Obamacare enrollment is down nationwide as funding cuts, shorter deadlines and immigration fears conjure a perfect storm that is adversely impacting the program. The declines — seen from western states such as Nevada all the way to eastern states such as Pennsylvania — is causing concern among several state exchanges that have less than two weeks left to enroll people.

“We are 13 percent below where we were at the same time last year so we’re hoping to close that gap,” said Heather Korbulic, executive director of Nevada’s Silver State Health Insurance Exchange. “We are really hoping to push the pedal to the metal in the next couple of weeks by increasing our planned advertising and marketing.”

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Nevada’s situation reflects a trend that is being seen nationwide. With the Dec. 15 deadline looming for health insurance exchanges across the country, enrollment for the first four weeks of the ongoing sign-up period is at 2.4 million, according to the Centers for Medicare & Medicaid Services (CMS).

Like Nevada, the number represents a 13 percent drop from the 2.8 million enrollees that were signed up during the same period the year before. The totals comprise enrollees from 39 states that use the Healthcare.gov exchange platform.

Despite the decline in enrollees, Korbulic noted that healthcare remains an important subject for Americans. Even Nevadans who do not support the Affordable Care Act considered healthcare a key topic and wanted lawmakers to address it, according to several polls conducted before the last election.

“Healthcare was the single biggest issue for Nevadans as they voted in the midterms a few weeks back,” Korbulic said. “There is a lot to discuss both at the state and federal level.”

Trump effect

The falling Obamacare numbers show the ongoing challenges faced by the Affordable Care Act. Those challenges especially came to a head in the last two years as the election of Donald Trump handed Republicans control of all three branches of government.

Despite failing to repeal the healthcare law, GOP lawmakers were still successful in getting rid of its individual mandate, which required most Americans to carry insurance or face tax penalties. The mandate is a key cog of the Affordable Care Act that not only helped the exchanges get a bigger and more diverse pool of enrollees but kept costs down by adding younger, healthier individuals to the marketplace.

The Trump Administration also decreased funding for health insurance exchange navigators who help people enroll in the program. Last year, navigator funding was cut by 43 percent from $63 million in 2016 to $36.1 million in 2017, according to the Kaiser Family Foundation. The grants saw even steeper cuts this year. On September, CMS awarded only $10 million in grants for navigators — an 84 percent decrease from two years ago.

Nevada says it is fortunate from a funding standpoint this year.

“Our budget was not cut,” Korbulic said. “In fact, we’ve invested even more widely in outreach and marketing.”

Another change implemented by the Trump Administration is to shorten the enrollment period to just 45 days. Starting last year, the enrollment period is scheduled from Nov. 1 to Dec. 15., which is half as long as before.

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In response to the shorter window, several states that ran their own program, including California and New York, decided to extend their deadlines during last year’s enrollment period. Nevada, which switched to the Healthcare.gov platform after issues with original health exchange contractor Xerox, is not able to extend its deadlines. The state, however, will start running its own exchange next year, which should give it added flexibility, Korbulic said.

Meanwhile, proposed changes issued by the Department of Homeland Security to the country’s public charge rule is also discouraging some immigrants from enrolling in the health insurance exchanges.

The rule is used by immigration officials to identify which people have a high probability of becoming dependent on the government, which is then used to reject applicants either seeking legal entry into the United States or applying for permanent residency through regular channels. The Trump Administration is proposing that use of programs such as the Supplemental Nutrition Assistance Program or Medicaid be added to the list of factors that can lead to a person being considered a public charge and having their application rejected.

Although taking subsidies from Obamacare plans are not included in the proposed changes, several prospective applicants to the Nevada exchange mentioned it to navigators as the reason why they don’t want to sign up for insurance through the state exchange.

“What’s happening is it’s creating a chilling effect among immigrants here who are weary of accepting any kind of federal subsidy or assistance,” Korbulic said.

A blip or a trend?

Other factors cited for the decrease in Obamacare plan sign-ups include increased competition from cheaper options such as short-term limited duration insurance plans or health-sharing ministries.

Korbulic cautioned people, however, to make sure they read the fine print when considering such products. The reason they are cheaper is that short-term limited duration insurance plans and health-sharing ministries are not subject to the same strict standards that exchange plans are, she said.

“They can discriminate based on pre-existing conditions, they can rate you according to your health status and they can bar you from accessing health products,” Korbulic said. “We’re concerned that consumers are being misled into thinking they’re getting comprehensive health benefits when they’re not.”

In some cases, however, the reason for people not signing up can be a positive one. With the economy continuing to see improvement in the last few years, some people might be leaving the exchange because they have a new job and are getting insurance through work, Korbulic said.

The question now is whether the declines are an anomaly or an ongoing trend. After seeing enrollment gains during its first three years, the nationwide numbers for individual sign-ups have seen decreases in the last two years.

For the 2017 plan period, the number of enrollees dropped by 465,871 people or nearly 4 percent to 12.2 million. For the 2018 insurance cycle, the number of enrollees dropped by nearly 4 percent once again to 11.75 million. While the numbers are still better than the first three years of the program, the upcoming 2019 plan period would mark the third straight year that enrollment numbers have dropped if the declines are not shored up prior to the Dec. 15 deadline.

The repeal of the individual mandate, which takes effect in the upcoming 2019 plan year, could also adversely impact the stability of the health insurance exchanges. The concern is that healthier individuals between ages 26 and 30 will opt not to get insurance, causing older or less healthy individuals to account for a larger share of the insurance pool.

“Insurance is all about having a healthy, diverse risk pool,” Korbulic said. “If people who are healthy leave the market, what’s left is a more sick population, which means more risk and higher premiums for everybody.”

Jason Hidalgo covers business, technology and gaming for the Reno Gazette-Journal. Follow him on Twitter @jasonhidalgo. Support local journalism: RGJ digital subscription.

More information: For more details about Nevada's health insurance exchange plan, including help with enrollment visit Nevada Health Link.