Chip Brownlee
Alabama Political Reporter
OPELIKA, Ala.—In Opelika, Alabama, there is a small office, tucked away on the second floor of a law practice along the small town’s main street. There’s no sign on the front door indicating its placement, and most wouldn’t know it’s there.
The office belongs to Hannah Duncan, a recent graduate of Auburn University who works as a health care navigator for EnrollAlabama, an organization that helps sign low- and middle-income Alabamians up for health insurance coverage through the federal health insurance exchange set up by President Barack Obama’s 2010 health care law.
Most people probably think of it as “Obamacare.”
Since she began working for EnrollAlabama, Duncan has helped dozens of people sign up for bronze, silver and gold health care plans provided on the exchange by Blue Cross and Blue Shield of Alabama. Many of those people had cancer and chronic pain, what are known as pre-existing conditions, and would have been discriminated against with higher premiums or no coverage at all before the ACA’s implementation in 2011.
One couple with cancer came to EnrollAlabama’s Opelika office for help signing up. Their household had been paying high premiums with plans that still left them without what they needed. Large deductibles, many doctors visits, lab work, imaging and the treatment needed for the cancer diagnosis left the family in distress.
Through the health care marketplace, Duncan found the couple a better health insurance plan for a lower price thanks to a lower premium and the family’s eligibility for a cost-sharing reduction subsidy. It covered lab work, diagnostic imaging and had good copays, which were absent in their previous plan. It allowed the family to begin treating their cancer without going bankrupt.
“It doesn’t even have to be that dramatic,” Duncan said. “Even the people who come to me after just having found out that this is an option for them are important.”
The plan through the marketplace, Duncan said, allowed the family to begin treating their cancer without going bankrupt. And they weren’t the only two people in Alabama who have gained coverage under Obama’s health care law. Since 2010, 215,000 more people got health insurance in Alabama, which pushed the State’s uninsured rate down 4.5 percentage points from 14.6 percent in 2010 to 10.1 percent in 2015.
165,534 people in Alabama got their coverage through the Federal exchange.
Not everything is sunny in Alabama
But even with higher insured rates and better plans even for people who still get their insurance through an employer, not everyone is happy with the health care law — or the price they pay for their health insurance.
And not everything went as according to plan with the implementation of the law, either. In 2012, the Supreme Court punched a hole in Obama’s signature law by allowing states to opt-out of Medicaid Expansion. The expansion was intended to cover individuals who didn’t previously qualify for Medicaid but wouldn’t make enough to qualify for marketplace subsidies.
Despite a lower average increase in premiums from 2010–2015 than the decade before, a lack of competition, a lack of rate-plan choices and increasing premiums for some Obamacare plans in Alabama still have many wondering if the Affordable Care Act is really that affordable.
In 2016, Blue Cross and Blue Shield of Alabama announced a 36 percent hike in premiums for some Silver rate plans on the Federal exchange. The year before BCBS increased prices for some plans more than 20 percent.
Humana and UnitedHealth, two other insurance companies who previously offered select plans in some counties in Alabama, announced last year that they would be pulling out of the Alabama health care exchange, leaving BCBS — a company facing a class-action lawsuit over anticompetitive conduct — as the sole provider.
For years, the State, which has long been dominated by BCBS, has been ranked by the American Medical Association as having the least competitive health insurance market in the U.S.
Problems and solutions, maybe
One of the main rallying cries from politicians on the right over the past eight years was a call to repeal the law. The U.S. House, which came under Republican control in the 2010 mid-term elections, has voted more than 60 times to repeal, tweak or revamp the law. Dissatisfaction with the law reached a fever pitch during the 2016 president election as then-candidate Donald Trump promised to repeal what he called a “disaster.”
With the president-elect’s inauguration on the steps of the U.S. Capitol Friday, the likelihood of an Obamacare repeal, or at least a revamp, is imminent. But what comes next has many in Alabama, including some on the right, anxious.
Trump has promised to repeal the law but keep many of its most popular provisions, including allowing young adults to stay on their parents’ plans until age 26 and protecting those with pre-existing conditions.
Last week, Trump took it one step further, advocating “insurance for everybody.” It’s hard to hammer down exactly what Trump’s plan is for health insurance, but it’s unlikely that a Republican congress would support any type of universal coverage — making a full or partial repeal far more likely.
On Thursday, Gov. Robert Bentley sent a letter to U.S. House Majority Leader Kevin McCarthy outline his suggested changes for the Affordable Care Act. In the letter, he asked for more “patient-oriented solutions” and latitude for the states if changes are made to Medicaid funding. But even Bentley seemed concerned about a swift repeal with no replacement, which could cause up to 200,000 Alabamians to lose health coverage.
“Consumer choice also is vital,” Bentley said. “Repealing the Affordable Care Act without a clear replacement could raise concerns among insurers nationwide and cause some to withdraw from the market, limiting consumer choice.”
Duncan, who is finishing up a busy season of the ACA’s open-enrollment period, has hope that legislators may improve the law instead of scrapping health care for millions of people outright.
“My outlook is positive because that’s who I am as a person,” Duncan said. “I don’t want to jump to conclusions before I have full details. My hope is that our representatives and our government will take into account the number of people this has helped and the number of people this will affect if it is to be repealed.”
Several Republican lawmakers have outlined plans that would provide a replacement for the Affordable Care Act if it were to be repealed including Rep. Tom Price, R-Ga., who is Trump’s pick for health secretary. His plan would offer tax credits for health coverage, instead of direct subsidies and a federal exchange, and would encourage health savings accounts.
Sen. Susan Collins, R-Maine, has rejected the idea of repealing Obamacare without any replacement and instead has supported her own plan that would keep many of the popular provisions and repeal other unpopular provisions like the individual and employer mandate.
“My concern with the repeal and delay plan is that the Obamacare exchanges, already on very shaky financial grounds, would go into a death spiral as consumers would face uncertainty and insurers would have no basis for pricing their policies,” Collins said on the floor of the Senate.
All of Alabama’s congression delegation, save Alabama’s sole Democrat Rep. Terri Sewell, support repealing Obamacare. Duncan, and others who fear many may lose their coverage, hope legislators consider the gains made under the health care law.
“It has absolutely helped people who didn’t have access to the kind of insurance that, for instance, I was used to growing up because both of my parents were employed,” Duncan said. “It was an eye-opening experience for me starting out because the number of people who had not had access to proper health care was just mindblowing to me. Regardless of how much experience you’ve had, you’re always näive to certain situations.”
No Medicaid expansion in the Yellowhammer State
No singular surrounding the health care law has been more heated here in Alabama than the debate over whether the State should expand its Medicaid coverage as initially prescribed by the law.
Lee County, the home of Auburn University and its surrounding technological hub, boasts per capita average incomes and median incomes higher than the Alabama average and lower unemployment rates, but many people still live in poverty.
Twenty-one percent of Lee County residents, more than 1-in-5 people, live at or below the poverty line, according to the U.S. Census Bureau. That rate is higher than the Statewide poverty rate of 18.5 percent and much higher than the nationwide rate of 13.5 percent.
Medicaid Commissioner Stephanie Azar and Gov. Robert Bentley discuss RCO implementation at the State Capitol.
In Duncan’s Lee County coverage area, there are also many people still without health insurance. More than 13.4 percent of people are uninsured, as compared to the State’s uninsured rate of 10.1 percent and the nationwide uninsured rate of 10.5 percent.
Many of the 10 percent who still don’t have insurance are low-income individuals who “fall through the cracks” because of the State’s choice not to expand Medicaid. Here, it’s hard to qualify for Medicaid: You have to be elderly, disabled, pregnant, taking care of an elderly parent or raising children.
Many low-income families who make too much and all childless adults, no matter how poor, don’t qualify for Medicaid, but they also don’t make enough money to qualify for the ACA’s subsidies, either, leaving more than 139,000 Alabamians without any affordable options for health care.
Bentley and others have said that the State, which already faces near-annual crises over its beleaguered General Fund, can’t afford to pay for the 300,000–400,000 new enrollees who could get Medicaid coverage if the State expanded it, even with funding from the Federal government.
The Federal government would have paid the full cost of the expansion from 2013–2017. From 2017–2020, the Federal funding would have gradually taper to just above 90 percent funding for the cost of the expansion. The State would have been responsible for 10 percent of the expansion after 2020.
Just last year, the Legislature had to resort to using money from a settlement with BP Oil over the 2011 Deepwater Horizon Oilspill to balance an $84 million shortfall in the State Medicaid budget.
In Bentley’s letter to U.S. House Republican leadership, he requested any Obamacare replacement plan include provisions that would allow states to reduce Medicaid benefits and enrollment, to impose premiums on low-income beneficiaries or reduce Medicaid spending in other ways to match any Federal cuts.
Duncan bemoaned the State’s decision to opt-out of the expansion.
“People hear great things from their friends and family members about this low premium, and sometimes they don’t understand why they can’t benefit,” Duncan said. “It seems so obvious sometimes that we could be helping more people.”
