Tuesday is the last day of open enrollment for health care through the Affordable Care Act in most states, and millions of Americans are eligible to sign up for private insurance plans through the law's exchange, often for free.
If that's news to you, however, don't be surprised. People working to enroll Americans through HealthCare.gov, the federal website for the insurance marketplace, say they're worried that the program's benefits aren't reaching as many people as they could, especially in a pandemic and an economic crisis.
That's thanks in part to a 90% cut in funding for marketing since President Donald Trump took office and additional cuts to navigator programs, which assist people trying to sign up.
"One thing that has been a challenge over the last three years, and again this year, is that awareness about open enrollment remains incredibly low," said Joshua Peck, co-founder of Get America Covered, an advocacy group that promotes enrollment. "This year, with a lot of new people in the system, that's likely to be a particularly acute gap."
Trump's efforts to dismantle the law have been numerous: He is supporting a Republican attempt to overturn the Affordable Care Act, or ACA, in the Supreme Court after having tried to repeal it in Congress. He has encouraged the use of alternative short-term plans that aren't required to cover pre-existing conditions or other comprehensive benefits required by the ACA, also known as Obamacare. And he signed a tax law that eliminated the ACA's penalty for people who go without insurance.
The uninsured rate had ticked up on Trump's watch even before the coronavirus pandemic began, and some health experts say they fear that his handling of the law could undermine enrollment right when people need insurance the most.
The administration has argued that previous spending to raise awareness of ACA enrollment was inefficient. A spokesman said the Centers for Medicare & Medicaid Services, which oversees the law, was promoting the enrollment period through SMS, email and automated calls and authorizing more private insurance brokers to sign up customers.
Advocacy groups trying to enroll people say the lack of promotion and individual help is especially difficult this year. The pandemic has made insurance coverage even more valuable, but it has also raised new hurdles for people trying to participate in the ACA marketplace, many for the first time.
More than 10 million people are still without jobs since the coronavirus arrived, and millions more were temporarily out of work, often putting their employer-based health care at risk. Because the ACA is designed primarily to cover people who can't get insurance coverage through their jobs, more people are likely to be eligible for private plans through its marketplace, potentially with heavy subsidies.
Comprehensive data still aren't available about total enrollment in ACA plans, but an analysis by the Kaiser Family Foundation found that the uninsured rate has been relatively stable during the pandemic, suggesting that a significant number of workers may have obtained backup coverage through the law. As of last week, about 14 percent more people were signing up for plans through HealthCare.gov during the open enrollment compared to last year.
But some experts say that they worry that bureaucratic obstacles are making the process more difficult and that a more active campaign to educate and aid customers could help.
The ACA provides tax credits to help pay for premiums based on projected income going forward. Because of economic uncertainty created by the pandemic, that can be hard for people to predict, and the amounts they are subsidized will change if their incomes change later in the year.
Kristen Anderson, founder and CEO of Catch, which helps workers find benefits on the exchanges, said the company had seen signs that people who had become intimidated or confused by the process were dropping out without buying plans.
"This year you had lots of people who had employer coverage their whole careers and then need coverage independently and have no idea where to go," Anderson said. "It's not intuitive, and those marketing dollars are critical."
Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms, who tracks the ACA's marketplace, said a lack of customer and public service announcements to help educate and guide enrollees was a concern.
"If there's any complexity in your sources of income or that of your family members, it's complicated, and it takes time," she said. "A lot of people need help, and there's not a lot of help available since that funding was cut."
Some of the concerns are likely to be addressed by the next administration. President-elect Joe Biden has pledged to shore up administrative support for the law. He could even potentially declare another open enrollment period midyear, which some states that operate the ACA marketplace opted to do in the spring.
But other significant obstacles that predate Trump will be harder for Biden to tackle, and they will require legislation, which is unlikely unless Democrats win control of the Senate by sweeping two runoff campaigns in Georgia next month.
At the top of the list is cost. While premiums on the ACA have been stable on average in recent years after a surge in 2017, they're still out of reach for some customers, and deductibles continue to rise. In many places, the number of insurance options is also limited.
Julie Becker, 56, said she and her husband purchased a plan through HealthCare.gov in Florida with a $17,000 deductible this year, the highest allowed under the law for a family plan. She said she views it as little more than a hedge against catastrophic illness.
"That's basically all we're using it for," Becker said. "I definitely would want a lower deductible."
Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, said that shoppers shouldn't be thrown off by sticker shock and that they should explore the marketplace before deciding whether they can afford a plan. Millions of uninsured Americans are likely to qualify for Medicaid or for enough tax credits to buy private plans with no monthly premiums.
"I know it sounds like one of these electronic store ads where you go to buy the cheap TV and it's not there, but this really is free insurance," Levitt said. "It may not be the best option for them, because it would have a big deductible and they may be better paying a small premium for better care, but free insurance is still absolutely better than nothing."
More robust marketing could make a difference by helping publicize the options. Lower-income customers may also be eligible for additional help with out-of-pocket costs.
At higher incomes, however, premiums and deductibles have both become major barriers to coverage, and they have been blamed for more Americans' decisions to go without plans. Enrollees making over 400 percent of the federal poverty level ($51,040 for an individual and $104,800 for a family of four) aren't eligible for tax credits to help cover their premiums, which can become unaffordable as a result.
Biden has proposed capping premiums at 8.5 percent of income, increasing subsidies to allow more customers to buy lower-deductible plans and adding a public insurance plan to compete with private options. He also wants to close the "Medicaid gap," which leaves some low-income workers unable to qualify for Medicaid or subsidized ACA plans in states that opted out of the law's Medicaid expansion.
"Those all require Congress and will probably be stymied with the party divide," Levitt said.