Joan Long says the Affordable Care Act, commonly called Obamacare, came along just when she needed it.
The 63-year-old former Fort Worth school district employee used the federal health exchange to obtain coverage after she lost her job. Having had polio as a child, the pre-existing condition might otherwise have stopped her from landing coverage.
When she fell and broke a leg, the policy picked up her mountain of hospital and rehab bills.
“I’m eternally thankful for my ACA plan. It is a godsend,” she said. “People who mean to disband it are obviously the ones who don’t need it.”
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Vince Hawkins, a financial adviser in Colleyville, has had a different experience. When the ACA took effect, his insurer dropped his plan and he had to shop for new coverage. Now he has changed policies again after his premiums shot through the roof.
Not eligible for federal subsidies, Hawkins was paying $1,900 a month to cover his family of five, which he hardly found affordable.
100,800people in Tarrant County have obtained health insurance under the Affordable Care Act.
“My premiums have gone up 400 percent while my benefits decreased 50 percent,” he said, referring to changes over three years. “I had a $6,000 deductible, but then it changed to two $6,000 deductibles.”
The contrasting perspectives show the two sides of the controversial federal healthcare law. As the new Congress and President-elect Donald Trump prepare to follow through on their pledge to repeal and replace Obamacare, more than 100,000 people in Tarrant County who’ve used it to obtain coverage are anxiously awaiting what comes next.
“I’m terrified,” Long said. “If they’re going to revamp it or do away with it, I hope it takes a year or two so I’m closer to Medicare.”
‘2017 is locked in’
Action is expected to come more quickly in Washington. Last week, legislators took preliminary steps to enable Congress to repeal President Obama’s signature law. Trump has said he expects a replacement plan to be proposed quickly, allowing consumers to transition from one plan to another.
ACA policies signed during this year’s open enrollment — which closes at the end of the month — are expected to stay in place for the year, along with the federal subsidies, according to insurers, advocates, politicians and the federal agency that oversees the ACA.
“The marketplace for 2017 is locked in despite what Congress does,” said Stacey Pogue, senior policy analyst for the Center for Public Policy Priorities in Austin. “It’s changes in the future they will be voting on, not immediate changes.”
Critics say the law has not worked, bringing huge losses for insurers and big premium hikes for consumers. In Texas, Blue Cross Blue Shield raised its rates on average 58 percent for 2017, according to documents filed with the federal government at Healthcare.gov.
By one measure — the number of people insured in Texas, long home to the most uninsured in the country — the ACA has had a big impact.
Census data released in the fall shows the ACA marketplace helped reduce the number of uninsured in Texas from 5.7 million in 2013 (22 percent of the population) to 4.6 million in 2015 (17.1 percent). The state still has the largest number of uninsured in the country, however.
Also, a report showed the number of Texas children uninsured declined by 23 percent from 2013 to 2015, partly because of the ACA, which enhanced Medicaid and CHIP coverage for children.
Those who qualified for federal subsidies have been somewhat protected from huge hikes in annual premiums.
Like 84 percent of Texans on an ACA plan, Long qualified for a tax credit to help defray the cost of monthly premiums, co-pays and out-of-pocket expenses. Texans were able to collect $3 billion last year in subsidies that are awarded based on income, according to the Kaiser Family Foundation.
‘Thank God I’m a healthy person’
Even with that help, Long said her monthly premiums rose this year to $460 — almost twice last year’s. Part of that increase was because she began collecting Social Security disability, which raised her income slightly and lowered her subsidy.
Long’s actual cost without the subsidy this year would have been $1,000 a month, she said.
In addition to rising costs, other policy holders have complained about limited choices for medical care.
“I have had tons of clients that gained insurance, many of them with significant pre-existing conditions. But the recurring theme is either their premiums have skyrocketed or they’re frustrated with the limited access they have,” said Dale Mason, who runs Mason Insurance in Fort Worth.
One of Mason’s clients has a child who receives periodic care at Cook Children’s Medical Center. But neither of the two ACA insurers this year (BCBS or Ambetter) have Cook Children’s in their network, nor the specialist whom her child sees, he said.
“She said she was excited when she first got coverage, but now that she doesn’t have access to the providers that are important to her, she didn’t even renew her policy this year,” Mason said.
Another limitation of ACA coverage is that there are no more Preferred Provider Organization plans, or PPOs. Both insurers are offering only Health Maintenance Organization (HMO) plans or Exclusive Provider Organization (EPO) plans on the exchange.
My premiums have gone up 400 percent while my benefits decreased 50 percent. I had a $6,000 deductible, but then it changed to two $6,000 deductibles.
Vince Hawkins, financial advisor
An EPO is a hybrid plan that has lower premiums and no referral needed to see a specialist. But it carries a narrow provider network like an HMO, Mason said.
Lisa Escue, a 54-year-old real estate agent in Trophy Club, was getting ready to drop her ACA policy because the closest hospital system for her, she said, was John Peter Smith Hospital in Fort Worth.
“I was trying to be on an ACA plan, but none included my doctors and there were no medical facilities in my area,” she said. “The whole northeast corner of Tarrant didn’t have any ACA plan hospitals.”
This changed on New Year’s Eve, when BCBS and Texas Health Resources came to an eleventh hour agreement for THR’s extensive network of hospitals to continue taking BCBS plans in 2017.
Escue, who takes medication for high blood pressure and cholesterol, said she would go back and look at Blue Cross again. Her current plan, an off-exchange PPO with a $10,000 deductible, costs around $800 a month. This cost is on top of another $800 monthly premium for a policy that covers the rest of her family.
While some Texans make too much to qualify for federal subsidies, self-employed people can deduct 100 percent of their health insurance premiums to lower their adjusted gross income on their federal taxes, providing some relief.
“It’s not about the cost, it’s the lack of access to medical care,” Escue said. “Thank God I’m a healthy person.”
‘No insurance at all without it’
Terri Mason of east Fort Worth has not been healthy. She was uninsured in 2012 — a year before the ACA took effect — when she started to notice her leg going numb sometimes and losing feeling in her hands.
Mason (no relation to Dale Mason) attributed the changes in her body to aging and “blew off” the symptoms, knowing that a lack of coverage would keep her from checking on her health. A computer support technician, her employer did not provide healthcare coverage.
“I just kept putting it off,” she said. “When you don’t have insurance, you don’t take care of yourself, which means you probably get worse.”
Then on the way to her younger son’s basketball game, her face started to droop and she had trouble speaking.
Her sister, a physical therapist, encouraged Mason to go to a doctor. Mason chose a nearby CareNow, which told her to go to a hospital emergency room.
Census data released in the fall shows the ACA marketplace helped reduce the number of uninsured in Texas from 5.7 million in 2013 (22 percent of the population) to 4.6 million in 2015 (17.1 percent).
She went to JPS, where she was already signed up on an assistance program, JPS Connection, which reduces costs for the ER, testing and hospital stays for low-income people.
The hospital kept her three days and ran a series of tests, including an MRI that detected lesions in her brain. The diagnosis — multiple sclerosis.
Mason now had a pre-existing condition that no insurer would touch and an expensive drug treatment for her MS that required once-a-week injections.
Like most consumers in her position with little money for treatment costs, Mason started negotiating for her healthcare. Her doctor helped get her drug co-pay to $10, with the drugmaker covering the rest. When she needed an MRI and the lab wanted payment upfront, she negotiated them to a down payment of half. The MS Society helps subsidize a fitness and yoga studio necessary for Mason to keep her body moving.
Then the ACA was enacted and doors opened up for her. Mason got on a Blue Cross Blue Shield plan that covered her doctor and treatment with minimal co-pays. She was able to add her son, a scholarship student at Baylor University, who was dropped from the state’s children’s insurance plan at age 18.
Mason qualified for a tax credit to help cover the costs. Last year, her monthly premium for her and her son was just $128.
This year her monthly premium has almost doubled to $254, despite an additional tax credit. But, she said, the coverage is worth it.
“I probably wouldn’t be going to the doctor without insurance,” she said. “And I’m supposed to get yearly MRIs for my condition. I know for some people the ACA is not good. But for me, it is. I would have no insurance at all without it.”