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Health Law (ACA) Faces Its Toughest Stress Test Yet (#GotBitcoin?)

Recent and pending GOP efforts to chip away at Affordable Care Act cause new uncertainty as open enrollment begins.

The Affordable Care Act’s sixth open-enrollment season begins Thursday, marking a test of the health law’s stability following a series of Republican efforts to roll it back.

The sign-up runs through Dec. 15 for coverage beginning on Jan. 1, 2019, the first year when consumers won’t face a financial penalty for forgoing health coverage. Republicans in Congress repealed that penalty in 2017, but the change won’t take effect until next year.

This is also the first open-enrollment period under a Trump-administration change expanding access to cheaper plans that don’t cover the panoply of benefits mandated by the ACA. Those less-expensive plans can also deny coverage to people with pre-existing conditions.

Both of these changes could weaken the exchanges where millions of Americans who don’t get insurance from an employer or government program go to obtain coverage. Health analysts say the moves will likely siphon off younger and healthier consumers who are needed to offset the health costs of older, sicker people remaining on the exchanges because they need more robust coverage.

Republicans, however, say the initiatives will provide financial relief to consumers who have been hard hit by higher premiums and penalties under the ACA and who are looking for more flexibility.

“There is as much uncertainty in this open-enrollment period as in any since the law first went into effect,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. “Republicans have jettisoned some of the onerous parts of the ACA, and now we’ll find out if what’s left is a workable structure.”

The open-enrollment season is kicking off just before the congressional elections in which health care has emerged as a top issue for voters. Both Democrats and Republicans are trying to portray themselves as guardians of the ACA’s protections for people with pre-existing health conditions.

The blizzard of ads and heavy campaigning on health care could have a spillover effect, driving more people to sign up for coverage. But some ACA advocates worry that intense politicking around the issue could be distracting and discourage people from signing up.

“The election is going to take away media coverage,” said Joshua Peck, co-founder of Get America Covered, which backs the ACA. “There are a lot of very challenging things we face this year.”

The law has proved resilient despite President Trump’s assertion last year that “Obamacare is finished.” Many health analysts had predicted enrollment would drop off and premiums would rise this year because of GOP efforts to chisel away at the ACA, including cutting the law’s advertising budget by 90%.

But nearly 12 million people signed up or were re-enrolled in coverage for 2018, a similar figure as the previous year. The number of consumers who paid their continuing premiums, however, slid to around 10 million, because not everyone pays their monthly bill and others may get insurance later from another source such as an employer. This type of falloff has happened each year and is typical in the individual insurance market.

Many consumers’ expenses didn’t soar this year. Roughly 85% of enrollees received a tax credit to help reduce their premiums. The average credit covered about 85% of the total premium cost, making the average premium after the subsidy $80 a month.

Analysts had warned 2019 could usher in higher premiums on the individual market—both off and on the exchanges—because of the repeal of the penalty for lacking insurance and because of Mr. Trump’s decision to end billions of dollars in payments to insurers that covered certain cost-sharing subsidies.

But that spike hasn’t happened. Average premiums sold under the ACA will fall 1.5% next year, according to the Centers for Medicare and Medicaid Services, while more insurers are participating or expanding their footprints in the exchanges.

Both are signs that the ACA’s exchange markets are becoming increasingly stable—despite predictions of its imminent demise from all sides. One likely reason: consumer demand has remained unexpectedly steady, which in turn has helped insurers’ bottom lines. Additionally, many insurers set high premium levels in past years, allowing them to keep increases to a minimum this year.

Uncertainty still looms. Twenty Republican-led states are asking a U.S. district judge in Texas for a preliminary injunction to invalidate the entire ACA, arguing that the repeal of the penalty invalidates the health law overall. The Justice Department has also weighed in, asking the judge to strike down key parts of the ACA, including its protections for people with pre-existing health conditions. Mr. Trump, however, has said Republicans will protect pre-existing conditions.

A hearing on the case was held in September and a decision could come any time, although legal experts expect it to land after next Tuesday’s election.

While the Trump administration has significantly cut outreach funds, states that run their own exchanges are working to get the word out about the sign-up period.

Connecticut will hold enrollment fairs with free in-person assistance, for example, while California got a jump start by beginning its open-enrollment season in mid-October. Minnesota is providing free walk-in enrollment help at a variety of locations.

Consumers have been able to go online at the federal exchange,, to preview plans and prices before open enrollment begins. The Centers for Medicare and Medicaid Services, which oversees the ACA, is staffing a call center as usual.

CMS is also encouraging consumers who are currently enrolled to update their information, shop, and pick a plan that suits their needs before the December 15 deadline. As in previous years, CMS will automatically sign up consumers who don’t re-enroll in the same plan or a similar one.

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