Five months ago, Michael Orlie could barely afford his family’s monthly health insurance premiums, debating at month’s end what he should pay first: the mortgage or the health care bill.
Now, he needs a new socket for his prosthetic leg. And it’s estimated to cost $13,000.
As the GOP tries once again to repeal and replace the Affordable Care Act, patients such as Orlie are watching to see what kind of coverage they will be able to afford and what exactly will be covered.
“And I’m scared to death come November,” Orlie said.
While nothing that passes Congress is likely to go into effect immediately, many experts expect confusion as the period to enroll in health insurance plans on the open marketplaces established by the ACA begins on Nov. 1.
Republican lawmakers have struggled to reach consensus on overhauling the Obama-era health law, often called Obamacare. The latest attempt to push a new policy forward was once again called into question on Friday, with Sen. John McCain indicating he planned to vote no.
“I cannot in good conscience vote for Graham-Cassidy,” he wrote in a tweet. “A bill impacting so many lives deserves a bipartisan approach.”
The House’s first attempt to vote on a measure to dismantle Obamacare collapsed due to warring factions, though that bill was ultimately passed in May after major tweaks were made.
The Senate, with narrower margins for success, had an even tougher path. Its “skinny repeal” failed in spectacular fashion in July, when three GOP members, including McCain, broke ranks and gave a thumbs down, dishing a major blow to the effort.
The Senate is set to vote by the end of next week on the most recent Graham-Cassidy bill.
It would send federal money to the states in the form of block grants to allow them to develop their own health insurance systems, among other changes.
States like Texas, which did not expand Medicaid, would see the biggest benefit initially.
The block grant for Medicaid would increase federal funding in Texas by $28.4 billion between 2020 and 2026, an analysis from the Kaiser Family Foundation estimates. The additional money appears to be good for the state, but nationally and long-term, there could be consequences.
The GOP would cap federal spending on Medicaid on a per-enrollee basis, so the program would receive $160 billion less overall, the analysis concluded.
Right now, the federal government pays states a specified percentage of money, based on how much they actually spend on the program.
When the block grants expire in 2026, Texas would see its Medicaid funding decrease. All states would be given a fixed, per-capita allotment, instead of funding that’s based on changing needs.
But lack of a final plan this late in the game is a major frustration for Orlie, who voted for Donald Trump and expected a repeal and replacement of the health law.
“I was just disappointed,” Orlie said. “It seems like it’s the dilemma we’re in as a country — our government is just locked up fighting each other.”
“Our government is just locked up fighting each other.”
‘Everyone is in limbo’
Indeed, the environment is prompting anxiety among health policy groups, consumer advocates, navigators and others about how smoothly things will go when open enrollment begins.
The process for purchasing exchange plans will be managed, for the first time ever, by an administration that has openly said Obamacare will “implode.”
That’s already having an impact. “There’s a lot of misinformation and misunderstanding,” said Daniel Bouton, director of community health services for the Community Council of Greater Dallas, a nonprofit that receives federal money to hire enrollment assistance staff.
“Everyone is in limbo given the current landscape of health care in our country,” he said.
One thing remains certain, despite the year of back-and-forth, said Karen Pollitz, a senior fellow focused on market reform and consumer protections for the Kaiser Family Foundation.
“It’s still on,” she said. “But there’s new management, so some things will change.”
For one, there will be less time to shop. The period to purchase a plan on healthcare.gov has been shortened by 45 days. This year it will run Nov. 1 to Dec. 15.
In previous years, the time period ran through the end of January.
“That helped get a lot of stragglers,”said Stacey Pogue, senior policy analyst for the left-leaning Centers for Public Policy and Priorities based in Austin. Specifically, she’s referring to the younger and healthier individuals needed to balance costs.
“The people who sign up on the very last day aren’t usually the sickest,” she said. “And the people who sign up on Day One sign up whether you advertise or not.”
It will also be harder for consumers to find assistance from individuals trained to help them navigate the marketplaces. The budget for navigator and education programs was slashed 41 percent, down to $37 million from $62.5 million.
The 12 nonprofits in Texas that receive federal grants to staff navigators and run advertising and awareness campaigns saw cuts ranging between 14 and 25 percent.
Bouton’s organization, the Community Council of Greater Dallas, will get nearly half a million dollars less this year. “It puts a dent in what we can do,” he said.
And some, like Orlie, could need help determining which plan is best. He needs a new socket because he lost 20 pounds. His prosthesis no longer fits.
“It’s gotten to the point where I’m losing suction, so the leg just wants to fall off constantly,” he said.
Recently, due to an accidental missed payment, Orlie was temporarily kicked off his Scott & White insurance plan. The 46-year-old cancer survivor needs insurance, so immediately, he signed up for Medi-Share, a Christian-based insurance co-op.
Just like his private plan, it will cost $13,000 for the new socket under Orlie’s new insurance. Unlike his private plan, Medi-Share does not have prescription coverage. But after calculating the costs of each option, Orlie is saving money under Medi-Share — with similar coverage.
The people who sign up on the very last day aren’t usually the sickest … and the people who sign up on Day One sign up whether you advertise or not.”
It is yet to be determined how much plans will cost for Texans and which providers will be in- and out-of-network in 2018. Health insurers submitted their suggested rates for plans this past spring. Nearly all of them included an increase.
The requested increases, which ranged from less than 1 percent to over 53 percent, are still awaiting federal approval with no release date specified.
The good news is that, for now, subsidies will remain in effect for families and individuals making up to 400 percent of the poverty level. That would equate to an annual salary ranging from $12,060 to $48,240 and a salary of $24,600 to $98,400 for a family of four.
As usual, the full price hikes will be felt most by people who are not eligible for premium assistance. “That’s where you feel the full brunt,” said Pollitz. “It’s possible fewer people will sign up.”
Two years ago, Orlie received a subsidy. When the health plan that covered most of what he needed was no longer available in North Texas, he switched to a different plan, one that no longer qualified him for a subsidy because it was a private plan off the exchange.
And come November, he doubts he’ll find what he needs when he logs on to healthcare.gov.
“I don’t have much hope.”