Obamacare is about to have its worst open-enrollment season ever — and that’s no accident.

President Donald Trump and Republicans in Congress still aim to dismantle the 2010 law. Making it look bad helps their cause, even as they’ve failed repeatedly to repeal or replace Obamacare. The new theory for Republicans: If fewer people enroll in Obamacare, there will be less of a constituency to save it.


"I think it's going to implode on its own,” said Rep. Chris Collins (R-N.Y.), a strong ally of the president on the Hill. But with Trump undoing his predecessor’s rules and policies, “to some extent, perhaps he's expediting the implosion."

When the fifth open-enrollment season opens on Wednesday, it will look a lot different than when Barack Obama was in office. Trump won’t be going on TV comedy shows to urge people to sign up. His chief of staff won’t be talking up the value of health insurance on sports radio. His Cabinet won’t be crisscrossing the country to energize sign-up drives.

And if enrollment dips — as health care policy experts predict — the poor numbers will be used as evidence by Trump and Republicans that Obamacare is failing.

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“Maybe this enrollment period will produce the kind of problems necessary to get everybody’s attention that we need to get our house in order, and do the work we need to do to get the program fixed,” said Sen. Johnny Isakson (R-Ga.).

From the day he took office, Trump and his administration have taken steps to undermine the markets, including gutting outreach and marketing. Competition in the Obamacare exchanges has diminished, with nearly half the counties nationwide having just one insurer selling plans. Premiums have skyrocketed — partly because Trump himself cut off federal subsidies, leaving the insurers facing billions in extra costs.

On Sunday morning, Trump tweeted about the situation anew. "As usual, the ObamaCare premiums will be up (the Dems own it), but we will Repeal & Replace and have great Healthcare soon after Tax Cuts."

And the noise created by Republicans’ repeated failed attempts to dismantle the federal health care law has sowed vast confusion about the status of the marketplaces, as several polls have shown.

That chaos has been compounded by Trump’s repeated assertions that Obamacare has somehow ceased to exist — despite the fact that more than 10 million Americans obtain insurance through the law’s insurance exchanges.

“Obamacare is finished,” Trump said earlier this month. “It’s dead. It’s gone.”

Shrinking enrollment will erode the markets politically — and weaken them, practically.

Enrollment dropped nationwide this year. Trump officials turned off the outreach spigots immediately after they took office, and they dampened the last-minute surge of sign-ups right before the cut-off date on Jan. 31. Joshua Peck, who served as chief marketing office for HealthCare.gov in the Obama administration, estimates that at least 1.1 million fewer Americans will enroll in coverage next year due to the Department of Health and Human Services' cuts in Obamacare advertising.

Yet Republicans might be putting themselves in political peril if they’re seen as intentionally making wobbly markets more wobbly. Most polls have shown that the public will blame Republicans — by a roughly 2-to-1 margin — for future problems with Obamacare.

"I don't think President Trump and the Republicans in Congress realize it's on them now,” said Rep. Diana DeGette (D-Colo.). “So if they have trouble with the Affordable Care Act because of their efforts to undermine it, the public's going to blame them even if they try to say it's someone else's fault."

Trump’s decision to cut off cost-sharing subsidy payments, which insurers rely on to reduce costs for low-income Obamacare customers, further rattled the marketplaces. But fears that it could spark a mass exodus of insurers, and potentially lead to market collapses in some states, haven’t materialized.

That’s in large part because insurers were able to boost premiums for next year in order to make up for the lost federal payments. Insurers will still take a short-term financial hit, but they should be on steady financial ground for 2018.

“The CSR hand grenade, if it was thrown in January or February of this year, would have forced a lot of carriers to do midyear exits and it would have destroyed the exchanges in some states,” said Dave Anderson, an insurance expert at Duke University, using shorthand for “cost-sharing reduction” subsidies. “Pulling CSRs in mid-October was a nothing-burger.”

On top of all the confusion about those subsidies — because they affect the insurers, but don’t have a direct impact on the costs for people who get subsidized — the enrollment window that wraps up on Dec. 15 is roughly half the amount of time of earlier years.

Consumers who are currently enrolled and don't renew by that date will be automatically re-enrolled in a plan soon after the sign-up window closes, according to the Centers for Medicare and Medicaid Services. Officials also plan to deploy similar tools that queue customers during high-traffic times on HealthCare.gov.

But anyone without insurance who thinks they have until January to sign up, like they did last year, will be out of luck.

“You’ve got a lot of confusion out there about what is truly available in the market,” said Alexis Miller, a senior vice president at Highmark, which sells Obamacare plans in Pennsylvania, Delaware and West Virginia. “All of that is hitting our members right now.”

Another wild card is what effect cuts to marketing and outreach will have on enrollment. The Trump administration reduced federal spending on advertising by 90 percent and chopped grants to organizations that help individuals sign up for coverage by 40 percent.

For the first time, the federal government won't promote HealthCare.gov through television ads — a tactic that Obama-era health officials argue was most effective in reaching the broadest range of potential enrollees.

The Trump administration has also pulled back on community partnerships that played a key role in reaching important but harder-to-attract demographics like minorities, younger enrollees and rural residents. And in some states, the budget cuts forced in-person assistance groups to close up shop.

"It's been very clear how much the void of the administration not doing what they've done in the past is being felt across the country," said Lori Lodes, a former Obama health official and the co-founder of Get America Covered, a nonprofit formed to help promote Obamacare's open enrollment period.

Get America Covered will run its own digital outreach campaign during enrollment, and is trying to piece together a network of businesses and health care groups to boost awareness. But Lodes openly admits it'll be difficult to fully counter the confusion created by Trump's repeated insistence that Obamacare is already "dead."

"We don't know what sort of impact that will have," she said. "There are just so many asterisks."

Insurers are stepping up their own efforts to fill the void; it’s their customers, after all. Michigan’s Priority Health, for example, is running television ads aimed at enticing potential customers to call and get a copy of a booklet: “Separating Fact From Fiction in the Age of Health Care Reform.” The insurer has also boosted the number of webinars it's holding to help educate brokers about its coverage options.

“Plans are stepping it up, but they can’t mirror exactly what the marketplace had been doing in the past,” said Kelley Turek, executive director of exchange operations and policy at America’s Health Insurance Plans.

Some Obamacare-friendly states are also marshaling additional resources to make up for the cuts to federal outreach and marketing. Pennsylvania is spending $100,000 on a campaign that includes television, radio and digital ads. The spots will direct potential customers to HealthCare.gov, as well as Consumers' Checkbook, a plan comparison tool.

“I believe that this campaign can make a difference,” said Jessica Altman, the state’s acting insurance commissioner, on a call with reporters last week. But she criticized the federal government’s decision to chop Obamacare ads down to $10 million this year because of the void it creates.

"Our resources are certainly not as great as those of the federal government,” she said.

It remains to be seen whether the Trump administration will be a reliable partner for insurers going forward. So far, they don’t see any signs of outright sabotage, and they’ve gotten used to rolling with the punches when it comes to Obamacare.

“This is our fifth rodeo,” said Marty Anderson, chief marketing officer for Wisconsin’s Security Health Plan. “None of those rodeos have been the same. Each one has been challenging in and of itself.”

