Republicans have been vowing to repeal the Affordable Care Act – pejoratively called “Obamacare” – since the day it passed in 2010. And their promise finally appears to be coming true.
With support from President-elect Donald Trump, congressional Republicans last week began efforts to dismantle portions of the health care law that was President Barack Obama’s signature legislative achievement.
But neither Trump nor Republicans have settled on a replacement, and that means about 20 million Americans who get their insurance through the ACA marketplace are in limbo.
“If they don’t repeal and replace on the same day, what are we supposed to do?” asked Sara Kelly Jones, a Charlotte bartender who recently bought 2017 insurance with a subsidy that gave her an affordable monthly premium of $164.
“I just wish there was something concrete we could look at,” said Jones, who earns $2.13 per hour plus tips and is facing major surgery this year. “Give us something, anything, instead of just pieces of a plan. I just think it’s such a disservice to consumers.”
Many Republicans and Trump supporters have repeatedly called the ACA a “failure” and a “disaster.” They cite skyrocketing premiums, high deductibles that mean higher out-of-pocket expenses, and the dwindling number of participating insurers. Only one insurer, Blue Cross Blue Shield of North Carolina, offers plans through the federal marketplace in all 100 counties in the state.
The latest Kaiser Health Tracking Poll released Friday found that 20 percent of Americans support repeal alone, but three-quarters either oppose repeal (47 percent) or want to wait for repeal until there is a replacement, (28 percent).
Surveys show that most enrollees in the ACA marketplaces are happy with their plans. Despite the uncertainty, enrollment for 2017 exceeded previous years. In the final two months of last year, nearly 9 million Americans – including 530,000 North Carolinians – signed up for health insurance for 2017. Once again, North Carolina was an enrollment leader, with the third highest number of sign-ups among states using the federal marketplace.
“We have been doing this work for four years now, and we’ve been watching those enrollment numbers grow every year,” said Madison Hardee, a lawyer for Legal Services of Southern Piedmont, which provides enrollment assistance.
But as repeal gets closer to reality, some health care experts are predicting chaos that could leave millions of Americans without coverage just as they’ve finally been able to afford it.
“Moving forward with a repeal plan without any replacement is dangerous,” said Brendan Riley, a health policy analyst at the NC Justice Center.
“There would likely be devastating effects for safety net providers, especially rural hospitals,” he said. “The needs of the uninsured would still be there, and the financial strain on our health care providers would be severe.”
Critics of the ACA have talked about eliminating key provisions of the law – such as premium subsidies and the mandate that Americans buy insurance or face penalties. But they want to preserve popular features, including protection for people with pre-existing medical conditions and allowing children to stay on their parents’ plans until age 26.
Republicans have also discussed a “repeal and delay” strategy that would continue ACA insurance coverage for two or three years, until a replacement is approved.
But health research and advocacy groups cast doubts on the workability of these ideas.
“All the experts are saying it would be disastrous,” said Doug Sea, senior attorney at Legal Services. “This very uncertainty is going to wreak havoc in the market, and it’s going to affect real people. The effects would be so far-reaching, it’s really shocking that there’s been no real policy debate about what is a better way to go.”
Last month, the Urban Institute projected that partial repeal of the ACA without an immediate replacement would raise the number of uninsured to 59 million by 2019 – more than the 50 million uninsured before passage of the ACA.
It could also lead to a disruption that would cause a part of the insurance market to “virtually collapse,” the report said. It projected that some people would stop paying premiums and insurers would suffer substantial financial losses, and at least some insurers would leave the ACA market midyear.
Most Americans get their insurance through their employers, Medicare or Medicaid. The ACA was aimed at the “nongroup” market, which refers to those who buy individual policies through private insurers. Even if the effective date for repeal was delayed two years, the Urban Institute predicted that more insurers would stop offering ACA plans, knowing the marketplace would soon be dismantled.
In a letter to lawmakers last month, the American Academy of Actuaries warned of the “potential adverse consequences” of repealing the ACA without a replacement. For example, the letter said, eliminating the mandate to buy insurance would cause healthy people not to buy coverage, thus reducing the risk pool that insurers count on to cover the cost of claims for the sick. “A premium spiral could result, with fewer and fewer insureds and higher and higher premiums.”
In another report, the Urban Institute said hospitals and other health care providers “stand to lose considerable revenue” because they will be asked to absorb the cost of uncompensated care for the growing number of uninsured patients.
In Charlotte, Carolinas HealthCare System CEO Gene Woods said repealing the ACA would create “a tremendous amount of uncertainty not just for patients, but for health systems” that have been subject to reductions in Medicare reimbursement that helped pay for the ACA. As chairman of the American Hospital Association this year, he’ll be watching the issue closely.
Carl Armato, CEO of Novant Health, shared Woods’ concerns. “Those cuts are still in place,” he said. “Hospitals, particularly rural hospitals, have a lot to lose. There’s a lot of details that need to be looked at.”
Some support repeal
Just as Congress is divided over the ACA, so are consumers.
Steve Griffith, 59, a self-employed sales representative in Charlotte, earns too much to qualify for a subsidy, so he was hit hard by the increase in premiums. He and his wife, who buy separate policies, will pay $1,200 a month total for health insurance in 2017. He said it “frankly isn’t worth that much” because they must pay all charges before they reach the deductibles of $5,000 each.
“I pay too much for too little, and for most people in my position, that’s been the story,” Griffith said. “It’s become crazy expensive. Just for a cough, it’s $200 to see your doctor.”
Griffith says he supports repealing the ACA – “This was a lousy idea. Not just for me, but for a lot of people who are self-employed.”
But he adds that he hopes the new president and Congress “take some time and get it right.… It needs to be bipartisan instead of making a political statement. To just repeal it without having something in place doesn’t make a lot of sense.”
‘I’ve lost sleep’
Others have qualified for tax credits that made insurance premiums affordable and allowed them to escape the ranks of the uninsured.
Lana Rubright, 55, who is undergoing treatment for breast cancer, said her cancer might not have been detected if she had not had insurance coverage through the ACA.
She and her husband own a small construction business and once bought high-deductible insurance for their family for about $1,500 a month. Their business took a hit during the recession, and when faced with the prospect of losing their home, they ditched their health coverage. Since 2013, when the ACA took effect, they have qualified for premium subsidies to buy insurance. For 2017, they’re paying about $100 a month.
Hearing about the ACA repeal “pretty much makes me sick, unless they want to replace it with universal health care,” Rubright said.
Having insurance had enabled her to get annual screenings and not worry about the cost of her cancer care. In June, a mammogram found breast cancer. She had surgery and chemotherapy, which continues through September. She’s also having five weeks of radiation treatment.
Now, she’s worried that insurance won’t last. “I’ve lost a lot of sleep over wondering if this is going to get pulled out from under us.”