll in 2019, said Ben Isgur, head of PwC's Health Research Institute.
"You're really kind of sitting there with a lot of uncertainty," Isgur said. "For some insurers who are sitting on the bubble, maybe they haven't been doing very well in the exchanges, this may be the last door for them to exit."
The situation could further worsen after the 2018 enrollment period, which some have described as a perfect storm, with fewer enrollment dollars, a halved timeframe and heightened uncertainty. That's why insurers say for now, they're just focusing on the next two months.
"I think the truest answer from any insurer is we can only approach this a year at a time," Heller said.