The Trump administration's efforts to undermine the Affordable Care Act have health care advocates and insurers concerned that the open enrollment period will be one of chaos and confusion.
That's not true everywhere.
A dozen states operate their own health insurance marketplaces, maintaining control over advertising and the help they can offer consumers. That will create a striking difference when open enrollment begins Wednesday between those states and the others that rely on the federal marketplace, essentially creating a tale of two countries.
For the individual health insurance market in much of the country, the Trump administration has slashed spending on advertising by 90 percent and drastically reduced budgets for the groups that help consumers choose a plan.
It cut the open enrollment period in half, to six weeks. Shortening the sign-up window further, the federal government will shut down its online marketplace, healthcare.gov, for 12 hours of maintenance nearly every Sunday during open enrollment.
The 12 states with their own exchanges are free to chart their own course and make it easier on consumers.
Nine have extended open enrollment beyond Dec. 15 — by a week in some states and six weeks in others.
They also can make their own decisions about spending because their budgets are free from Washington politics. State-run exchanges typically pay for their operations through fees charged to insurers on plans sold through their marketplace.
Minnesota, Colorado and Washington will continue heavy advertising for their exchanges. Thousands of enrollment specialists will continue to help consumers navigate insurance plans in California and New York.
For many of these states, 2018 looks like a payoff for the political risks and costs they assumed when they decided to set up their own exchanges.
"When I think about what's going on at the federal level, I'm sure glad we have the reins here at the state," said Allison O'Toole, director of Minnesota's health insurance exchange, MNsure.
With the help of a separate and costly state program that is keeping premiums stable for 2018, O'Toole said she thinks Minnesota's exchange may be on track for its best year yet.
No state is totally immune from the spikes in insurance premiums since the health care overhaul launched in 2014.
Many states are bracing for double-digit rate hikes in the individual market, from an average increase of 12.5 percent in California to jumps of roughly 45 percent in Florida and nearly 60 percent in Iowa. Premiums for the most popular plans are up 34 percent nationwide, on average.
Millions of shoppers, whether they buy coverage on HealthCare.gov or through their state's marketplace, will see another modest spike after Trump's decision earlier this month to halt payments to insurers that help cover some consumers' deductibles and co-pays. Trump called those cost-sharing payments "bailouts" to insurance companies.
The federal subsidy on actual premiums remains, but some state officials are concerned that consumers will be confused and believe those, too, have been eliminated. The worry is that they simply would not bother to shop for a plan, thinking they couldn't afford it. About 12 million Americans buy individual overage on the exchanges, according to the Kaiser Family Foundation.
The morning after Trump's Oct. 12 announcement, Colorado's Connect for Health exchange sent an email blast to current and prospective enrollees, stressing that "financial help is still available for 2018."
That's the kind of autonomy that gives states with an independent marketplace an upper-hand, said Larry Levitt of the nonpartisan Kaiser Family Foundation.
"That's where state-based exchanges are maybe in the best position to help stabilize markets, by just putting extra resources into educating consumers in a very confusing time," he said. "They have the ability to dial that up at times like this."
Amid the changes at the federal level, California is staying the course. As always, open enrollment on Covered California, the state marketplace, will run through January.
Its $66 million advertising budget is steady from last year — and more than six times the total that HealthCare.gov will spend in all 38 states it covers.
Peter Lee, Covered California's executive director, was perplexed by the Trump administration's decision to gut advertising spending. With premiums on the rise and confusion mounting, promotion and marketing are more critical than ever, he said.
"Health insurance needs to be sold. To walk away from selling it is a formula for increased costs," Lee said.
In Washington state, lawmakers set aside an extra $1.5 million to help their marketplace cut through the confusion.
The state's Healthplanfinder has added four enrollment centers — for a total of six — and is running digital and radio ads that promote the exchange as a beacon of stability amid the uncertainty in much of the rest of the nation.
Chief Marketing Officer Michael Marchand is grateful for Washington's independence from the federally run marketplace. That is particularly true when it comes to so-called navigators, the specialists who fan out across the state to help consumers study various plans and enroll.
State-based exchanges in Washington and elsewhere are maintaining their funding levels at a time when the federal government has slashed navigator grants from $63 million to $36 million.
"They have to play by the house rules," Marchand said of the states using the federal marketplace. "That's a difficult thing."