Trump moves, health rate spikes shape turbulent sign-up start Nov. 1

Oct. 27--BOSTON -- Insurance rate hikes are tripling to 26 percent in Massachusetts, the state with the nation's lowest uninsured rate and a pioneering health marketplace.

Make it 45 percent for Florida, the state with the most customers using the federal exchange at healthcare.gov and one of the five highest uninsured rates in the country.

Consumers in blue and red states alike are starting to find out what it means after President Donald Trump's administration yanked billions of dollars in funding and kicked off a string of Obamacare changes without waiting for Congress -- right before enrollment for 2018 plans starts Nov. 1.

In Florida, Lester Johnson of Wellington said his wife is facing a 47.8 percent increase to renew her current plan. She is among about 100,000 consumers in the state who stand to suffer most from volatile premium jumps, because she makes too much income to qualify for government financial assistance under the Affordable Care Act.

"Who do I blame?" Lester Johnson said. "Certainly the Trump administration bears the bulk of the blame for introducing the uncertainty into the market by threatening to not pay the already approved cost sharing payments."

The effect: Florida's 2018 premium increases on benchmark ACA plans skyrocketed, from less than 18 percent initially expected to an average of 45 percent.

Trump says the real culprits are Democrats and the Affordable Care Act they created, not him.

"Any increase in ObamaCare premiums is the fault of the Democrats for giving us a 'product' that never had a chance of working," Trump tweeted.

Polling in August by the Kaiser Family Foundation found 78 percent of Americans, and 52 percent of Republicans, said the administration should do what it can to make the law work, not make it fail, if Congress cannot agree on how to overhaul it.

As Johnson sees it, "If one tenth of the effort put forth to repeal the Affordable Care Act were put toward improving it, we would not be in this situation. States that set up their own exchanges were at least able to negotiate with the insurance companies. Florida, thanks to the governor, would not do that."

Massachusetts and Florida represent opposite ends on the spectrum on how states embrace or resist the Affordable Care Act.

Neither is escaping the impact of Trump's moves. But their contrasting histories and the resources they put into health care have something to do with how their consumers are affected.

Massachusetts had been expecting about an 8 percent premium rise on 2018 market plans. Forced to recalibrate on the fly, state officials announced an average 26 percent increase after Trump's actions.

The Massachusetts marketplace, like the exchanges that came after it, is designed primarily for people not covered by employer plans or government programs like Medicare or Medicaid. Its enrollment stands at about 253,000, up from 228,000 a year earlier.

The people who run the marketplace in Massachusetts, created in 2006 under former GOP governor and later presidential nominee Mitt Romney, say it is a source of pride that helps produce the country's lowest uninsured rate by most measures, under 3 percent.

A sustained commitment "has allowed us to improve and strengthen our exchange, to insure over 97 percent of our population, and to improve overall health care landscape over the last decade," said Audrey Morse Gasteier, chief of policy and strategy at the Massachusetts Health Connector.

In contrast, Florida did not set up its own exchange or expand Medicaid and ranks among the five states covering the fewest people, with more than 12 percent lacking health insurance.

Still, big moves in Washington affect all the states.

"Massachusetts is a health care leader and success story, but even we are not immune to President Trump's efforts to sabotage the Affordable Care Act," stated U.S. Sen. Ed Markey, D-Mass. "When Bay Staters see their premiums spike next year, they can place the blame squarely on President Trump."

Not everyone in the state thinks Massachusetts is such a great model.

Yes, the state has succeeded in covering a lot of people, but it is "only affordable for those with taxpayer-funded subsidies," said Josh Armchambault, senior fellow on health care policy at Boston's Pioneer Institute of Public Policy Research, which describes itself as a nonpartisan market-oriented think tank.

Archambault, who is also a senior fellow with the Naples, Fla.-based Foundation for Government Accountability, argues taxpayer spending on government-subsidized health care in general is "unsustainable" in the long run.

OK, but do consumers -- in Massachusetts or Florida or anywhere else -- have a right to be upset with the Trump administration if their costs are going up now?

"Maybe the Trump administration could be to blame for drawing out uncertainty about cost-sharing reduction payments, but that is an issue of who pays the cost, not an actual reduction in the overall cost of insurance," Archambault told The Palm Beach Post.

The underlying problem, as he views it, is "ACA regulations that have driven up the cost to taxpayers."

After continuing cost-sharing payments for months, Trump's administration stopped them on a dime, citing a legal opinion from the U.S. attorney general advising that Congress, not the administration, should appropriate the money.

The payment dispute has been at the center of an ongoing court battle for years, but Trump's sudden action on the eve of 2018 enrollment made him, in the words of U.S. Rep. Lois Frankel, D-West Palm Beach, a "one-man wrecking ball."

Costs and choices for a wide range of consumers could be affected if the turmoil causes more insurers or policyholders to drop out of ACA markets.

For now, more than 90 percent of Florida's more than 1 million marketplace customers are likely to see little change in what they pay out of pocket each month. Some could even see slight reductions. That is because other subsidies rise to compensate for the cost-sharing dollars.

Taxpayers might seem at first glance to benefit, but they stand to lose big because the triggering of other subsidies results in a net budget deficit increase of about $194 billion over 10 years, the Congressional Budget Office said.

And the developments are most disruptive for about 100,000 Florida marketplace customers whose incomes are too high for subisidies. Insurers are advising them to shop carefully, both on or off the marketplace, for options that can help blunt the biggest premium spikes.

Since Florida has the nation's highest number of customers using the federal marketplace at healthcare.gov, that means it is the state affected most by Trump administration moves such as slashing the advertising budget for the enrollment period by 90 percent. Money for one group of Florida navigators, who offer in-person assistance to help people sign up, was trimmed from $1.8 million to about $720,000.

"We are disappointed that our budget was cut so substantially, but also relieved that some funding is still available to help Floridians navigate the marketplace," said Karen Basha Egozi, CEO of a group that coordinates navigator help, the Epilepsy Foundation of Florida. She said her group will try to "maximize every penny."

Navigators associated with her group and serving Palm Beach County and the Treasure Coast were reduced to five from eight, officials said.

Then there's this wrinkle: The administration announced planned outages for healthcare.gov overnight on the first day of sign-ups Nov. 1, and most Sundays during the enrollment period. Weekends and evenings are when many working people want to use the system. ACA supporters have called that petty and ridiculous, hardly justified by any plausible maintenance needs.

"That's obviously a hurdle we have to work around," said the foundation's navigation program manager, Islara Souto. "We have people who want to make appointments then. We have to rule out those days."

Unlike Florida, Massachusetts enforces its own individual mandate, meaning it can collect penalties for not having health insurance even if the administration balks at enforcing federal fines, officials said. Such penalties rank among the leading objections of ACA opponents, who argue the government shouldn't be forcing people to buy insurance.

Massachusetts also dedicates $4.2 million in state dollars for outreach and marketing to encourage people to sign up, officials said.

Things like the penalty and assistance programs matter because the more people there are who pay into the insurance pool, the more stable rates tend to be, supporters say.

The premiums most people pay after subsidies have barely changed: $83 per month in 2017 on a common plan for those making up to 250 percent of the poverty level, for example, up from $82 a year earlier.

But about 80,000 Massachusetts customers are likely to be affected by significantly higher 2018 premiums, officials said.

In Florida, the state's largest health insurer Florida Blue estimates more than 90 percent of its marketplace members should have modest premium increases or even slight reductions next year.

"We do have a subset of members, however, who will be impacted by the large premium increases," spokesman Paul Kluding said. "This would be our non-subsidized members -- those who are not subsidy-eligible due to higher personal income."

He continued, "Importantly, we do have options for these members. We are introducing 12 new off-marketplace plans with similar benefits to current plans. Members will be familiar with the coverage and provider network and not have to worry about the unexpected premium increases due to (cost-sharing) funding rate adjustments."

Income limits to qualify for subsidies amount to about $47,000 for an individual or $97,000 for a family of four.

In Wellington, Johnson said he and his wife are looking over her options as a 60-year-old female in good health. But the couple living on taxable IRA withdrawals is bracing for higher costs ahead, whether in premiums or deductibles they must pay out of their own pockets.

Johnson said insurers seem to be making out just fine as consumer costs go up, while state regulators seem more worried about the financial health of the companies than the customers they are supposed to serve. The couple complained to Florida's Department of Financial Services and quickly got what they considered to be a form letter saying insurance companies need higher premiums to"remain in business," offering assurances actuaries "closely check" increases before they are granted.

"It is as if they had planned on hearing from citizens who believe the state has failed to protect us, and had the letter all ready to go," Johnson said.

Signing up for 2018 health plans

Enrollment starts Nov. 1 and ends Dec. 15, half as long as last year. In some cases people affected by hurricanes can get extensions.

Preview plans or seek help to sign up at healthcare.gov

Federal marketplace call center: 1-800-318-2596

For navigator help signing up in Florida: 1-877-553-7453 or 1-877-813-9115

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