In the sixth year of open enrollment under the Affordable Care Act (ACA), many states have two big hurdles to overcome: less federal funding for outreach and advertising, and people who may choose to be uninsured now that there's no tax penalty for lacking health coverage.
The Trump administration has dramatically scaled back grants for ACA outreach and advertising -- an 85 percent cut over the past two years. This year, it will spend $10 million on advertising and $10 million on so-called navigators, who help people sign up for health insurance during open enrollment. In 2015, the federal government, under President Barack Obama, spent $67 million on advertising and navigators.
Last December, the tax overhaul that Congress passed nixed the ACA's individual mandate, which was a penalty for going without health insurance. So this year, convincing people to sign up for health care will be harder.
"We’re limited by the amount of resources we have, so we’re framing things around the value of having health insurance. [The loss of the individual mandate] has really changed the way we frame the sales pitch, and it’s made the challenge a bit bigger," says Zach Sherman, director of HealthSource Rhode Island, which runs the state's insurance marketplace.
Though the state hopes to insure everyone, it is specifically targeting younger Latino males who tend to go without health insurance. The state has created a Spanish-language site on par with the English version that's mobile friendly and is sending text messages to those populations to encourage enrollment.
Not every state relies on federal funding for outreach or advertising, but even those that don't are still feeling effects from the Trump administration's funding and policy changes.
"There’s an ancillary effect," says Sherman. "Anytime that much funding is cut, there’s an impact. For example, there aren’t as many [ACA] ads [from the feds] running on TV."
The elimination of the individual mandate has made advertising more important.
"The decision [for states] to spend money on advertising and navigators is not taken lightly, but it’s key to survival," says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.
After all, the states that run their own insurance marketplace fund their outreach efforts with assessment fees, which are based on the number of people who sign up.
Research shows that advertising pays off. According to Corlette, people who live in areas with a high concentration of marketplace advertising are more likely to sign up for coverage. California credits its above-average enrollment -- which is 25 percent higher than states that rely on the federally run HealthCare.gov -- to spending a lot, $111 million, on marketing and outreach.
Oregon funds its own outreach, but "when the federal government decided to scale back, we increased in those mediums" to mitigate any losses that might result from federal decisions, says Elizabeth Cronen, communications and legislative manager for the Oregon Health Insurance Marketplace.
Oregon has invested in hiring health insurance brokers, who are licensed to give advice on what plans make sense for a particular person. While navigators help people through the enrollment process, they can't offer advice on what plan people should choose. The brokers, Cronen says, also have "deep community roots. They are really closely connected to us and can answer technical questions as well as give a scoop on an impending federal regulation coming down the pipe."
The navigator program has been criticized by the Trump administration because they don’t tend to enroll large amounts of people. But according to Corlette, that’s not the point of navigators.
"The average appointment is 90 minutes. So what’s happening is they’re taking on complicated family situations, tricky issues like if you’re not salaried or if you have a mixed-status family. There’s all kinds of reasons determining eligibility is incredibly complicated. Navigators are there for those people," she says. "It's not about volume, it’s about quality."
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