By Rose Hoban

It seemed like this year’s Affordable Care Act open enrollment was going to be lackluster, after all, at the end of six weeks of the online marketplace being open, only 236,693 North Carolinians had signed up for health insurance coverage, less than 50 percent of last year’s total.

But the last week of open enrollment almost always packs a surprise punch.

“People are procrastinators,” said Mark Van Arnam, the head of the North Carolina Navigators Network, a group that promotes access to insurance through the online Obamacare marketplace. “We saw traffic picking up [at the end], as it normally does.”

Van Arnam had been criss-crossing the state, attending enrollment events and rallying the small army of volunteers to assist people through the sometimes complicated process of buying insurance online before the deadline at midnight last Saturday.

“I was at an enrollment event in Winston-Salem as the final hours wound down,” he said. “People were calling into the site that we were at, because… our call center had closed by that point.

NewsMatch announcement: We are the only newsroom in NC fully dedicated to covering health. Your donation TRIPLED thru Dec. 31 thanks to NewsMatch. Donate at“They were asking if they could get there by 7:30 or 8:00 and would we still be there?”

In the end, 502,464 North Carolinians signed up for health insurance, down only about 3 percent from last year’s tally, and in line with enrollment trends across the nation.

Van Arnam said his organization encountered tens of thousands of people over the past year at more than 1,600 informational events, and his people did a final push to send out emails and make phone calls. But he also admitted that much of the enrollment surge came from people who simply re-enrolled in the same plan they had this year.

While the number of enrollments is strong, it’s down 18 percent from a high enrollment mark of 613,487 in 2016.

Nonetheless, the final count was surprisingly robust, said Mark Holmes, a professor of health economics at the Gillings School of Global Public Health at UNC Chapel Hill. He said that’s despite considerable headwinds.

“We’ve seen relatively invisible changes… to the way that the marketplaces are run that have led to decreases in the number of people who sign up through them,” Holmes said. He noted court decisions, including one handed down late last week where a district court judge ruled the entire Affordable Care Act unconstitutional, had lead to confusion for many potential enrollees.

2017 saw a steady drumbeat of news about Congress attempting to repeal the Affordable Care Act, attempts which ultimately failed, but which may have lead to consumer confusion, Van Arnam said.

In addition, the Trump administration made changes to other parts of the insurance market, making allowances for short-term insurance plans that are cheaper, but that don’t provide all of the guarantees found in ACA-compliant plans. Then at the end of 2017, Congress eliminated the penalty for not buying insurance that was part of the individual mandate, eliminating one incentive to purchase coverage.

All of this was on top of cuts to the marketing budget for encouraging enrollment and fewer weeks to sign up.

“It’s hard to get people to buy something that seems to always be changing just a little bit and you’re not really sure what you’re getting,” Holmes said.

Fewer adults with coverage

The steady ratcheting down of Obamacare insurance enrollees has been paralleled by a slow uptick in the number of uninsured people in 2016 and 2017.

The number of uninsured Americans reached a low point of 9.8 percent in 2016, but a recent study in the journal Health Affairs finds an “erosion of the ACA’s coverage gains, especially in Medicaid nonexpansion states.”

The number of uninsured Americans had crept back up to 10.8 percent by the first quarter of 2018.

graphic shows rates of uninsured for adults in Medicaid expansion and non-expansion states, as well as the overall adult average
Trends in Uninsurance Among Adults Ages 18 to 64, by 2018 State ACA Medicaid Expansion Status, Quarter 3 2013 to Quarter 1 2018 Graphic courtesy: Health Affairs

A similar erosion of coverage occurred in North Carolina.

“The rate of uninsured went up a bit from 12.3 percent in 2016 to 12.7 percent in 2017, and this is among adults under the age of 64,” explained Michelle Ries, a project director at the North Carolina Institute of Medicine.

She said that while cost is a barrier for some, many of the people without insurance earn enough to qualify for subsidies on the Affordable Care Act insurance marketplace that could bring their insurance costs to almost nothing.

“There’s a big awareness barrier also about the subsidies that people might be eligible for,” she said.

Uninsurance Rates Among Adults Ages 18 to 64, by 2018 State ACA Medicaid Expansion Status and Family Income, Quarter 1 2018 Graphic courtesy: Health Affairs

Holmes said it “defies logic” to see increases in the number of uninsured in such a strong economy and job market.

“We’ve really known how, in the past, that strong economies lead to decreases in the uninsured rate,” he said. “Here we have the opposite trend and we can really only look to policy changes as a major driver of those differences.”

Fewer kids too

Of concern to many advocates was the uptick in the number of kids under the age of 18 who lacked insurance this past year, said Ciara Zachary from NC Child.

A study from the Georgetown Center for Children and Families found an increase in the number of uninsured children nationwide for the first time since they’ve kept count.

Nationwide, “the rate for children age 18 and under went up from 4.7 percent in 2016 to 5 percent in 2017, according to our analysis of U.S. Census Bureau’s American Community Survey data,” wrote Joan Alker, who leads the center.

graphic shows steady decrease in uninsured rate since 2008, with an upturn in 2017
Graphic courtesy: Georgetown Center for Children and Families

Alker also noted a rising number of uninsured kids happening even as the economy strengthened.

In North Carolina, the uptick consisted of about 4,000 more kids who lacked coverage, increasing the overall number of uninsured children to about 119,000, the report showed.

Zachary said that leaving kids uninsured creates risks for their future.

“We know it from studies of public health coverage, like Medicaid, [coverage] is really key in making sure that children get the screenings and the immunizations and the well-checks that they need as a young child to really build that foundation,” for long-term health, she said.

Coverage of adults has been found to be correlated to coverage in children, the Institute of Medicine’s Ries said.

“As parents are seeking out services for their children, they find out about services or programs or plans that they might be eligible for just in that process of connecting with the system,” she said. “We also see that parents who have health insurance tend to have healthier children.”

So, the increased number of uncovered adults could be related to the number of kids without coverage, she said.

“When parents are insured, their kids are insured,” Zachary added. “So once parents start losing insurance and don’t access care, the more children are at risk.”

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...