Open enrollment for health insurance under the Affordable Care Act begins Wednesday, and enrollees may see greater challenges this cycle following federal budget cuts.

Two cuts in particular could have serious ramifications for Texans looking to register on the federal market. President Donald Trump in an executive order slashed subsidies for cost-share reductions, which finance cheaper premiums for low- and middle-income customers. Trump also decreased funding for outreach and advertising by 90 percent, leaving many Americans in the dark about how and when to register.

The enrollment period has also been shortened, ending this year on Dec. 15 rather than January as in the past. Though several states have extended enrollment periods on their state health care markets, Texas, which relies on the federal Healthcare.gov as a platform for the insurance marketplace, has not.

A recent U.S. Census report showed about 4.5 million Texans still do not have health insurance. Though the number has been shrinking, Texas still has the largest percentage of residents without insurance, with 16.6 percent uninsured in 2016 compared to about 8.8 percent nationally.

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Though some states have enacted programs to make up for the federal cuts, Stacey Pogue, senior policy analyst at the Center for Public Policy Priorities, said she doubts Texas will pick up any slack.

"The state of Texas has not historically ... done anything to make enrollment better, to drive down prices, to add to competition, to get the word out," Pogue said. "There’s been virtually no state role in extending the good or mitigating the bad."

Despite slashed funding for cost-share reductions, insurers are still federally required to offer lowered rates for eligible customers. Those earning at the federal poverty level — $24,600 for a family of four, for example  — or up to four times that amount can qualify for premium reductions, and their premiums will not see dramatic increases this year, according to data from the Kaiser Family Foundation, a nonprofit research organization on health policy issues. But the funding for those lower rates will now have to come from other places, probably meaning increased rates for some plans not eligible for subsidies, Pogue said.

Others say those subsidies are part of the problem.

Drew White, senior federal policy analyst at the conservative Texas Public Policy Foundation called cost-share reduction subsidies unconstitutional because Congress never approved them. White said the true cause of rising premiums is over-regulation of the insurance market by the creation of the federal marketplace.

"We're living in this crazy system where we're keeping the regulations in place that are driving up patients' premiums and reducing their choices and creating this chaos, and then we're asking the same patients to fork over their tax dollars to give to insurance companies to then be used to suppress their premiums a little bit," White said. "That's insane."

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Some states have worked proactively to temper rising premiums, but not Texas. Ben Gonzalez, a spokesman for the Texas Department of Insurance, said in an email to the Tribune that neither the department nor any other state agency reviews or approves rates on the federal exchange.

It still is possible to automatically renew current plans into 2018, Karen Pollitz, senior fellow at the Kaiser Family Foundation, said during a media briefing — though she strongly advised shopping around as premiums on old plans may rise this year and better plans may become available.

Pogue said she would not be surprised to see fewer people enroll this year because of the decreased outreach and potentially dramatic changes in available insurance plans. More potential customers could be unaware of how to navigate the federal marketplace or of open enrollment at all, Pogue said. According to statistics by the Kaiser Family Foundation, 81 percent of uninsured adults under 61 did not know when open enrollment ends this year.

Cover Texas Now, a coalition of advocacy organizations for greater insurance coverage, has filled in some gaps in outreach and enrollment assistance. Melissa McChesney, outreach coordinator with the Center for Public Policy Priorities, which is part of Cover Texas Now, works to increase awareness of this year's changes to open enrollment and coordinate volunteers who can help customers navigate the insurance market.

Following news of Trump and Congress' agenda to dismantle the Affordable Care Act, McChesney said many customers are confused if the law still even exists, let alone how it has changed in the past few months. She also said enrollment can be inaccessibly convoluted for new enrollees and that customers who work with a trained navigator are 60 percent more likely to successfully enroll.

"[As] an individual consumer, you can have as many as 30 plans sitting in front of you, depending on where you live in the state," she said. "It's important to have somebody sitting with you that can help you understand what are the differences between each plan option."

Details about what plans will be on the market and how much they cost will become available when enrollment begins Wednesday.

Disclosure: The Center for Public Policy Priorities and Texas Public Policy Foundation have been financial supporters of The Texas Tribune. A complete list of Tribune donors and sponsors is available here.

Read related Tribune coverage:

  • More Texans are insured now than four years ago — but the state is still home to 4.5 million people without health coverage, the largest share in the country. [Full story]

  • Texans signing up this year for health insurance under the federal Affordable Care Act may see higher costs but should also qualify for larger subsidies. [Full story]

  • Doctors offering direct primary care charge a monthly fee for services that can be handled in the office. But patient advocates warn it is not insurance and offers no coverage for hospital or specialist care. [Full story]

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