Enerica Rodriguez didn’t wait until the last minute. She signed up for health insurance at the end of November, ensuring that she and her husband Marcelino continued the coverage they’ve been relying on.
“We are trying to hold onto that insurance,” said Rodriguez, 40, who works at a Dallas-area dry cleaners. She’s a fan.
Despite attacks on the Affordable Care Act by Republicans in Congress and President Donald Trump, millions are signing up in the last days of open enrollment for health insurance on the exchanges the law created.
Most have access to free policies, or to very cheap coverage.
"In many cases, we're finding that many people are signing up for better plans than they had last year for just a few dollars more in some cases," Anil Pandya, Director of Programs at the Health Council of Southeast Florida, told MSNBC.
Rodriguez snapped up one inexpensive policy.
“As soon as the Obama insurance came out, that’s when we started buying,” Rodriguez said.
She is not alone. As of last Saturday, 4.7 million people had signed up for health insurance on the federal exchanges set up by the 2010 Affordable Care Act, the Health and Human Services Department reports.
That’s 650,000 more than had signed up at the same time last year.
But open enrollment ends sooner this year than in years past. Friday is the last day for people wanting to buy insurance that starts Jan. 1 on the federal exchanges. Some states that run their own exchanges have extended this period — Maryland extended the signup period for its exchange to December 22, while Massachusetts allows signups until Jan. 23.
And so unless another 4 million people sign up in the coming days, total enrollment will likely fall short of last year’s total of 9.2 million who got health insurance on the federal exchanges.
“This is clearly a critical week,” said Sara Collins of the nonprofit Commonwealth Fund, which conducts research into public health.
It is about more than just numbers. In the U.S., having health insurance is a basic requirement for people to get medical treatment.
“If people are going to continue to be able to get and afford the health care they need, it will be essential to hold on to and build on these coverage gains,” Collins said.
“Millions of people who got health insurance will enjoy better health status over time,” added Commonwealth Fund president Dr. David Blumenthal.
'Death by a thousand cuts'
Report after report show the number of people going without health insurance has plummeted since 2013.
“Between 2013 and 2016 — the first three years of the ACA’s major coverage expansions — the number of uninsured Americans under age 65 fell by an estimated 17.8 million. Uninsured rates declined in every state and the District of Columbia,” the Fund said in a report released Thursday.
But the Trump Administration and a new Republican-dominated Congress waged open war on the ACA for most of 2017, with Trump repeatedly saying Obamacare was dead, even as Congress failed repeatedly to repeal the laws.
"2018 will have a high number of free subsidized options.”
The White House ordered HHS to scale back enrollment outreach and fought with insurance companies over subsidies, a battle that resulted in higher premiums in some places.
And HHS also shortened the enrollment period for 2018, raising fears that four years of coverage gains would be lost.
“They cut the enrollment period, they slashed the outreach and they are trying to do everything they can to give it death by a thousand cuts,” said Wisconsin Rep. Mark Pocan, a Democrat.
“Many incorrectly believe Obamacare has been repealed,” said Kevin Nix, spokesman for Legacy Community Health, a not-for-profit federally qualified health center in Texas.
The worry was that with Trump declaring Obamacare “dead”, people would give up on getting insurance. And the federal government has said it won't enforce the mandate, which requires most people to have some sort of health insurance or pay a fine on their income tax.
“When Obama left office, people thought so did Obamacare,” said Trilena Amos, director of patient access for Legacy. “Initially, people were very confused. They didn’t know the difference between Obamacare and marketplace insurance.”
Groups and clinics like Legacy launched their own outreach campaigns, buying ads on social media, television and radio, posting billboards, and holding events. And they are holding their own events to help people get signed up — a complex and confusing process made harder without the help of teams of navigators that were deployed in years past by the federal government.
Health insurance companies have been advertising heavily, also.
“We have been having to educate people,” Amos said. But she fears efforts will fall short, anyway.
“With it being the shortest open enrollment period that we have ever had, we are not touching everyone,” Amos said. “I don’t know if everyone is set.”
News media have typically covered open enrollment heavily, especially after the disastrous first year of the exchange rollout when the web-based signup system crashed repeatedly.
The controversy over the ACA may have made some people want health insurance more badly than ever before, said Amos. Social science shows that people often value something more if they have had it and may lose it.
“I think the community may have grown in appreciation,” Amos said.
“A lot of individuals become very excited wanting to enroll, because they know — if I can get insurance now let me go for it. Those who missed opportunities in the past, they definitely want to take advantage of it now.”
“People are much more aware of the availability of coverage than before,” she said.
ACA critics have pointed to rising premiums and the decision by many insurance companies to pull out of markets they’d previously offered policies in. The result has been that people in many counties have just one, or maybe two, companies to choose from.
“They cut the enrollment period, they slashed the outreach and they are trying to do everything they can to give it death by a thousand cuts."
But there have been some unexpected benefits for people, too. Rising premiums aren’t necessarily passed on to the customer and many people have options for free health insurance. Health consulting firm Avalere Health reported this week that 98 percent of counties covered by Healthcare.gov have at least one free policy on offer.
“In 2018, these highly-subsidized consumers will also have access to free silver plan options in 18 percent of counties,” Avalere said.
“Further, 10 percent of counties will have free gold plan options available to individuals making $18,090, or 150 percent of poverty, per year. While availability of free subsidized options decreases for individuals with higher incomes, 2018 will have a high number of free subsidized options.”
That includes markets with no competition. Medica, the only company offering policies in Iowa and Nebraska, says 24,000 of its customers have plans with 100 percent of the premium covered by the federal government.
Related: Obamacare's biggest day, in 2016
Children's coverage at risk
HHS says 80 percent of people signing up on Healthcare.gov have the choice of a plan with premiums of just $75 or less a month— although people buying those plans may have higher co-pays and deductibles.
Nonetheless, the outlook remains uncertain for people relying on federal government support for health insurance. Congress has failed to renew funding for the Children’s Health Insurance Program (CHIP), which covers more than 9 million low-income kids.
Rodriguez said she may be forced to buy a more expensive ACA plan if her kids, aged 10 and 13, lose CHIP. And her plan won’t cover their medication for asthma, eczema and ADHD.
“It will be expensive for us,” she said.
“In the absence of an extension, more than half of states are projected to run out of federal CHIP dollars by March 2018,” Commonwealth said. “The result could be a loss of coverage for millions of children.”
So for the next two days, the push is on.
“This is the busiest week of my career,” said Amos. She hopes people don’t wait until the very last moment.
“History has proved that on busier days the website does blow up a little bit,” she said.
“We will see a lot of sad people on the 15th.”