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ASHINGTON — In less than six weeks, despite months of Republican attempts to dismantle Obamacare, millions of people will return to HealthCare.gov to buy insurance.

Or at least, they should.

You might not know it from the political rhetoric, but the Affordable Care Act is still the law. Every American is still legally required to carry health insurance or face a tax penalty of at least $695. There will still be plans available on the exchanges in every county, and the federal government will still provide the subsidies that help more than 9 million people afford their premiums.

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But while much is the same, the actual sign-up process will look very different. The Trump administration has made an array of changes that, taken together, will make the process more rushed and more confusing, consumer advocates and insurance experts told STAT.

“The big question for me is, how hard are they going to work for this? Right now, there are a lot of signs pointing that they have very little interest in meeting consumers where they are,” said Josh Peck, who was the chief marketing officer for HealthCare.gov under the Obama administration.

Below, your guide to Obamacare under President Trump.

The deadlines loom much closer

In past years, Americans looking to buy insurance on HealthCare.gov could expect at least 90 days to do so, stretching from the fall into January.

This year, the Trump administration shortened the sign-up period to just 45 days. Anyone who wants 2018 coverage will have to make that determination by Dec. 15, 2017, unless they’re in a state that runs its own insurance website.

That could be trouble for procrastinators: In 2015, nearly 60 percent of new enrollees and almost a third of people who switched plans did so during the second half of the open enrollment. If those people are motivated by the deadline, they may simply shift their planning up by a few months. But if they’re used to signing up or renewing in January, they may be out of luck.

Sunday morning sign-ups are out

Not only is enrollment shorter this year, but the administration is planning to take HealthCare.gov offline between midnight and noon on five of the six Sundays during open enrollment.

Critics say the timing will make it that much harder for working families — who often make such purchasing decisions on the weekends — to sign up for coverage.

“That’s another hurdle we have to get over,” said Shelli D. Quenga, director of programs for the Palmetto Project, a South Carolina-based group that helps with enrollment. “Even the messages I’m getting now, for scheduled maintenance, none of these outages are for 12 hours. So they’re going to wait until open enrollment and then put the system down for 12 hours?”

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A Trump administration spokesman told Kaiser Health News, which first reported the outages, that the downtime was scheduled in advance this year to help people prepare, and suggested that it shouldn’t cause many problems.

Consumers will have less help

Health insurance is complicated. And unlike people who get coverage through their jobs, Obamacare customers can’t rely on human resources professionals to explain their options. Instead, the Affordable Care Act allocated around $60 million in annual funding to “navigators” — organizations and individuals who help explain health insurance options.

The Trump administration says the programs aren’t worth their costs — and it’s cutting the federal funding nearly in half.

Navigators, though, say that nearly all the people who visit them lack the confidence to sign up on their own. Among the tricky questions they field: how to handle enrollment for a pregnant woman who might no longer qualify for Medicaid after having her baby, or for an undocumented child seeking coverage through a parent’s plan. Small business owners, too, might need advice to ensure they qualify for tax credits.

“The complicated issues begin when you say, ‘So tell me about your family,'” Quenga said.

There will be fewer ads to push consumers to sign up — or to explain their options

Perhaps the starkest difference from last year: There will be far less money to promote the sign-up period and explain people’s options. The Trump administration late last month announced it would slash its advertising budget from $100 million to just $10 million.

That kind of reduction means there won’t be any of the television or radio ads that advocates say were especially effective at driving new enrollees. It will likely nix Spanish-language outreach, which accounted for about $12 million of the Obama administration’s budgeted advertising.

“There’s really no other way to put it than ‘devastating,'” Peck, the former chief marketing officer, said. “It’s far worse than I could have expected. … Even with that cynicism in place, I was shocked to hear they were cutting it to $10 million. It’s just really stunning.”

Rather than broad TV ads to reach brand-new customers, the administration will have to rely on email and text messages to existing consumers or those who have visited HealthCare.gov in the past. And it’s not clear how aggressively they will do that. During his tenure, Peck’s team was sending 40 to 50 different emails at least three times a week to specific target audiences— such as those who had started but not finished an application, or those who had not yet selected a plan.

The Trump administration has defended the cuts, saying it’s working to ensure it gets the most bang for the taxpayer’s buck.

“Judging effectiveness by the amount of money spent and not the results achieved is irresponsible and unhelpful to the American people,” said Health and Human Services spokeswoman Caitlin Oakley.

But even internal HHS reports have shown a clear correlation between outreach and enrollment, as The Huffington Post reported.

Private insurers are considering filling the gap with their own advertisements. In New York City, for example, health insurer Oscar is boosting its own spending to promote open enrollment. Other plans are considering similar moves, according to an insurance industry official.

Consumers counting on renewing their coverage may end up with a different plan

It’s been a tumultuous year for the marketplaces.

In part because of the political uncertainty and in part because of the financial challenges, a number of companies have decided to stop selling plans on the Obamacare exchanges.

Every locality in the country will still have multiple plans available from at least one insurer. But in many places, those options may be different than they are now.

Existing HealthCare.gov customers will be automatically renewed in a new, comparable plan — but there’s no guarantee that plan will offer the same access to a given doctor or drug, or cost the same per month. Customers are free to shop around for new plans, but only during the open enrollment period that ends Dec. 15.

Adding to that time crunch: This year, renewal notices may come later than usual. Because of the tumultuous Republican efforts to repeal Obamacare, the Trump administration has several times delayed insurers’ deadlines for filing certain information with state and federal regulators.

Because of those delays, the administration said this week it would also give insurers more time to tell existing customers whether their plans will be renewed next year. Originally, they had to do so by Oct. 31 — one day before open enrollment starts. Now, they’ll just have to do so as soon “as reasonably possible.”

Premiums will likely increase — but so will subsidies

Both new and returning customers will find out in mid- to late-October exactly how much plans in their area will cost. Many insurers were still finalizing those numbers even this week.

Early signals from insurers this year, however, suggest that in almost every state, political uncertainty, coupled with an expected but noticeable increase in health care costs, will drive up prices — in some cases, substantially.

Blue Cross Blue Shield of North Carolina, for example, suggested that more than half of the 22.9 percent increase it has requested for its Obamacare plans is attributable to political uncertainty. One left-leaning blog that tracks the rate filings, ACASignups.net, estimates that insurers could hike their prices by as much as an average 30 percent, nationwide for 2018.

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The vast majority of people who buy their insurance on HealthCare.gov, however, won’t see their out-of-pocket payments spike nearly that much. As prices go up, so too do the subsidies available under Obamacare. In the past, especially when consumers shopped around for a cheaper health care plan, their premium costs didn’t increase substantially.

Twitter is alight with cries of ‘sabotage’

The long list of changes to Obamacare enrollment has some supporters of the law screaming sabotage. That’s in part because they want to see as many people sign up as possible, with minimal confusion.

“We’re not building on the successes that we’ve had with enrollment. We’re not building on what works,” said Sandy Ahn, an associate research professor at Georgetown’s Center on Health Insurance Reforms.

But their anger also stems from the fact that enrollment — and in particular, enrollment of younger, healthier people — really matters for the success of the marketplaces. Older and sicker people will overcome any number of hurdles to get insurance because they know they need it. But insurance markets depend on premiums from of young, healthy individuals to help spread out the costs of providing care for everyone else.

If those younger, healthier people don’t sign up this year, it will likely mean higher prices in 2019 — and still more political rhetoric about Obamacare imploding.

“It is death by a thousand cuts,” Quenga said.

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  • Death of the ACA by a million cuts. Praying that I won’t have to change policies for the third time in three years, although the insurance company was the same in 2016 and 2017, and that the premium increase won’t be too drastic. Yes, Pres. Trump I do like my ACA coverage even though it is expensive and I make too make money to qualify for a subsidy. With a pre-existing condition, it’s my only option. Any GOP plan could have made coverage for me and millions of others a cruel joke.

    Trying to find out if I can be trained to be a volunteer navigator. As someone who already volunteers to complete income tax returns for others, I can imagine how difficult it might be for someone who is not computer-savvy to complete an ACA application on his or her own.

  • My daily news feed this morning said I can expect heath insurance premiums in my state to increase by 40% next year. That means that I will spend $5000 more for insurance next year because this administration and republican congress do not have the political will to fix the ACA. I am extremely frustrated that I will foot the bill for this. I expect the next financial blow to come from republican tax ‘reform’. So far, the only accomplishment of the current administration is to erode my standard of living faster than I imagined was possible.

    On another note, if the changes to the ACA described in this article aren’t sabotage, then they reflect profound incompetence. Things like scheduling website downtime during a shortened enrollment period is pathetic management. Whoever is running the ACA under the Trump administration should be fired.

  • Readers should be aware that they can go to healthcare.gov *right now* and create an account (for those who are using the exchange for the first time) or update their information if anything has changed. Especially those who have never been on the site, if you familiarize yourself with the process now and have any questions, you can call before Nov. 1 and perhaps spend less time on hold (the phone reps are available 24/7 excepting national holidays). A good place for first-time users to enter the healthcare.gov site is the contact page. It has a link to a PDF checklist of the information and documents you will need to begin, a link to the “create an account” start page, and a link to an overview of the system: https://www.healthcare.gov/contact-us/. Click on the “individuals and families” tab.

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