The final numbers are in for 2018 open enrollment in the Affordable Care Act (ACA) exchanges. About 11.8 million people signed up for coverage, which was a nearly 4% drop from 2017.
States that run their own exchanges saw a 0.2% increase, while the 34 states that have federal-run exchanges dropped 5.3%.
States with federal-run exchanges had only half the open enrollment period (six weeks) as previous years. States with their own ACA exchanges extended the open enrollment beyond six weeks, though most still did not offer the full three months as in previous years.
ACA plan enrollment continues to trend down after a peak of 12.7 million in 2016. The 2018 results are similar to the 2015 numbers (11.7 million people).
However, those numbers don't tell the whole story. The 2018 numbers were expected to fall well below 11.8 million after the Trump administration spent the past year trying to dismantle the ACA.
President Donald Trump cut the open enrollment period for ACA plans in half, slashed the program’s advertising budget by 90% and reduced the navigator program that helps connect people with ACA plans. The president also banged a regular drum beat that the ACA was “failing” and he promised its repeal, which didn't happen. In fact, the White House’s opposition to the exchanges was reportedly part of a larger campaign to damage the ACA.
Trump and his administration’s actions were expected to drastically cut into ACA membership in 2018, but a late surge before the federally-run exchanges open enrollment deadline in December put the number at 8.8 million insured people in federally-run exchanges. That number was smaller than the 9.2 million in 2017, but better than expected given the opposition coming from the White House.
The latest figures from the state-run exchanges show a slight uptick with some states seeing huge gains. Rhode Island led the way with a 12% enrollment increase for 2018. Kentucky increased by 10% and Washington by nearly 8%.
State-run exchanges weren't all successful, though. Vermont dropped by 6% and California, which has the largest state-run exchange, decreased by 2%.
Meanwhile, federally-run exchanges saw multiple states with large decreases. Louisiana plummeted 23%, West Virginia dropped by almost 20% and Arizona fell by nearly 16%.
The percentage of uninsured Americans has risen in recent years after decreasing with the arrival of the ACA. The uninsured rate dropped from 18% in 2013 and stood at 10.9% in November 2016 when Trump was elected.
The rate then increased 1.3 percentage points in 2017, finishing the year at 12.2% of adults, which was the largest single-year increase since Gallup and Sharecare started measuring the rate in 2008.
An estimated 3.2 million Americans became uninsured in 2017 and that number will likely increase given the lower ACA open enrollment numbers.
In addition, even more Americans may become uninsured in 2019 when the individual mandate penalty goes away. Congress included the repeal in its tax bill at the end of 2017. Another potential driver of fewer insured Americans is the Trump administration’s policies involving Medicaid, such as requiring people to work to get Medicaid coverage.
That said, expanding catastrophic health plans and association health plans, which the Trump administration supports, might offset some of those losses, though the former provides barebones insurance coverage. Providing more affordable insurance options could help offset some of the uninsured increases, but likely won’t be enough to decrease the uninsured rate again.