Since President Obama’s Affordable Care Act was signed seven years ago this month, it has remained in the forefront of controversy.

Nearly 114,000 Clark County residents are enrolled, but many voters remain dissatisfied. Leaders at the federal and state level are divided, but nonetheless reform seems likely. Today, we look at the act, and how its repeal or redesign could affect our community.

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What’s at stake

Complex rules could be scrapped, changed in repeal of ACA

Within the 1,000 pages of the Affordable Care Act are well-known components, such as the individual mandate requiring everyone to have insurance, as well as pieces that some may forget are tied to the law, such as the requirement that chain restaurants include calorie content on their menus.
Here is a list of some of the things included in the ACA and could be at stake if the law is repealed:

• Elimination of lifetime limits on insurance coverage.
• Free preventive care, such as mammograms and colonoscopies, including for those on Medicare.
• Young adults’ remaining on a parent’s insurance plan until age 26.
• Medicaid expansion.
• Requirement that 80 to 85 percent of premiums be spent on benefits (otherwise, rebates must be paid).
• Prohibiting discrimination due to pre-existing conditions or gender.
• No-cost birth control.
• Tax credits to help cover the cost of health coverage.
• Coverage for breast-feeding support and breast pumps.
• Prescription drug coverage included in all plans.
• Rules requiring employers to provide a place for moms to express breast milk and reasonable breaks to do so.
• Individual mandate requiring everyone to have insurance coverage.
• Discounts on name-brand drugs for Medicare beneficiaries (addressing the “donut hole”).
• Elimination of annual limits on insurance coverage.
• Menu labeling requirements for major restaurants.
• Coverage of mental and behavioral health services in all plans.
• Insurance companies required to justify premium increases of 10 percent or more.
• Guaranteed right to appeal an insurance plan denial.
• Coverage of tobacco-use cessation in all plans.

Q & A with state and local officials

Talk of an Affordable Care Act repeal has brought up many questions. We turned to state Insurance Commissioner Mike Kreidler and local elected officials for answers to some common questions.

Is the plan I purchased for 2017 safe, even if the Affordable Care Act is repealed?

It depends.

“It’s entirely possible that you could see something destabilize the market so badly that you don’t even get through 2017,” said Kreidler.

For example, the House v. Price lawsuit alleges that the government illegally allocated billions of dollars to insurance companies to subsidize the cost of health coverage. House Republicans — who originally filed the lawsuit against the Obama administration in 2014 — recently asked the U.S. Court of Appeals to delay the case.

“That would have knocked out funding for subsidies for people in the health insurance exchanges,” Kreidler said. “The subsidies would have gone away overnight. I can tell you, if you did that, the exchange would go away overnight.”

The lawsuit was the “preeminent threat,” Kreidler said. With that decision on hold, Kreidler doesn’t expect anything to change this year.

“The odds are very strong that things stay in place for 2017,” he said. “’(20)18 is the big question.”

I have health coverage through my employer. How will my plan be affected by a repeal?

“I would not anticipate a major change,” Kreidler said.

The ACA requires every health plan to cover 10 essential health benefits, which include emergency services, prescription drugs and maternity care. The large employer plans were the basis for that requirement, since most included those benefits, Kreidler said.

Such comprehensive plans help employers with employee recruiting and retention, so they’re likely to keep the coverage in place, he said.

What happens to people on Apple Health (Medicaid) if the Affordable Care Act is repealed?

“2017 would be good,” Kreidler said. “We’re still just holding our breath for what happens in 2018.”

Those who were covered by Medicaid before the expansion — predominantly pregnant women and children — would still have coverage. But the single adults who acquired coverage through the expansion would likely lose coverage or see their benefits decrease, Kreidler said.

Currently, the federal government pays for 95 percent of the cost of coverage for those under the expansion. If the federal government lowers its contributions to states, it would have a “disastrous impact,” Kreidler said.

“In very short order, you would find the state unable to maintain coverage for single adults,” he said.

How does the uncertainty of the future of the Affordable Care Act affect the insurance marketplace in Washington?

“There’s a great deal of uncertainty and anxiety about what happens in 2018, and so it’s hard for (insurers) to be really certain of what they can anticipate in the 2018 market,” Kreidler said. “It is really destabilizing to be talking about repealing and yet not have a firm indication of what you’re replacing it with.”

Washington insurers have a deadline of May 5 to submit plans for 2018. Kreidler suspects insurers in the state now will submit plans for next year, but depending on what happens later in the year, he fears insurers could leave the state.

“I’m so afraid, if one of our major insurers backs out of the market in 2018, I have every reason to believe the rest will follow,” he said.

Why not allow insurers to sell plans across state lines? Wouldn’t that make the market more competitive?

Kreidler, who has served as insurance commissioner for 17 years, has seen this proposed countless times. Half a dozen states have passed legislation to allow sales across state lines, yet none have found success, he said.

“They could never get an insurance plan that wanted to participate across state lines,” Kreidler said.

Washington even explored the possibility, at the request of the Legislature, about 10 years ago and came to the conclusion, “It’s just plain not workable,” he said.

Kreidler sees many problems with the idea, besides the fact that insurance companies don’t appear interested. If a consumer purchases a plan from a different state, for example, which local providers will accept it? And if you have a problem with your plan, which state insurance commissioner do you turn to for help?

“It’s fraught with multiple problems,” Kreidler said.

What is the state government doing? Can it be proactive?

Two local state senators — Ann Rivers, R-La Center, and Annette Cleveland, D-Vancouver — sit on the state’s Senate Health Care Committee.

Cleveland said she’s been working with the governor’s staff and the Health Care Authority to make an inventory of all the health care protections that were required in the state before the Affordable Care Act, to ensure they remain in place if the ACA is repealed.

“We want to ensure we don’t make any decisions based on poor information,” Cleveland said.

The two senators also back a measure to ensure those in the highest-risk pool, who might be concerned about losing insurance coverage, are guaranteed protections.

“These are people who need dialysis to live. They are waiting for a kidney. These are people who are AIDS patients, who are hemophiliacs, who have the very worst conditions a human being can get,” Rivers said. “And we need to make sure we’re not making their condition worse by putting them in fear. … So we are doing some things right now to position ourselves.”

Cleveland said that, much like the rest of the nation, the state is in limbo and waiting to see what happens at the federal level.

But, she added, “We live in a state that has been very much a leader when it comes to affordable health care for our citizens, and we have in place many aspects of what’s contained within the Affordable Care Act. We’re committed to working together to ensure that no one loses coverage regardless of what action might take place at the federal level.”

Local Voices on the ACA

Kim Renteria

After four years of purchasing health plans under the Affordable Care Act, Kim Renteria voted for Donald Trump in November largely because he vowed to repeal and replace the massive health care law.

“We aren’t just Trump supporters,” Renteria said. “A lot of the reason that we voted for Trump is to fix this mess of health care that we have. Something has to change. Period.”

Renteria and her husband have struggled their entire adult lives to purchase health insurance. Renteria was thrilled to hear about the Affordable Care Act and the prospect of having coverage they could afford.

So when plans became available on the state-based insurance marketplace, Washington Healthplanfinder, Renteria went shopping. She found and enrolled in the best plan they could afford. The premium was slightly less than their mortgage payment.

“Come to find out, deductibles were pretty steep, and we started to go into debt,” Renteria said.

Renteria’s husband works in construction and started having back problems that required various medical procedures. About a year later, Renteria started having back issues, as well. By then, their insurance premium was as much as their mortgage, and their deductible was going up.

“We found out all too quickly how expensive our coverage was,” Renteria said. “Barely anything was covered, but we had to have the tests and procedures.”

They opened credit card accounts for the first time in order to cover the medical costs.

“We had medical problems that had to be addressed or we couldn’t work,” Renteria said. “What choice did we have?”

As their premiums continued to climb — now more than their mortgage — and deductibles got higher, so did the credit card debt. After having no credit card debt four years ago, they now owe more than $20,000.

“We are a middle-income family,” Renteria said. “We have always done OK for ourselves, never lived outside of our means, and, although things have sometimes been tight, we’ve always made it.”

“Since Obamacare, we are now in debt over our heads (and) have never had good enough (health) coverage to really fix our problems,” she said.
— Marissa Harshman

Jennifer Browning

As an organ donor coordinator, Jennifer Browning has witnessed the lives of people with declining health transformed after receiving a new organ.

She’s also seen the other side — those who end up as organ donors.
One donor, who didn’t have health insurance, had an asthma attack and died because proper health care was too expensive. Another donor, she said, had untreated hypertension and suffered a stroke.

“Very simple things and the medication isn’t always expensive. But if you (can’t afford) insurance.  …” Browning said, her voice trailing off.

Browning has a particular insight into the process. When she was 13 months old, she contracted a virus that led to kidney failure. It was 1973 and dialysis was still fairly new, but as a child, she relied upon it. At 25 years old, she received a kidney transplant from her mother.

“I realized, ‘This is how I should feel.’ I would be driving places, pull over and take a nap in the car because I was tired. I rationalized it was normal. I work hard all day, sure, I’m tired. But it was after the transplant that I realized: This is how I should be feeling all along,” she said.

But kidney transplants have a shelf life. And her kidney has started failing again.

For most of her life, there’s been an underlying fear.

What if she lost her job?

What if she couldn’t buy health insurance?

When the Affordable Care Act passed, prohibiting discrimination based on pre-existing conditions, for the first time the weight lifted.

“I almost can’t put it into words. Imagine you’ve had a fear your entire life, some huge weight on your shoulders. … And all of a sudden, it’s just gone. I can go forward, live my life, be a mom,” she said.

Browning knows the Affordable Care Act isn’t perfect, but said repealing it without replacing it with something acceptable is “unconscionable.”

She’s worried that without the Affordable Care Act there could be a decline of living kidney donors. After donating a kidney, she said, people could be considered “risky.”

“It’s about being considered as having a pre-existing condition after becoming a donor,” Browning said.

The consequences of a repeal, she said, could be deadly.
— Lauren Dake

Without a mandate: Washington experience makes the issues clear

State’s health care market fell apart in late 1990s as only the ill sought policies

As Republicans continue to propose an Affordable Care Act replacement that would require insurers to cover people with pre-existing conditions but not mandate that everyone purchase health coverage, Washington Insurance Commissioner Mike Kreidler sees the system headed down a familiar path.

“That is what destroyed the insurance market in the state of Washington,” said Kreidler, who is a Democrat.

In 1993, Washington adopted extensive health care reform laws. The state’s Health Services Act of 1993 eliminated waiting periods for people with pre-existing conditions and guaranteed that health insurance policies would be issued to anyone who could pay.

But when key pieces of the law were repealed — most notably, the requirements that individuals purchase plans and employers offer coverage to employees — it sent the state’s individual market into a death spiral.

Healthy people opted to not purchase coverage, leaving insurers with a pool of customers who were much sicker. As costs to the insurer climbed, so did premiums, making the plans unaffordable.

“The insurers felt their only choice at that point was to withdraw,” Kreidler said. “There were no policies being sold by 1998, 1999.”

For insurers, the marketplace needs to have a balance of good risk and bad risk, Kreidler said. The individual mandate ensures that balance, he said.
The absence of the mandate in the 1990s allowed people to purchase health care when they needed it and drop the coverage when they didn’t. For example, women could pick up coverage before getting pregnant and cancel the plan after their babies were born.

Officials with one insurance company received a letter from a woman, thanking the insurer for the great coverage during her pregnancy, Kriedler said. She was dropping her coverage since she was no longer pregnant, but said she would return to the insurer if she decided to have another child, he said.

“There are a number of people who think, ‘I only want coverage for maternity when I’m going to have a baby,’ ” Kreidler said. “If you only charge people for maternity when they want to have a baby, nobody could afford it. Things like maternity need to be there for everyone; otherwise, insurance will never cover maternity.”

That’s why President Donald Trump’s promises during the campaign that people will be able to purchase only the coverage they need — and at a cheaper price — have given Kreidler and others in Washington flashbacks to the state’s market collapse.

“That’s what you could have again,” Kreidler said. “Very, very easily.”
– Marissa Harshman

The ACA by the numbers

Clark County uninsured rate
2012: 14.7 percent
2014: 8.7 percent

Percentage of Clark County residents enrolled in health plan through Washington Healthplanfinder: 29.4 percent

Number of Clark County residents enrolled in health plan through Washington Healthplanfinder: 113,899

Number of Clark County adults covered through Medicaid expansion: 37,665

Number of Clark County residents who purchased exchange health plans: 11,429

Average monthly tax credit per Clark County enrollee: $325

Total federal subsidy in Clark County in 2016: $34,516,601

Sources: Washington Office of the Insurance Commissioner and Washington Health Benefit Exchange

National:
47 percent of people say Congress should repeal the ACA; 48 percent say Congress should not repeal the ACA

Of those who support a repeal, 60 percent want replacement details set before the repeal, 40 percent want details worked out after repeal

85 percent of people favor the ACA provision that allows young adults to stay on their parents’ plans until age 26.

83 percent of people favor the ACA provision that eliminates out-of-pocket costs for preventive services.

80 percent of people favor the ACA provision that creates health insurance exchanges where people can purchase coverage.

69 percent of people favor the ACA provision that prohibits insurance companies from denying coverage based on medical history.

35 percent of people favor the ACA’s individual mandate requiring health coverage.
Source: Kaiser Health Tracking Polls (February 2017 and November 2016)