The Trump administration cut the advertising budget for health insurance markets, leading to an increase in uninsured Americans.
More Americans are going without health insurance, and stable premiums plus greater choice next year under the Obama health law aren't likely to reverse that.
As sign-up season starts on Friday, the Affordable Care Act has shown remarkable resiliency, but it has also fallen short of expectations. Even many Democrats want to move on.
Donald Trump doesn't conceal his disdain for "Obamacare" and keeps trying to dismantle the program.
During President Barack Obama's tenure, open enrollment involved a national campaign to get people signed up. The program's complexity was always a problem, and many lower-income people didn't understand they could get financial help with premiums.
For example, the nonpartisan Kaiser Family Foundation has estimated that some 4 million uninsured people may be eligible for coverage at no monthly cost to them, after taking subsidies into account. Zero-premium plans are skimpy, but experts say it beats going uninsured.
But the Trump administration says it's not specifically advertising that. Early on, it slashed the Obamacare ad budget. Officials say they're focused on providing a quality sign-up experience and keeping the HealthCare.gov website running smoothly.
Democrats who once touted the health overhaul as a generational achievement now see it as a stepping stone, not the final word.
Presidential candidates Bernie Sanders and Elizabeth Warren would bring the 20 million people covered under the law into a new government-run system for all Americans. "It's time for the next step," says Warren.
Former Vice President Joe Biden, who asserts "Obamacare is working," is proposing a major expansion of current ACA subsidies and a whole new "public option" insurance program.
For John Gold, a self-employed graphic designer from Maine, health care that's stable, affordable and comprehensive still feels more like a goal than a reality. He's been covered by the ACA since 2014.
"It's a great start, but it's not the be-all and end-all of health care," he said.
Health care "takes up too much of my budget, and it doesn't need to," explained Gold, who lives near Portland. "There are appointments my doctor suggests, that I turn down because it's going to cost me $300."
Gold's income fluctuates, and when he makes too much to qualify for subsidized premiums, he must pay full freight. He's in his 50s, so his monthly cost is higher, about $700. On top of that, the plan comes with a $4,000 deductible and an $8,000 out-of-pocket limit, potentially leaving him on the hook for a lot more.
Nonetheless, Gold said he hasn't looked at the cheaper alternative the Trump administration is touting, though it can cost up to 60% less. One reason is "short-term plans" don't have to cover pre-existing medical conditions.
With the economy strong, it's unusual for progress to falter on America's uninsured rate. Yet the Census Bureau reported that 27.5 million people were uninsured in 2018, an increase of nearly 1.9 million from 2017, and the first time the rate went up in a decade.
Caroline Pearson, a health insurance expert with the nonpartisan NORC research institution at the University of Chicago, said she doesn't expect to see ACA coverage gains in 2020.
"Premiums are still expensive for people who have other costs," said Pearson. "It's a challenging proposition unless you are getting a big subsidy or really need insurance."
Enrollment has been slowly eroding since Trump took office, from 12.2 million in 2017 to 11.4 million this year. The drop has come mainly in HealthCare.gov states, where the federal government runs sign-up season. State-run insurance markets have held their own.
But Trump administration officials say they're doing just fine managing Obamacare. They recently announced that premiums for a hypothetical 27-year-old choosing a standard plan will decline 4% on average in 2020 in HealthCare.gov states.
Despite the relatively good news on premiums, Trump's actions still cast a shadow over the ACA's future.
His administration is asking a federal appeals court in New Orleans to strike down the entire law as unconstitutional. The White House has released no plans to replace it.
Seema Verma, the top administration official overseeing the health law, sounded confident in a recent appearance before a House committee.
"The president has made clear that we will have a plan of action to make sure Americans will have access to health care," Verma, head of the Centers for Medicare and Medicaid Services, said when asked about the court case. But she added, "I'm not going to get into any specifics."
A decision in the court case could come any day. Whatever they decide, it's likely to go to the Supreme Court.
Gold, the graphic designer from Maine, is worried. "I do not trust them to replace it with something better," he said.
Sign-up season ends Dec. 15 in most states. Coverage starts Jan. 1.