Two months before President-elect Donald Trump begins his attempt to repeal the Affordable Care Act, the Obama administration and its allies are making an aggressive final push to sign-up some of the program’s most reluctant customers -- young people.

Healthy and new to the workforce, the “young invincibles” -- people aged 25 to 34 -- represent the highest uninsured rate of Americans, according to a survey released in November by the Centers for Disease Control and Prevention. While coverage of people in that range has grown under Obamacare, the group has for the last five years had the highest rates of uninsurance compared to other age bands.

Their participation is critical to the law’s future, politically and as a way to stabilize its insurance markets. The young and healthy offer not only a constituency of supporters, they can also help balance the cost of older, sicker people.

“The more people that enroll this year, the harder it will be to repeal or replace the law,” said Larry Levitt, senior vice president at the Kaiser Family Foundation, a health research and advocacy group. “If enrollment doesn’t grow, particularly among young and healthy people, it could undermine the entire insurance market.”

Enroll America, an Obamacare advocacy organization that’s been central to sign-up efforts, said its working with the U.S. Department of Health and Human Services and more than 15 other organizations to go after young people online and in person.

Groups are holding sign-up events at restaurants and bars to draw a younger crowd; and more than 350 colleges and universities have signed up for this year’s on-campus sign-up efforts.

Reluctant to enroll

Despite those efforts, advocates for the law still haven’t cracked the code to get America’s youth insured. Some find the cost of Obamacare plans unaffordable, while others haven’t found a plan that works for them.

Megan Tice-Royea, 29, didn’t sign up for health insurance last year. “I’ve always been a healthy person,” Tice-Royea said in a phone interview. She works 40 hours a week as a manager at a family grocery store in Newport, Vermont, a job that pays $14 an hour. In September, she was admitted to the hospital with a gallbladder infection. The surgery left her $32,000 in debt.

“I knew I couldn’t afford it,” she said. “It was a life-or-death situation.” Now she’s considering signing up for an insurance plan through Obamacare, but only if it will help pay off her earlier medical bills. “I feel like this is the only way to go. I just wish we had better options.”

Unstable market

Millions of people have gained coverage under Obamacare, bringing the uninsured rate to a near-record low. At the same time, premiums for insurance plans in the program are rising rapidly -- by an average of 22 percent next year for mid-level plans, according to a report from the U.S. Department of Health and Human Services. Part of the blame for the rising premiums is the failure to attract the young and healthy.

Trump has attacked the cost of plans under the law as bad for the youth. “This is particularly unfair to millennials and younger Americans generally who will be totally crushed by these massive health-care costs before they even get started on their journey through life,” Trump said in a Nov. 1 speech. He’s promised to repeal and replace or amend Obamacare as one of his first acts in office.

Basic health insurance plans under the law can protect against catastrophic expenses like Tice-Royea’s bills, but also often feature deductibles that require spending thousands of dollars before most coverage kicks in -- leaving many young people to question the value of what they’re buying, especially at an early, lower-earning stage of their time in the workforce.

Worth it?

Even after her surgery, Tice-Royea is still unsure she wants to buy insurance.

“The deductible is super high, so the only way it would benefit me is if I had another surgery,” she said.

For others, getting insured isn’t a priority -- at least not compared to their other obligations. In October, Mark Bertolini, the chief executive officer of health insurer Aetna Inc., said that “young people can do the math. Gas for the car, beer on Fridays and Saturdays, health insurance.”

Maria Puche, 23, is a student and part-time worker in Irving, Texas. She lost her insurance three months ago when her mother switched jobs.

“It’s hard for me to take classes, work, and pay for everything at the same time.” she said. “I’m trying not to get sick.” With all of that, she said she hasn’t had time to think much about signing up for health insurance on her own.

That’s not uncommon, said Ebonee Rice, national strategic partnerships director at Enroll America. Many people don’t know about available assistance -- even though about 77 percent of current enrollees can find a plan for less than $100 a month when tax subsidies are taken into account, according to the Department of Health and Human Services.

“When young people have to choose between paying student loans and paying health insurance,” Rice said, “it seems like the easier option is to pay attention to more pressing things.”

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