It's sign-up season for the Affordable Care Act, but the Trump administration isn't making it easy – cutting the enrollment period in half, slashing advertising, and dialing back on counselors who help consumers get through the process.
Many people already faced fewer choices and higher premiums. But President Trump's decision to cancel a subsidy to insurers that lowers consumer costs compounded the turmoil, pushing premiums even higher.
Add it all up and the number of uninsured people may start rising again, eroding gains that drove the uninsured rate to a historic low.
"It certainly is a hostile takeover," said health policy expert Joe Antos of the right-leaning American Enterprise Institute. "We are going to see a decline in enrollment. The people who will drop out in droves are the ones who are not getting a premium subsidy."
Open enrollment starts Wednesday and ends Dec. 15 in most states, a sign-up period six weeks shorter than last year's.
Some 9 million to 10 million people currently have private plans through the ACA's government-sponsored markets. More than 8 in 10 receive subsidized premiums, and are cushioned from rate increases. Federal help paying premiums is still available despite GOP efforts to repeal the health law.
Subsidized customers have a strong incentive to renew, but how many new people will join remains an open question. They're vital because healthier, younger people are needed to keep rising premiums from destabilizing the marketplaces.
Already this year there was a big drop-off among consumers who buy individual coverage outside the government markets, and aren't eligible for premium subsidies. Their costs, however, are generally tied to rising "Obamacare" rates. A recent analysis found premiums for popular silver plans rising an average of 34 percent next year. Monthly premiums can be as a high as a mortgage payment in some cases.
Polls show widespread consumer confusion. Some are unsure if the health law has been repealed.
Trump administration officials say they're aiming for smooth and efficient sign-ups. HealthCare.gov has new features intended to make it more user-friendly and the call center is fully staffed.
Officials say they cut ads because spending so much money wasn't warranted, and the scaled-back counseling programs weren't enrolling many consumers. The programs take issue with that.
Consumers who already have "Obamacare" are worried.
"It's gone beyond what I would have called the politics of the normal," said Elizabeth Stone, a real estate agent in the Washington suburbs. She was diagnosed with lymphoma in her mid-20s, and with treatment has kept the cancer in check for five years. She doesn't qualify for subsidized premiums, but without the ACA she questions if any insurer would have covered her.
"People have forgotten that everyone can get sick," said Ms. Stone. "This battle has become so politicized that they're not thinking of the consequences for themselves, for their friends, and their families."
Karen Vied coaches people in treatment for substance abuse. She and her husband David live in Millsboro, Del., a short drive from the shore.
Ms. Vied said she voted for Mr. Trump because she believed he would deal with the opioid epidemic. Now she's scared, she says, because she and her husband rely on their subsidized ACA coverage for treatment for physical ailments.
"I literally wonder from day to day, am I going to have insurance next month?" said Karen. "I can't turn around and go from paying $450 a month for premiums to $2,000. That's just not going to happen."
Her husband said without insurance one hospitalization could wipe out their home equity. "I'm not asking the government to give me insurance, but I am asking them to do what they need to make it affordable," said David Vied. He voted for Hillary Clinton.
Trump's own words leave little doubt where his administration stands.
"ObamaCare is a broken mess," the president tweeted recently.
And on Sunday, he said: "As usual, the ObamaCare premiums will be up [the Dems own it], but we will Repeal & Replace and have great Healthcare soon after Tax Cuts."
While repeal remains Trump's goal, he also abruptly stopped paying a "cost sharing" subsidy to insurers. Officials say the payments were never properly approved by Congress, although they are called for under the ACA.
Those payments offset reduced copays and deductibles for people with modest incomes, and unless they're restored insurers will lose an estimated $1 billion the remainder of this year. State regulators have approved premium increases in the double digits to compensate insurers.
In Austin, Texas, a nonprofit that provides support services for the working poor is trying to prove Trump wrong. Foundation Communities has helped more than 22,800 enroll for coverage since 2014, without any federal money for its efforts.
"We're hoping to enroll about 5,000 people; of course we have to do that in half the time," said insurance program director Elizabeth Colvin. "Full steam ahead."
Around the country, other nonprofits are ramping up. Some insurers plan on advertising. States running their own insurance markets remain focused on growing enrollment.
In Las Vegas, lawyer Kaine Messer says he and his wife decided to renew their unsubsidized plan partly as a way of standing with their community – "Vegas Strong."
Pondering the mass shooting that traumatized the city, Mr. Messer said it dawned on him that the hundreds injured would need health insurance to recover. Before the ACA, their wounds might have been deemed a pre-existing condition and a barrier to coverage.
"While Obamacare is by no means perfect," said Messer, "it is a step in the right direction."
This story was reported by the Associated Press.