Early reports suggest that even more New Jersey residents signed up for insurance policies governed by the Affordable Care Act in recent months than in the same period last year, despite federal efforts to diminish enrollment and amid growing uncertainty over the future of the landmark law.

The lack of clarity regarding potential reform of the ACA, and the influx of new patients with potentially unmet health needs, leaves insurance companies without effective guideposts as they craft policies and determine if they will participate in the ACA marketplace next year, a decision they must make in the coming months.

President Donald Trump and Republicans in Congress have made repealing the ACA, or Obamacare, a priority. And, while Trump has promised to replace it with another system that will protect those now insured, details are scarce and the president said it may take a year for a replacement to be realized.

Despite the Trump administration’s efforts to downplay the recent ACA enrollment period by suspending outreach ads and marketing, data released last week by the Centers for Medicare and Medicaid Services showed more than 295,000 Garden State residents signed up between November and February — at least 8,000 more than submitted applications during last year’s enrollment period.

Data from the state Department of Banking and Insurance suggests that, based on past years, roughly 105,000 additional individuals most likely bought ACA-regulated policies directly from the carriers, without the benefit of the federal subsidies that help offset the cost of commercial policies. New numbers from the latest enrollment period have yet to be reported for these plans.

Individual market could have 40,000 more insured

Some who sign up for marketplace policies don’t follow through with premium payments and are never technically enrolled — so the final enrollee figure may be lower than early numbers indicate. But Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, said this individual market could still end up with nearly 400,000 people insured — or 40,000 more than last year. Many of these new enrollees, who may have seen this as a last chance for coverage, are likely to have unmet health needs that will require costly care, she noted.

“I think there is definitely demand in New Jersey,” Schwimmer said. “The question is, are you going to have a more expensive group of people now and what does that mean for insurers” as they price products for the coming year, she added.

To help address these concerns, Sen. Joe Vitale (D-Middlesex), the longtime chair of the Senate health committee, has asked the Health Care Quality Institute to lead a work group that will explore the impact of potential ACA reform on the individual insurance market.

The panel will include representatives of hospitals and healthcare systems, pharmacies, health insurance plans, employer groups and consumer advocates, among others, Schwimmer said — “people who are willing to leave their day-job hat to make New Jersey’s individual market work.” At one point, Garden State consumers had a half-dozen plans to choose from in this market; today, only two companies are doing business here.

(The ACA also extended Medicaid coverage to reach an additional 500,000 New Jersey residents; these individuals join FamilyCare plans coordinated by the state. Debate continues over how these patients would be covered in the future, but Gov. Chris Christie has expressed support for one likely option: federal block grants, which limit resources but give states more flexibility.)

Opting for cheap, bare-bones plans

New Jersey’s individual insurance market has a volatile history. According to a report released in September by the Rutgers Center for State Health Policy, before the ACA took full effect in 2014, this market covered fewer than 150,000 people — typically couples or families that didn’t have access to insurance through a work plan and earned too much to qualify for Medicaid. At least two-thirds of these people opted for cheap, bare-bones plans that covered major medical expenses only, with high out-of-pocket costs, the report found.

But the ACA also included a host of insurance regulations designed to make sure patients could get insurance and that it would be broad, comprehensive coverage. People can no longer be denied for pre-existing conditions and insurance plans must pay for behavioral healthcare, birth control, and preventive care. While many of these protections were built into New Jersey law before the ACA took full effect, the bare-bones policies sold in the past are no longer legal under the federal law.

Trump and congressional Republicans have spoken in favor of some of these protections, but on his first day in office the president signed an executive order that may prevent other aspects of the law from being upheld in the coming year — including the tax penalty the ACA required of anyone who didn’t enroll in insurance coverage of some kind. Experts agree the penalty is a critical mechanism needed to encourage participation of healthy people, a group that insurance companies need in order to balance out the risk associated with covering patients who have major health issues.

Meanwhile, anger continues to grow among patients — both Medicaid expansion and marketplace customers — over the likelihood of a repeal of the ACA. The NJ For Health Care coalition — a group of patient advocates, business leaders, labor groups, and other stakeholders — has continued to hold weekly vigils outside the offices of New Jersey’s GOP congress members in hopes of convincing them to oppose the law’s repeal. (A Garden State congressman, Tom MacArthur (R-Ocean), was one of only nine GOP members to join Democrats in a January vote against repeal.)

Although the Rutgers report documented numerous problems with the marketplace enrollment process — patients complained of confusing options, prohibitively high plan costs, and a lack of guidance from federal officials — many involved in the sign-up process said they had never seen such “grateful” clients. Enrollment counselors described patients who hadn’t had insurance in 20 years and were excited by the possibility, with at least one asking, “So you mean I can finally go to the doctor?”