Despite facing repeated blows from President Donald Trump, enrollment in the federal Affordable Care Act's health insurance exchange is underway, and coverage for thousands of Louisiana residents is on the line.
"It's important that people sign up before December 15, and they get the assistance they are eligible for under the Affordable Care Act," Insurance Commissioner Jim Donelon, a Republican who has been in his statewide elected role for more than a decade, said in a recent interview.
Open enrollment in the exchange, formally known as the Health Insurance Marketplace and accessed through healthcare.gov, started Wednesday. The 45-day enrollment window is about half the time given in previous years – a decision made by the Trump administration as it has chipped away at predecessor Barack Obama's signature healthcare law.
The exchange is largely built for people who don't receive health care coverage through their employers and have to seek out their own plans. The service industry – bartenders, hair dressers, casino and hotel employees – freelancers and the self-employed are among those who have most often relied on it.
About 150,000 Louisiana residents received health insurance through the marketplace last year.
People who earn less than 400 percent of the poverty level, about $48,000 for a single adult or $98,000 for a family of four, can receive tax credits to subsidize the costs of their premiums. More than 85 percent of Louisiana enrollees last year earned below that threshold and received assistance.
Additionally, enrollees below 250 percent of poverty level, about $30,000 for a single person or $61,000 for a family of four, can qualify for further incentives, including copay assistance, if they enroll in "silver" plans. More than half of the Louisiana residents who signed up through the exchange qualified for those additional subsidies.
"It's substantial," Donelon said. "Everybody should get it – it's in everybody's interest."
Louisiana has historically had a high rate of uninsured residents, but the number has been on the decline since the Affordable Care Act went into effect in 2010.
About 10.3 percent of Louisiana residents were uninsured in 2016 – down from 11.9 percent the previous year and 16.6 percent in 2013, according to U.S. Census data, but it remains higher than the 8.6 percent national average.
Health care advocates say they worry that months of health care debates that have dominated Washington politics have muddied the waters, leaving people confused over the status of the Affordable Care Act.
Trump, citing ballooning premiums and shrinking options, campaigned on repealing and replacing the health care law. Most Republicans in Congress, including members of Louisiana's delegation, have liberally shared horror stories of exorbitant health care costs that have followed the ACA's implementation.
In May, Trump and U.S. House leaders held a celebratory news conference after the chamber passed the American Health Care Act, their version to repeal and replace the Affordable Care Act. The U.S. Senate never approved the House proposal, largely scrapping it after multiple unsuccessful attempts to pass its own legislation.
That means that, despite many efforts, the ACA, commonly called "Obamacare," is still the law of the land.
"So many people think the ACA has been repealed," said Brian Burton, the state director of Navigators for a Healthy Louisiana, a group tasked with providing outreach, education and free enrollment assistance to marketplace consumers under the health care law. "There's a lot of confusion around that right now."
Those who don't sign up for coverage face penalties of $695 per adult and $347.50 per child or 2.5 percent of household income, whichever is higher.
"Folks won't realize that they will have to pay a penalty for not having insurance until they go to file their taxes," Burton said.
Under the ACA, the navigators are identified as a key resource to helping guide people through their often complex health insurance needs.
This year, Blue Cross Blue Shield of Louisiana and Vantage Health Plan are offering 40 plan options on the exchange in Louisiana. All plans on the exchange cover comprehensive benefits, including doctor's visits, preventive care, hospital stays and prescriptions but vary by cost and other features.
U.S. Sen. Bill Cassidy met with White House officials on Monday to talk about ongoing efforts to repeal and replace the Affordable Care Act.
Burton and the other Louisiana navigators are having to work with less this year – much less. The Trump administration slashed Louisiana's funding for navigators by 80 percent. It went from slightly more than $1.5 million last year to barely $300,000 this year.
Thirteen navigators had to be cut, leaving just five for the entire state, and none in north Louisiana.
"It's going to be challenging for folks," Burton said.
The federal Center for Medicare and Medicaid Services issued a bulletin explaining that the cuts are directly tied to past performance and meant to weed out ineffective and costly programs.
"These performance-based adjustments will ensure accountability within the navigator program and avoid rewarding grantees that have failed to meet their performance measures," CMS said in a news release announcing the changes
Louisiana's navigators were given no notice that they would have to meet performance benchmarks to prevent funding cuts, Burton said.
"We always looked at our state's uninsured rate as a benchmark for success," he said.
Burton said Louisiana's navigators tended to provide information and resources but allowed people to complete the enrollment process on their own, which means that work was not counted under the calculations CMS used to determine cuts.
"If we had ever known that this was going to happen, we would have changed the way we did things," he said.
Additionally, the navigators also evaluated people for Medicaid, the health care program for the poor that Louisiana expanded last year to cover people who make up to 138 percent of federal poverty level, which is about $33,900 for a family of four or $16,643 for a single person. The navigators didn't get credit for any of the more than 446,000 people who have enrolled in the expanded Medicaid program since it took effect in July 2016.
"The navigator program was designed to be able to enroll everyone," Burton said.
The cuts sting even more, he said, because Louisiana's navigators were praised by the Obama administration for their work and were dubbed "uber navigators."
"It felt so great to be working on this. Louisiana got standing ovations. We never get standing ovations," Burton said.
Donelon doesn't have as favorable view of the navigators, though. He said the program puts the government in competition with the private market.
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In a Louisiana Department of Insurance news release promoting the open enrollment period, he urged residents to seek out "a licensed health insurance agent" if they needed help. The release didn't mention the navigator program, which is a free service for consumers.
"I think that health insurance is so complex and so important that the minimum cost of a professional to give you guidance and advice is well worth the money spent," Donelon said.
He said private agents make up an "army of folks across America who have long defended the private system of health insurance against the left's desire to move to a single payer government program."
Burton worries private agents may be susceptible to flaws in applications.
"If they don't get it right, (the consumer) will have to pay that money back," he said. "I'm afraid the consumers are going to get caught up in that."
On top of the Trump administration slashing programs that promoted and offered assistance with healthcare.gov's offerings, funding for some cost-sharing reductions has also been cut – a move that has made national headlines even though the Congressional Budget Office estimates net premiums, what consumers actually pay, will remain roughly the same because subsidies would increase to offset insurer hikes.
"There have been direct actions that the Trump administration has taken to undermine the health and viability of the health insurance marketplace," said Susan Todd, executive director of the New Orleans area nonprofit 504HealthNet. "Families are the ones who end up losing out. This is not the direction we want to go in."
504HealthNet and other nonprofits like it are trying to fill in the gap to educate people during the enrollment period. They are passing out fliers at second lines in New Orleans, showing up to libraries and other public spaces to spread the word, attending health fairs and other face-to-face engagement efforts.
The navigators are also partnering with other volunteer-based groups and federally qualified heath centers, educating them and providing printed materials so that they can educate people who may qualify for coverage.
"People are very confused about what's going on," Todd said. "A big concern is that people won't know about the new deadline and they will wait."
Donelon said the shortened timeframe makes sense and could help lower costs in the long run.
As Republicans continue efforts to repeal and replace the federal Affordable Care Act, Louisiana advocates say that without additional details…
"The Obama administration was liberal and squishy, if you will, in their enforcement of the enrollment period," he said. "The Trump administration, at the urging of the health insurers, is tightening down on that."
Narrowing the enrollment window reduces risks for insurers, he said.
"There are those who say that the Trump administration wants to undermine by tightening up on the limited enrollment period, but, frankly, there is a legitimate reason for it," Donelon said. "Folks are in large numbers waiting until they get diagnosed with cancer, and then buying health insurance. (It) is a significant problem that the insurers are pointing to as a reason why they are losing so much money in the individual insurance arena."
Louisiana residents have tended to sign up before the new Dec. 15 cutoff in past enrollment periods, Burton said, so he's also not overly concerned about the shorter enrollment period.
"There is a capacity to have everyone enrolled by Dec. 15," he said. "The challenge is going to be making sure that people know that."
Additionally, during the six-week enrollment period, the healthcare.gov website will be offline for maintenance for 12 hours each week, from 11 p.m. Saturday to 11 a.m. Sunday.
"At least we know that and we can tell people about that," Burton said.