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With the future of the Affordable Care Act uncertain, enrollees weigh their options

Tony Twitty, 55, founded his auto shop in 1999. Before the Affordable Care Act,it was hard for him to buy health insurance on his own.
Durrie Bouscaren | St. Louis Public Radio
Tony Twitty, 55, founded his auto shop in 1999. Before the Affordable Care Act, it was hard for him to buy health insurance on his own.

After running on a platform that included calls to repeal the Affordable Care Act, president-elect Donald Trump will take office alongside a Republican-controlled Congress in January. This leaves an estimated 20 million people who gained coverage through the law unsure of how their coverage will change.

In the weeks since the election, the general consensus among health law experts is that it’s unlikely that congressional Republicans will repeal the law entirely without a plan to replace it, particularly because Senate Democrats have enough seats to filibuster.

Keeping the parts of the law Trump has promised to keep, such as allowing young adults to stay on their parents’ insurance until they turn 26, may not be possible without the taxes that pay for it. The more likely scenario is that key tenants of the law — Medicaid expansion, federal subsidies for plans bought on Healthcare.gov and a requirement that insurers cover contraceptives — could be cut back or removed through budget reconciliation and executive orders.

What does this mean for people in the St. Louis region? We asked around.

'In this business, there’s no telling when you might get hurt.'

Earth, Wind and Fire’s “September” played on the radio as Tony Twitty, 55, finished a vehicle inspection on a 2006 Mitsubishi Eclipse.

"They say in this business, there's no telling when you might get hurt. So you need something at all times," Twitty said. 

Twitty opened Tech One Complete Auto Services in north St. Louis in 1999, and business is good. But before the Affordable Care Act, he couldn't afford health insurance.

“It feels good [to be covered]. In this line of work, if you get hurt, you can go somewhere and not get turned away,” Twitty said.

Last year, Twitty found a subsidized Coventry plan for $79 a month on the federal exchange to cover both him and his 9-year-old son. Later, when he hurt his knee while carrying luggage through the airport, he was glad he had it.

“I went in, and they X-rayed it and everything, gave me my advice,” Twitty said. “It was a little arthritis, and I was off and running.”

People have to be healthy to keep working, Twitty said. If Congress changes the Affordable Care Act, he hopes he can still afford whatever coverage is available.

“The poor keep the wealthy going, and the wealthy keep the poor going," Twitty said. "We all have to scratch each other’s backs to keep this thing going.” 

By mid-year, roughly 210,000 people in Missouri and 300,000 in Illinois were actively covered by plans bought on the Healthcare.gov in 2015. About 80 percent received income-based subsides to afford their premiums.

“The consensus among health policy folks is that the individual plans for 2017 are going to be OK. That’s because open enrollment will already have taken place, the insurance companies will have issued the plans,” said Elizabeth Sepper, a professor of health law at Washington University. “But in 2018, everything could be out the window. We could be looking at a whole new, brave new world of health insurance.”

Although Trump and other Republicans promised during the campaign to replace the Affordable Care Act, making good on that promise won't be easy, Wendy Netter Epstein, a health law professor at DePaul University. 

“It seems like there would be a lot of political fallout if folks lost their plans and there was nothing yet to replace them,” she said. “There are a lot of Trump supporters in traditionally red states that are getting their plans right now through the Affordable Care Act, and they’re only able to purchase their plans because of the tax subsidies.”

'I don’t know if I should be covered, or if it should go by the way.'

Jacob Seaward, 29, wipes down condiment containers at work in Belleville.
Credit Durrie Bouscaren | St. Louis Public Radio
Jacob Seaward, 29, wipes down condiment containers at work in Belleville. He purchased a plan on Healthcare.gov last year, but struggled to pay the premium.

With thick-rimmed glasses and an easy laugh, 29-year-old Jacob Seaward works as a server at the Round Table Café in Belleville. He slings plates of meatloaf, Reuben sandwiches and something called a Hamburger Horseshoe — Texas toast, hamburger patties, French fries and cheese sauce.

He's confused about what the election means for his own coverage and the requirement that everyone have health insurance. 

“I don’t know if I should be covered, or if it should go by the way. I don’t know, it’s just a whole lot of nothing,” Seaward said. “I feel like I should, as an adult.”

In 2015, Seaward signed up for Obamacare to avoid paying an income-based penalty for not having coverage, known as the individual mandate. The rule was designed to push younger, healthier people into the insurance pool to placate insurance companies, concerned about the cost of covering people with pre-existing conditions, as required by the Affordable Care Act.

On Healthcare.gov, Seaward found a subsidized plan for $149  a month. But he’s young and healthy, and never used it.

“Life happened, and I couldn’t afford the premium that they had, so it lapsed,” said Seaward, who when he files his taxes probably will have to pay a penalty for being uninsured part of this year.

So his view of the Affordable Care Act is a little complicated.

“I hope it stays around … I think? It seems like a great idea," Seaward said. "Most of my friends like it, and the other half of my friends don’t like it. And I’m still not swayed.”

But, he said, if there were no penalty for being uninsured, he probably wouldn’t enroll.

Trump has said he wants to gut the individual mandate. But that helps pay for a part of the law he says he wants to keep: the requirement for insurance companies to cover individuals who have pre-existing conditions.

“The reason that the pre-existing health condition (requirement) was designed to work was because the individual mandate was supposed to prompt healthy individuals to also enter the risk pool,” said Netter Epstein, the DePaul University health law professor. “And those healthy people would even out the health care costs.”

Removing the individual mandate would leave insurance companies with fewer healthy people, to help keep costs low for patients who have pre-existing conditions and higher health-care expenses, she said.

That likely would push the cost of health insurance up for the people who have it, said Sepper, of Washington U.

“The more people you have insured, the lower premiums are,” Sepper said. “So it’s good for all of us to have as close as possible to 100-percent insurance.”

'You want to have people covered because they’re going to get care in the right place.'

About 20 percent of Illinois Medicaid patients, or about 645,000 people, are covered through the Affordable Care Act’s expansion of the program. After a 2012 Supreme Court decision, each state legislature was given the option to raise the income limit to 138 percent of the federal poverty level, about $27,800 for a family of three. Illinois opted in. But Missouri opted out, leaving a significant coverage gap for the working poor

After the election, the federal funds that pay for most state expenses to expand eligibility could now be on the chopping block. In Illinois, it's about $2.7 billion, according to the state's Department of Healthcare and Family Services. 

With the state unlikely to step in and cover the costs, hospitals and their patients could take a financial hit, said Brian Reardon, a vice president of external relations for Hospital Sisters Health System, based in Springfield, Ill.

“The overall cost to the health care system is much more affordable to have people go in and get taken care of earlier in an illness, than waiting until they really need some acute care and they might need to be hospitalized,” Reardon said. “You want to have people covered because they’re going to get care in the right place.”

Trump has expressed support for using federal block grants to pay for Medicaid. But Reardon worries that could make it difficult for rural hospitals to compete.  

“How does that affect money flowing to less populated areas?" Reardon asked. "Will the Milwaukees and Chicagos of the world be first in line for a Medicaid block grant program?”

In Netter Epstein’s opinion, hospitals may be hard hit if large numbers of people lose their health insurance in a short period of time.

“Hospitals have given up a lot of those payments that they used to get to cover their unrecoverable debts, under the assumption that so many fewer people would be uninsured,” she said. “I think it’s a big open question, how a Republican Trump administration is going to deal with the hospital situation.”

What are your questions about health care under a Trump administration? How has the Affordable Care Act affected you? Email this reporter: dbouscaren@stlpublicradio.org.

Follow Durrie on Twitter: @durrieB.