Ashley Candler of Austin was able to get in-patient addiction and mental health treatment thanks to the Affordable Care Act. (Photo: Courtesy of Ashley Candler)

The latest health insurance data gives new ammunition to the Trump administration as it touts the latest bad news on Obamacare, but supporters of the law say there are positive signs for the state and federal marketplaces as 2019 open enrollment nears.

 A study out Thursday showed the number of uninsured people increased in 2017 for the first time since the Affordable Care Act exchanges opened in 2013. Last week, the Centers for Medicare and Medicaid Services reported 2.5 million people left the Obamacare health insurance exchanges between 2016 and 2018.

There’s as much disagreement over why and whether things are worse as there was over the health law.

Health and Human Services Secretary Alex Azar tweeted that the 40% drop in people covered by insurance represents half what the Obama administration promised when the law passed.

This group that left the state and federal marketplaces  doesn’t get federal tax credits to pay for their plans. Under the ACA, only people who make less than 400% of the federal poverty limit (or $103,000 for a family of four) are eligible for financial help.

The administration has also tried to repeal all and parts of the law, which ACA backers say has undermined the law, but some see bright spots in the more recent data.

Others say there’s plenty of blame to go around.

For those who don’t get federal help to pay their premiums, “there is nothing in the ACA that makes insurance affordable and nothing that has been passed that has or will bring down the cost of health insurance,” says Ronnell Nolan, a Baton Rouge, La. insurance broker and president of the trade group Health Agents for America. “Health care and the cost of drugs continue to skyrocket.”

The new numbers out Thursday from the Urban Institute show the uninsured rate climbed from 10.0 percent in 2016 to 10.2 percent in 2017, accounting for 700,000 fewer people with insurance.

Several factors, led by high premiums, slowed health insurance enrollment by people who aren’t getting their coverage subsidized by the government. Insurers that continued to sell on the exchanges after the first couple of years raised rates to adjust for sicker patients and these rates only soared higher after the administration refused to continue reimbursing insurers for their share of subsidies to reduce patients’ out of pocket costs.

Chief among them are all the other health insurance options that are now both available and allowable. Starting in 2020, They also include court battles over administration proposals including to allow employers to band together in what’s known as “association” health plans, the availability of group plans for as few as two people in some states and the elimination of the tax penalty for remaining uninsured.

“The result is that middle class people felt the full brunt and in many cases dropped out entirely,” says Larry Levitt, executive vice president at the non-profit Kaiser Family Foundation.

In some states, insurers can and will sell a group policy to even a married couple, said Nolan, although they have to work together. Tracy McMillan, who owns the Arlington, Texas-based Marketplace Insurance Exchange Group, says she has clients in very small group plans who wind up paying about half of what they’d pay if they bought unsubsidized plans on

Some insurance companies maintain these plans violate the Employee Retirement income Security Act and agents including Gail Hiller-Lee in Uniondale, NY have been pushing state and federal regulators to make them more widely available because of the premiums self-employed people ineligible for subsidies are facing. 

“We try to get them the cheapest price and group plans are cheaper than individual,” says Nolan.

Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, says there have been “signs of improvement” this year, including with enrollment by people who don’t receive financial help to buy their insurance.

Cathryn Donaldson, spokeswoman for the trade group America’s Health Insurance Plans, notes that every county had at least one option for individuals seeking insurance coverage. Premium increases were also generally lower, and decreased in some markets with increased competition.

Consumers in some rural states are starting to see more options and lower prices. Several states that have struggled with a lack of competition – Nebraska, Mississippi, Oklahoma, Utah, South Carolina, Wyoming and Iowa —  all showed healthy increases in enrollment among people below 400% of the federal poverty limit, according to CMS’ new data.

Several insurance companies, including Bright Health, Oscar, Centene, Cigna, and Anthem, have expanded where they are selling after years of declines in overall insurance participation on the exchanges, says Hempstead. For 2020, Hempstead says she expects premium increases to be below average and more insurers to enter the marketplaces than leave. The number of counties with only one choice has been declining since 2018.

Problems remain, however. Along with paying for insurance, they include:

Cost of care. Even the lowest income consumers who pay almost nothing out of pocket for their coverage, face considerable hurdles paying for their share of the actual care. McMillan hosts fundraisers to raise money for her low-income clients who need to use their cheap or even free insurance in emergencies yet can’t afford to.

Spotty networks.  Agents say many patients have trouble finding doctors who will accept the insurance they can afford. Debra Fallon and her husband Jim are paying nearly $1,000 a month with a $6,000 deductible for the least expensive plan they could find for Debra – and it doesn’t even include most of her doctors. Jim is on Medicare. The couple live in Dalworthington Gardens, Texas, where Debra’s Crohn’s Disease made it necessary for her to use the state’s high-risk pool to get her coverage before the ACA. The premium and deductible – $562 a month with a $1,000 deductible – was high at the time, but is now something they miss.

While the Fallons would be fine with the pre-ACA days, Ashley Candler of Austin credits the law with “saving her life.”

She had thousands of dollars in medical debt when the ACA passed and had no insurance after a divorce. Now she doesn’t have to pay anything for a premiums and just has to meet an $1,800 deductible. Candler says she suffers from post-traumatic stress disorder, bipolar disorder and attention deficit hyperactivity disorder. With insurance, she could get professional help for her mental health and in-patient treatment for addictions.

“Having the Affordable Care act made going to a regular doctor appointment less stressful due to not having to pay an arm and a leg to see a doctor,” said Candler.