AUSTIN — Texas has 1.1 million people enrolled in health insurance plans through the federal marketplace in 2018, an 8 percent dip in signups compared to the previous year.

The numbers were encouraging to proponents of the Affordable Care Act, who had worried people would fail to sign up after the Trump administration cut open enrollment time in half and slashed 90 percent of the budget dedicated to advertising the health insurance plans.

"That's why it was so difficult to send the message out," said Daniel Bouton, community health director of the Community Council of Greater Dallas. "It was the first year the administration didn't put out any marketing for everybody to know."

Community organizations stepped in to fill the gap, and enrollment was down only 3 percent nationwide, according to the Centers for Medicare and Medicaid.

"Everyone expected [enrollment] to fall lower than it did," said Melissa McChesney, an Affordable Care Act expert with left-leaning think tank Center for Public Policy Priorities.

In Texas, McChesney used federal data to analyze the 10 most populated Texas counties' numbers and compare them to 2017 enrollment. Denton and Tarrant counties had the largest decrease in overall enrollment at 17 percent, and renewals decreased 18 percent in Denton County and 16 percent in Tarrant.

In 2017, 120,976 Dallas County residents were enrolled in the marketplace. That number dropped to 106,923 in 2018, a 12 percent decrease.

Local organizations' outreach

The Community Council of Greater Dallas, which serves 56 counties in Texas, helped 1,850 people enroll in the marketplace. It exceeded its goal of 1,550, despite the Trump administration cutting their budget by 14 percent.

Bouton said potential health care applicants struggled most with misinformation — people didn't know how long open enrollment lasted or if they would qualify for insurance. Despite roadblocks, the council's application assisters were proud of how many people they signed up for health insurance, Bouton said.

At Dallas' Los Barrios Unidos Community Clinic, about 85 percent of children who visit have some kind of insurance thanks to the Children's Health Insurance Program and Medicaid, clinic director Leonor Marquez said. But it's the opposite for adults — about 85 percent don't have insurance. The only reason why that number isn't 100 percent is because the clinic does a lot of health care application assistance, Marquez said.

"Marketplace tends to be seasonal, and this was a short season," she said. "There was a lot more effort this year because we knew it was going to be a shorter enrollment period. We doubled our efforts, added more staff."

Marquez said while it's up to patients to pay premiums and select plans and doctors, the clinic does most of the legwork when assisting people with applications. Last year, the clinic helped 189 people sign up for health insurance plans — an increase from 158 the previous year.

Ramon Alvarez of Dallas, who recently moved to New York to study public health, enrolled himself and his parents in the marketplace when it opened in 2013. A business health care course he took at the University of Texas at Austin made him familiar with health care jargon, he said, but many families he knows go to nonprofits like Los Barrios for assistance.

"There is a special lingo that can blindside a regular person," he said. "That is a large barrier to entry."

Higher premiums, higher tax subsidies

The Trump administration's decision to stop paying insurers cost-sharing reductions drove up premiums for consumers — premiums for bronze plans went up by 17 percent, while silver plans saw a 42 percent premium increase from 2017 to 2018. In Texas, premiums increased an average of 34 percent.

Bouton said insurance companies told him they were prepared for the increased premiums because they lead to increased tax credits, which the government gives to consumers.

"When we started actually seeing the plans, it was really bad," he said. "Premiums were higher, but also premium tax credits were higher. It worked out."

The increased tax subsidy may have encouraged families to switch plans, McChesney said, either to spend more on better coverage or step down, using the credit toward a lower premium. This year, 64 percent of Texans signed up for silver plans, compared to 73 percent last year.

"I don't have to take that tax subsidy and purchase a silver level plan," she said. "Even though that may be a good option for somebody who goes to the doctor a lot, I can take that subsidy and apply it toward a bronze plan or a gold plan if I wanted to."