The young Philadelphian who walked up to Jessy Foster's table at the health-care enrollment fair on Friday afternoon had a lot of questions, but saved the biggest for last: What was going to happen?
"I heard something about defunding? Do you know?"
It was a question Foster, the lead community engagement specialist at the Pennsylvania Health Access Network (PAHAN), has heard almost constantly this year, since President Trump and congressional Republicans set out to repeal the Affordable Care Act — and, failing that, to dismantle it from the Oval Office.
Confusion has permeated her work since the enrollment period — when people can sign up for a plan on the federal health-care marketplace — began last week.
The Affordable Care Act — despite multiple repeal attempts and an executive order aimed at hobbling it — is still the law of the land. But this enrollment period, by Trumpian design, has posed particular challenges for insurance navigators like Foster and the people they will help to sign up over the next few weeks.
Normally, people have from Nov. 1 to Jan. 31 to sign up for a plan; this year, they have until Dec. 15. Normally, the federal government spends some $100 million nationwide on advertising encouraging people to sign up for health care; this year, it's spending $10 million.
And Trump, who has spent months on Twitter threatening to "let Obamacare fail" and is now apparently trying to help it down that road, has stopped paying insurers the cost-sharing reductions that cover some patients' co-pays and deductibles, spurring a panic about rising premiums.
"I don't think I anticipated quite how intentionally the administration would undermine the law," said Jessica Altman, the state's acting insurance commissioner.
So: How do you go about persuading people to sign up for health-care coverage that half of Congress despises, that the president is actively seeking to disrupt, and that may not exist in the foreseeable future?
Navigators say they're simply trying to stay the course — and remind people that, despite the turmoil in Washington, they can still get health insurance.
"It's difficult having to tell people that we don't know what will happen to health care," said Darlice Rocha, a navigator with the Public Health Management Corporation on hand at the enrollment fair at the Free Library's central branch on Friday. "But I really believe in what we do."
At the next table, Hannah Kamara, a community health specialist at the Health Federation who has worked through every enrollment period since the ACA took effect, walked Angela Vann through her options.
Vann, who has a seizure disorder, relies on the health plan her husband gets at work, which has debilitatingly high premiums. On Friday, she wanted to see if she could get a better deal on the health-care exchange. She had followed the repeal attempts closely, she said, trying to calculate how much more her health-care costs would have risen if Republicans had succeeded. She hadn't been pleased with the results.
"What exhausts me," she said, "was that [lawmakers] were talking about insurance companies. They weren't talking about us. They're not asking, 'What do most Americans need?' "
For many health advocates, dispelling misinformation about the repeals and Trump's own actions against the law has become part of their job.
Altman, of the state Insurance Department, said she'd fielded calls from people concerned about skyrocketing premiums, or losing their financial assistance. But in a perverse twist, she said, many people may end up paying less for ACA insurance this year.
For example: When Trump stopped paying for cost-sharing reductions, he kicked that expense onto insurers, who subsequently increased premiums to make up for the cost. But when premiums increase, so do the tax credits that help some 80 percent of people on the exchange pay for them — which means that some will end up paying nothing for health care. Others might be able to afford pricier plans that were once out of reach.
In short, Trump's efforts to sabotage the law — which he's framed as a bargaining chip designed to force Democrats to the table — may have actually made it more affordable, and expended more federal dollars, than it would have if Trump had just let things be, Altman said.
On Friday at the library, Foster spent a half hour working with her applicant — who identifies as nonbinary and trans-masculine and asked not to be identified by name. Foster passed pamphlets across the table, circled the important parts, dutifully entered information into sign-up forms. Financial assistance, she said reassuringly, was still available.
The 26-year-old, new to the city, had gotten health care through Medicaid for the last few years, and was looking to see what options were available. Following the health-care debate this year — all that uncertainty, all those proposed cuts — had been exhausting.