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With just days left to sign up, Arizona enrollment in Affordable Care Act health insurance plans is lagging.

Arizona enrollment as of Dec. 1 was at 55,090, which is 18 percent lower than it was as of Dec. 2 last year, according to federal data. Enrollment is down nationwide, too.

Saturday is the deadline for individuals and families to purchase health insurance on the federal marketplace created by the Affordable Care Act. Such insurance is often referred to as “Obamacare.”

The marketplace sells private insurance, and those who qualify are eligible for federal subsidies to help pay for it. Most Arizonans who bought marketplace insurance for 2018 qualified for subsidies.

ACA insurance is purchased by a minority of Americans — working-age people who are not covered by employer-sponsored coverage or by government insurance such as Medicaid.

Health-policy experts say the ACA marketplace is nonetheless an important factor in overall health costs. If too many people in this population go without insurance, there’s a higher risk that hospital costs for uncompensated care will rise.

That can cause cost-shifting, saddling the entire health system with more expenses, said Dr. Daniel Derksen, a health policy expert at the University of Arizona who helped draft a portion of the ACA.

Here are six reasons why Arizona’s numbers could be down:

1.  Lack of awareness

The Trump administration slashed federal “navigator” grants to states that are meant to help educate and enroll people in health insurance. Arizona’s allotment of money dropped by 74 percent — to $300,000 this year from $1.17 million last year.

“We can only surmise that with the big decrease in marketing over the past two years, a significant proportion of people don’t know about open enrollment,” said Allen Gjersvig, director of navigator and enrollment services at the Arizona Alliance for Community Health Centers.

MORE: 5 things Arizonans should know about ACA open enrollment

The alliance partnered with 14 entities to help Arizonans enroll in health insurance last year. This year, the number of partnerships fell to four. 

Open enrollment ends at midnight Pacific time on Saturday, Dec. 15. That means the system will allow Arizonans to sign up through 1 a.m. Sunday, Dec. 16, Gjersvig said.

2. In 2019, no penalties for being uninsured 

In prior years Americans who did not have ACA-compliant health insurance faced a federal fine.

But in 2019, those penalties are going away. There’s no clear consensus on whether that will make a difference in the tally of people who enroll in ACA plans.

The absence of penalties may make less expensive short-term medical plans more attractive to some Americans. Since those plans are not ACA-compliant, anyone who bought them in the past used to have to pay a penalty, too.

Derksen said, “Clearly having a penalty in place, as mild as it was, there is some effect.” 

Michael Malasnik, an independent Phoenix insurance broker, said based on what he’s noticed, the removal of penalties isn’t making a big difference. And he hasn’t noticed more clients opting for short-term medical plans, either. 

“I’m not seeing people dropping ‘Obamacare,'” he said. “Maybe the population of people who don’t use brokers — they may be the people who say they are going to go without insurance.”

Anyone who owns property or who has other financial assets isn’t typically going to want to risk going without insurance, Malasnik said. He’s also had clients this year switch from short-term plans to plans through the ACA marketplace because of health needs like an upcoming hip surgery.

“Honestly, if you want the most comprehensive coverage available, you buy ‘Obamacare.’ Period. End of story,” he said. “If you are willing to accept the limitations of a short-term medical plan, then buy it and enjoy the savings. They usually cost 30 to 40 percent of ‘Obamacare’ plans.”

A short-term medical plan doesn’t make sense for people with health problems, he said. And someone with a chronic illness could end up getting declined anyway. Short-term plans are not ACA-compliant and are therefore allowed to reject people with pre-existing conditions.

MORE: Arizona health premiums likely to drop in 2019 after years of increases

3. Cost could be a barrier

People who earn more than 400 percent of the federal poverty level don’t qualify for federal subsidies to help them pay for ACA insurance. For some people who just miss that 400 percent cut off, that can mean prohibitively high costs.

Take, for example, a 45-year-old single woman in Yavapai County who earns $50,000 per year, which is too much to qualify for a federal subsidy. The choice of Blue Cross Blue Shield plans for that woman range from $562.70 to  $856.39 per month, according to healthcare.gov. The annual deductibles are all $6,000 or more. 

Cost is still a major barrier for millions of Americans without health insurance, a new study from the Kaiser Family Foundation says.

For the first time since most provisions of the ACA were implemented in 2014, the number of uninsured people in the U.S. last year increased by 700,000 people to 27.4 million, the study says.

In Arizona, the number of uninsured people here rose by 11,600 people between 2016 and 2017, the study says.The study estimates 12 percent of Arizona’s population is uninsured, which is down from 20.5 percent in 2013.

4. People who auto-enroll haven’t been counted yet

The most recent data also doesn’t include people who signed up after Dec. 2.

And anyone who had ACA insurance in 2017 and takes no action to disenroll, to enroll in a different plan or to actively re-enroll has not yet been counted, either.

Malasnik said he’s encountered numerous clients in Maricopa County who are keeping their Ambetter from Arizona Complete Health plans from 2018.

“People just want to stay put,” he said. 

In all Arizona counties except for Maricopa and Pima, Blue Cross Blue Shield is the only insurance company selling marketplace plans, so people in those counties may just end up sitting back and auto-renewing what they already had.

“Next year will be the sixth year of coverage under Obamacare plans, so it’s logical to think that more people are satisfied with their plans and will auto-renew,” Gjersvig said.

But Gjersvig said all Arizonans who want to buy ACA insurance should consider their options and shop plans. In Maricopa County, three more insurance companies besides Ambetter have entered the market — Bright Health, Oscar Health and Cigna Health Insurance.

Pima County residents have more choice for 2019 plans, too. In addition to Ambetter, which was offered there in 2018, Blue Cross Blue Shield and Bright Health are offering plans in Pima County for 2019.

MORE: More health insurers to enter Arizona ACA marketplace in 2019

5. More people may get insurance through work

The economy has improved and more people are getting jobs. Average hourly wages have gone up, too. The number of Arizonans enrolled in Medicaid, a government insurance program for low-income Arizonans, is down 2 percent from the same time last year.

“A plausible explanation is that more people have employer-sponsored insurance,” Derksen said. 

6. Procrastination

There’s a procrastination factor in signing up for ACA plans, experts say.

“The last week is always the biggest week of enrollment. Unless this year is somehow different, that is always the pattern,” Gjersvig said. 

How to sign up for ‘Obamacare’

Those who need help signing up can go to www.coveraz.org, which also has a live chat option, or by calling 1-800-377-3536.

While some states operate their own exchanges, Arizona uses the federally facilitated marketplace, which operates via the website healthcare.gov.

Arizona consumers may also visit healthcare.gov to update their information, or add it for the first time, and select the health plan that best meets their needs. 

The phone number to get help via healthcare.gov is 1-800-318-2596.

READ MORE:

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