Former Health and Human Services Secretary Kathleen Sebelius said in a radio interview that there was "no question" that the Trump administration was actively sabotaging the ACA, noting in the report that the cut to advertising for the sign-up site alone "probably dampened this year's enrollment by about a million and a half people." 

Republicans' failed attempts to repeal and replace the ACA have spawned suggestions from bipartisan and Democratic groups, as well as independent consultants such as Oliver Wyman, on ways to support the ACA rather than kill it. And despite the administration's actions so far in the opposite direction, Slavitt says in the interview that if the administration decides to change its tactics, the ACA could be strengthened by additional signups. 

Slavitt says three things must be done right for a successful enrollment period. First, the technology must be "capable of scaling to meet the demand, which means you have to have some understanding of what the demand is." 

Next, operations must be working properly, with all policy changes made throughout the year implemented well on the website and on the call center, and there must be enough call center capacity. 

And third, outreach must be working, with numerous goals already achieved and actions already taken — such as notifying people of changes they need to be aware of. Says Slavitt, "For example, if they've had a plan change because there's a new plan in their market or their plan no longer exists, they've got an IRS issue that you want to make them aware of, you want to make sure they're aware of the new dates for open enrollment because they've changed, and … you've engaged local assisters and in-person help." 

However, he adds that two call centers have been closed, and the cancellation of ads for outreach will be problematic for both enrollment and reenrollment. Had all the actions been taken for a successful enrollment period, Slavitt says that this year could have seen record enrollments—particularly since the exchanges are more stable now than they were in the beginning of the ACA. 

In the report, Slavitt says that "this year, you can measure the impact on rates from actions the Trump administration has specifically chosen to take. Really, even if you just limit it to two actions: the decision to not enforce the individual mandate vigorously or leave it very ambivalent, and then the not making a commitment to pay for cost-sharing reductions. You know, those things have been estimated by the Congressional Budget Office, and certainly backed up by other independent analysts, as much as half to two-thirds of all the rate increases." 

Still, despite the inaction — or action detrimental to enrollment — already taken by the administration, he says it's not too late for a successful enrollment period. He concludes, "It's just a matter of deciding to do a good job versus deciding not to care. But all the pieces are in place for that to happen."