What you need to know about the forces reshaping our industry.


November 1, 2017

The Trump era is dawning for ACA open enrollment. Here are 6 big changes to expect.

Daily Briefing

    By Heather Bell, Managing Editor

    Beginning Wednesday, consumers will be able to shop and enroll in exchange coverage for 2018, but many will find the experience different than in previous years.

    Don't let uncertainty get in your way: Learn the 'State of the Union' for hospital executives

    The 2018 open enrollment period marks the first time the Trump administration will oversee an Affordable Care Act enrollment period from start to finish. President Trump took office midway through the 2017 open enrollment period, and since then White House and HHS officials have enacted a slew of policy changes.

    Here are the six biggest ways this open enrollment period will stand out from the past:

    1) Open enrollment will be much shorter—and that has major implications for consumers.

    The most evident change to consumers is likely to be HHS' decision to shorten the 2018 open enrollment period for the federal exchange by nearly six weeks compared with previous years, giving consumers in most states less time to shop and enroll in coverage.

    That change also could have implications for individuals who are automatically re-enrolled in coverage. In previous years, HHS automatically re-enrolled individuals in exchange plans on Dec. 16 if they didn't select a new plan by then—but as open enrollment continued past that date, consumers still had a chance to change course if they preferred a different plan. This year will be different: HHS reportedly did not change the auto-enrollment deadline when it set Dec. 15 as the new open enrollment end date for2018, meaning individuals in many states could be re-enrolled in plans the day after the exchanges close and have no opportunity to choose a new plan. 

    2) Fewer people will need to visit, but those who do may have an easier time understanding their premiums.

    CMS will no longer require individuals who reside in states that rely on the federal exchange, and who enroll in exchange plans via a direct enrollment pathway, such as a third-party enrollment broker website, to complete the process on

    For those who do enroll via, the user experience will be a little different: Consumers will be able to view plans based on their total monthly premium, after accounting for federal subsidies—a move that consumer advocates say will make it easier for consumers to find affordable plans.

    CMS also launched a new "Help on Demand" function through which consumers can request a time for an agent or broker to contact them for assistance. The agency also is piloting a feature that allows consumers using the federal call center to request a call-back instead of waiting on hold.

    3) The federal government will do much less to inform people about open enrollment.

    Consumer advocates are concerned many potential enrollees will be unaware of open enrollment because of the Trump administration's decision to cut spending on ACA advertising by 90 percent and on the in-person enrollment program by 41 percent. In effect, the administration has nixed nearly three-quarters of spending intended to promote enrollment in the exchanges and Medicaid.

    Administration officials have argued that in previous years the money was spent inefficiently and that they remain committed to promoting the open enrollment period in accordance with the law. But ACA advocates and some industry stakeholders have said the cuts will reduce the number of people who sign up for health plans for 2018.

    For example, a case study of Kentucky's 2016 open enrollment period—during which the state's new Republican governor halted all pending advertisements—suggested that the state-sponsored advertisements were "a substantial driver of information-seeking behavior in Kentucky during open enrollment—a critical step to getting consumers to shop for plans, understand their eligibility for premium tax credits or Medicaid, and enroll in coverage."

    The Trump administration also has scaled back federal workers' participation in state outreach events—a break with previous years, when HHS regional directors coordinated with states to raise awareness. State and local organizations are working to fill the gap to ensure consumers know about open enrollment period.

    4) Insurers on the exchanges will be subject to different regulations, potentially leading to higher out-of-pocket costs for consumers.

    In April, HHS issued a final rule that adjusted the actuarial levels—the percentage of an individual's health care costs a plan will cover—that exchange plans in each metal tier must meet. Previously, a silver-level plan was required to cover between 68 percent and 72 percent of an enrollee's costs; now, that bottom threshold is 66 percent. The administration also removed a federal network adequacy requirement for insurers, meaning that states will use varying approaches to determine whether a plan's network of doctors and hospitals is "adequate." For consumers, the changes could mean higher out-of-pocket costs and, in some states, a narrower selection of in-network providers.

    Further, under the new rule, consumers who have missed premium payments within the past year and who wish renew their health plans for the first time can now be refused coverage until they pay their outstanding premiums. 

    5) Many plans will have higher premiums—but federal subsidies will limit the impact on many enrollees.

    Premiums on the exchanges were already expected to increase in 2018, but after the Trump administration announced this month that it would no longer pay insurer cost-sharing reduction payments under the Affordable Care Act, many insurers added surcharges that raised premiums further.

    According to HHS, the average premium for benchmark silver-level plans sold through the federal exchange increased by 37 percent for the 2018 coverage year.

    Individuals who do not qualify for federal subsidies will feel the full effect of the increases. But because the amount of federal subsidies to low-income customers will automatically rise in line with the cost of silver-level "benchmark" plans, lower-income families will largely be shielded from the increases. Indeed, in some states the higher subsidies will give some consumers greater access to more comprehensive plans.

    6) The Trump administration won't define what "success" looks like.

    Ever since the first ACA open enrollment period, HHS has projected how many consumers would sign up for exchange plans—until now. An HHS official last month said the department would not project sign ups this year, leaving the open enrollment period without a well-defined enrollment target.

    Instead, ACA advocates and industry experts have released their own projections to measure the success of this open enrollment period—and estimate how the above policy changes could affect the total number of sign-ups.

    Most expect lower enrollments this year. Dan Diamond in Politico's "Pulse" reports some experts project enrollment could decline by 10 percent compared with 2017, when 12.2 million people signed up for health plans. A new report from S&P Global projects about 10.6 million to 11.4 million individuals will select health plans, while Charles Gaba, who has closely tracked exchange enrollment since year one, projected between 9.5 million and 10 million individuals will sign up.  

    A new analysis from the Center for American Progress suggests the projected decline largely can be attributed to Trump administration's policy changes. Without those changes, CAP projected that open enrollment sign-ups would have held steady at about 12.2 million individuals.

    The one webconference you need to understand health care in 2018

    Each year, our researchers spend months combing through thousands of pages of rules, ideas, and best practices to identify strategies to help health care leaders navigate today’s challenging health care environment.

    Join us on Nov. 14 to hear our experts’ biggest takeaways and learn how to position your organization for success in 2018.

    Register for the Webconference

    Have a Question?


    Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory.