As Nevadans continue casting ballots in an election that has the potential to shape the future of the Affordable Care Act on both the state and federal level, the state’s health insurance exchange is kicking off its sixth open enrollment period on Thursday.

The runup to the election has been dominated by talk of the Affordable Care Act (ACA), its protections for pre-existing conditions and what the future of health care should look like in Nevada and across the nation. But while the conversation headed into open enrollment last year centered around immediate threats to repeal and replace the ACA and the overall fragility of the individual health insurance market, this year has been marked by slow efforts to chip away at the federal health-care law.

Rule changes put forward earlier this year by the Trump administration loosening restrictions on two types of non-ACA compliant health plans are slowly and quietly changing the health-care landscape without attracting the panic-inducing headlines of last year warning that premiums on Nevada’s exchange were increasing by more than a third or that 14 rural Nevada counties briefly faced the threat of having no insurers offer plans on the exchange.

Heather Korbulic, head of Nevada’s health insurance exchange, said the constant focus on instability of the ACA last year in some ways actually increased awareness among consumers about open enrollment and allowed the exchange to overcome setbacks, including a shortened 45-day open enrollment period. In fact, last year 91,000 Nevadans enrolled in health plans through the exchange, the highest-ever number for the state.

But this year, the exchange is facing the same challenges as last year — including the same 45-day enrollment period, which runs from Nov. 1 to Dec. 15 — without the same kind of increased attention. Korbulic said that the comparatively wonky policy conversation being had about health care this year may not be filtering down to everyday Nevadans and encouraging them to sign up for plans with the exchange.

“I don’t know that we’ve generated that same level of interest,” Korublic said. “We’re having a system-level, policy-level conversation that is fascinating to me, but it doesn’t bring awareness to now is the time to get enrolled.”

Both insurance companies that offered plans on the exchange last year — Health Plan of Nevada and SilverSummit Healthplan — are continuing to offer plans to Nevadans. Residents of Clark, Nye and Washoe counties can choose between 14 health plans between the two companies, while those in the rest of the state can choose between five plans offered by SilverSummit.

Premiums have also gone slightly down this year, 0.4 percent on average, though that decrease is only a tiny dent in the 37 percent increase in premiums seen last year. About 80 percent of Nevadans who purchase plans on the exchange make 400 percent or less of the federal poverty level, meaning that they are eligible for subsidies on the federal government to help them purchase insurance, but the rest will continue to shoulder the burden of paying for the rate increases from last year.

“It’s a notable, dire cost for consumers who are not being subsidized,” Korublic said.

The exchange also has a new challenge this year. In December, Congress repealed the tax penalty associated with the ACA’s individual mandate to purchase health insurance as part of its tax reform package. Still, it is not clear how many people realize that they will no longer face a tax penalty should they choose to forego health insurance, Korbulic said.

“It’s very tricky to know who even knows that that’s the case,” she said.

That’s why Nevada’s health insurance exchange is being proactive about targeting the demographic group most likely to forego health insurance or purchase a non-ACA compliant health plan if given the choice — young people between the ages of 26 and 40. The exchange has focused its ad buys on online video and music streaming platforms and other sites frequented by millenials and is promoting the message that “you can’t afford not to be insured” by highlighting the high costs of medical care without insurance, even for small accidents.

It is also difficult to determine what kind of impact that the Trump administration’s changes to association health plans — which are being offered by several chambers of commerce in Nevada to small businesses and sole proprietors and aren’t required to follow the same requirements as plans sold on the exchange — and short-term limited duration plans, which are also exempt from ACA rules, will have on enrollment this year. Korbulic said that she’s “comforted” by what she’s heard from brokers about the benefits included in association health plans but cautioned people to look closely at the benefits offered by short-term limited duration plans, which typically only offer limited benefits.

Whether people choose to migrate to those types of plans is “still to be determined,” Korublic said. She urged Nevadans to work with a navigator organization or broker that the exchange partners with to find the best insurance option that fits them.

“We always emphasize the same high-level message: There are great, affordable options on the exchange,” Korbulic said. “Our plans are really comprehensive, but work with an enrollment professional to make sure you’re getting a plan that’s right for you.”