NASHVILLE — Sharon Barker is not used to new health insurance customers in deepest summer, long before the enrollment season for the Affordable Care Act. But this year, everything is different.
Despite surviving Republican efforts to repeal it, the law known as Obamacare remains vulnerable. President Donald Trump has repeatedly threatened to end billions of dollars in payments to insurance companies, but his administration decided this week to continue them for another month.
An even more crucial question is whether administration officials who openly detest the law will lead a vigorous nationwide push to persuade the uninsured to buy policies sold under its banner, and existing customers to keep their coverage, when open enrollment for next year starts on Nov. 1.
The evidence so far suggests they will not. The administration recently ended $23 million worth of contracts with two companies that helped people sign up for coverage. It also is cutting the enrollment period in half in most states, to 45 days. A number of advocacy groups that worked closely with the Obama administration to get the word out about open enrollment have heard nothing from the Trump administration about re-upping the partnerships this year.
All of this has Barker and other Obamacare enrollment counselors around the nation, many of whom rely on federal grants to carry out their work and to keep their jobs, revving up earlier than usual, and bracing for the strange new challenge of promoting coverage that the president is attacking at the same time. They are not even certain the law's mandate that most Americans have health insurance or pay a tax penalty will be enforced.
A recent sticky Friday found Barker passing out flyers about open enrollment at a back-to-school fair in East Nashville, Tennessee. To every parent and grandparent who strolled past, she asked, "You have health insurance?" Nearby was her favorite prop: a wheel that passers-by could spin with a dial that landed on terms like "deductible" and "penalty," which she cheerfully explained to those willing to listen.
For the law's first four enrollment seasons, the Obama administration spent heavily on advertising, recruited celebrities like Katy Perry and companies like Uber to spread the word and scrutinized data to pinpoint potential customers. But this year, community-based enrollment groups, known as navigators, may be largely on their own.
"This is going to be the heaviest lift we have ever tried to undertake," said Jessie Menkens, navigator program coordinator for the Alaska Primary Care Association. "We will be shouting out for people to recognize this really is not over — that regardless of what deliberations are happening in Washington, this is still truly the law of the land."
The approximately 100 navigator groups around the country, which received $63 million in federal grants last year, are not sure the Trump administration will renew those grants, which are supposed to be awarded next month. Matt Slonaker, executive director of the Utah Health Policy Project, said he had had encouraging conversations with officials at the Centers for Medicare and Medicaid Services (known as CMS), but "no one will know for sure until the grants are finalized."
Slonaker also said that at a conference that CMS held for navigators in June, employees of the agency said the federal government would not run any ads to promote open enrollment this year. A spokeswoman for the agency would not confirm whether that was true or answer other questions about the administration's plans.
Other open questions include whether the Trump administration will automatically re-enroll people who did not actively cancel or change their plan, as Obama's did, and whether it will increase staffing at call centers that help people sign up, given the compressed enrollment time frame.
Insurance companies had asked for the shorter enrollment period, saying it would allow them to collect a full year's worth of premiums from Obamacare customers and reduce the number of people who wait until they are sick to sign up. The Obama administration had planned to cut the enrollment period to six weeks starting in 2018, but the Trump administration moved it up to this year.
Last year, Tennessee became a symbol of the law's growing problems. Insurers sought some of the steepest premium increases in the country after posting major losses they blamed on their Obamacare customers' high medical costs. Then BlueCross BlueShield of Tennessee decided to stop offering plans in Nashville, Memphis or Knoxville. Statewide enrollment dipped to 200,401 by February 2017, from 231,705 in March 2016.
The state became something of a poster child for the repeal-and-replace effort this year, when Humana announced it was pulling out of the Obamacare markets nationally. That left 16 Tennessee counties with no insurers for next year, a situation Trump seized on at a rally here in March. (BlueCross BlueShield has since agreed to offer coverage in those counties.)
The Health and Human Services department has produced a series of videos featuring Americans "burdened by Obamacare," which Price has posted on Twitter. In response to a request from Senate Democrats, the Government Accountability Office is investigating the videos as part of a broader look at whether some of the anti-Obamacare actions by HHS have violated restrictions on how federal funds can be spent.
Congressional Democrats said they would be sending a letter to Price on Friday, demanding detailed information about his plans for marketing and outreach during open enrollment. In the letter, the ranking Democrats on House and Senate committees with jurisdiction over health care said they were concerned the administration was "intent on depressing" sign-ups.
"It's pretty powerful," Barker said of the administration's frequent attacks on the law, "and that's what we're up against."