With the Trump administration taking steps to undercut these marketplaces and congressional Republicans having spent much of previous year trying unsuccessfully to dismantle large parts of the ACA, leaders of state insurance exchanges and other health-policy experts said that enrollment was surprisingly resilient.
While the state exchange directors said Obamacare remained strong this year, they were concerned about Congress' elimination of the individual mandate starting in 2019. But because subsidies rise alongside premiums, lower income consumers were insulated from the price hikes. But that also has drawbacks.
And they suggest surprising strength in many markets across the country, with consumers steadily signing up for health plans even as Trump and his Republican congressional allies derided the markets as crumbling and unaffordable. While the proposals have bipartisan support - and the idea is endorsed by many health industry groups - the legislation faces opposition from some lawmakers who see it as a bailout for the insurance industry.
The decline was concentrated in states where the federal government runs the Obamacare markets.
"There could be a number of different reasons for that", says James Scullary with Covered California.
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"Just the removal of the [individual mandate penalty in Congress' recently enacted tax overhaul] will mean premiums go up 15 percent to 30 percent or more depending on the state", said Lee. A drumbeat of advertising is needed, he explained, because the pool of potential customers is constantly changing.
Subsidized consumers paid less for health coverage in 2018 than 2017 due to the protective effect of their subsidy rising to offset higher premiums, while unsubsidized consumers in the individual market - both in and out of Covered California - saw their costs rise.
While premiums climbed, the overall effect on enrollment is unclear.
Officials from states operating their own exchanges said their ability to make changes led to their gains. In those 34 states, enrollment dropped 5.3 percent.
States that run their own marketplaces overcame some of those challenges, according to NASHP, through efforts such as conducting targeted outreach to key populations and improving their enrollment operations. Most state markets had longer sign-up windows than HealthCare.gov and some states advertised heavily.