Dissecting the cost of Obamacare in Ventura County

May 21--Connie Kline once paid $385 a month for health insurance. Now she pays $109 with $27 more to cover, for the first time, dental care.

The Democrat from Simi Valley who sometimes votes Republican does not know who she'll support in California's presidential primary on June 7.

One thing is absolute.

"Anyone who wants to shut down Obamacare, I would not vote for," said the income tax preparer with two children and a $40,000 annual income that qualifies her for premium subsidies. "It's made health insurance affordable."

The money-saving claim has been targeted like a prize fighter's chin during the presidential campaign, continuing a fight that erupted more than eight years ago when Barack Obama pledged to revolutionize health care. His Affordable Care Act created insurance marketplaces and expanded government-paid Medicaid insurance in moves that have covered 20 million previously uninsured Americans, nearly 5 million Californians and almost 90,000 people in Ventura County.

Insurance reform also has been accompanied by the continued rise of premiums as well as coverage costs that mean some of the working poor remain uninsured. The campaign battle and the calls for the health program's repeal orbit around whether reform has lived up to its name.

Affordable.

Steve Margolis answers with two words: "For who?"

The general contractor and business owner from Thousand Oaks is not insured through the Affordable Care Act but has a family policy that covers him, his wife and their two kids. He blames insurance reform for jacking up his premiums.

"I think it's like $16,800," he said of his annual costs, double what they were before the 2014 launch of insurance exchanges such as Covered California. He contends the Affordable Care Act means people like him end up paying for low-income people who were once uninsured.

"I feel bad for the people who can't get insurance. Does that mean the middle-class guy who's working his butt off pays for them?" he said.

Margolis knows exactly who'll get his vote on June 7: Donald Trump, who pledges to repeal the Affordable Care Act.

"I'm a Republican," Margolis said, explaining his opposition to the health plan.

PLACING BLAME

Insurance premiums in Affordable Care Act plans could rise 8 percent in 2017, according to budget estimates from Covered California. Premiums in outside individual and family plans, like the one Margolis owns, could see similar increases, according to Geoffrey Joyce, a USC health economist who studies medical costs and insurance.

In policies provided by employers, deductibles rose 67 percent from 2010 to 2015, according to a Kaiser Family Foundation survey.

It's fair to blame some rising insurance costs on the Affordable Care Act's prohibitions on denying coverage for pre-existing conditions, rescinding coverage and annual limits.

"Anytime you mandate coverage and you say you can't do some of the things you did to reduce liability in the past, it is going to translate into premiums," Joyce said.

But premium hikes were in the 4 percent range for the first two years of the insurance exchanges, Joyce said. He challenged claims that pin massive premiums solely on the Affordable Care Act. Such increases often reflect bare-bones policies that had to be expanded to reach standards set by Obama's health reform.

"It's not as if they have the same plans as before the ACA," he said.

MESSY NUMBERS

Hospitals and doctors face changes to their bottom line, too. The strategy is for government plans to reduce increases in payment but to compensate by adding more insured patients.

The math does not always work.

The Affordable Care Act's expansion in Medi-Cal brought coverage to 55,515 Ventura County residents. Visits covered by the taxpayer-funded plan to clinics in the Community Memorial Health System rose 54 percent in the two years after the expansion.

Patient discharges from Community Memorial Hospital and Ojai Valley Community Hospital jumped 36 percent.

More people didn't mean more money. Low reimbursement meant the hospital lost about $10 million in Medi-Cal in 2015, said Dave Glyer, Community Memorial's chief financial officer. That compares to a loss of about $5 million in 2013 before the Affordable Care Act.

"Governmental plans are not keeping up with the increase in costs," he said, noting that hospitals with a higher percentage of Medi-Cal patients own higher reimbursement rates. Community Memorial's rate could rise next year.

Even with the Medi-Cal loss, the health system's bottom line has not been dented by the Affordable Care Act. The system's $29 million profit in 2015 is higher than the pre-Obamacare days, but the increase comes mostly from the roller-coaster nature of a government supplemental payment program.

Joyce, the economist, said unchanging profits mean the Affordable Care Act has changed the way hospitals spend.

"It made a lot more providers and groups cost-conscious," he said. "Behind the scenes, it has led to greater efficiency."

$2 A MONTH

Manuel Arriola, an Oxnard insurance agent who sells Covered California plans, said premiums on his personal insurance rose from $450 a month before 2014 to $725.

Dr. Lee Wan, an Oxnard eye surgeon, credits the plan for lifting bans that barred people from coverage. But premiums for covering his 20 employees rose about 48 percent.

Belen Quezada pays $2 a month for health insurance. The Simi Valley outreach worker said the price is a result of a flawed income estimate made by the government that she's trying to fix because of possible tax penalties.

Quezada, once uninsured, has been insured through the Affordable Care Act since Covered California's launch two years ago. Before the glitch, she paid $157 a month to cover herself and her husband, who works as a window cleaner.

Stomach problems twice have landed her in the emergency room. She knows what the care would have brought if she didn't have the coverage.

"Big debt," she said.

SEARCHING

Dr. Robert Lum wants a candidate. He wants someone in the White House who protects the interests of doctors.

The problem is the Oxnard radiation oncologist -- politically an independent -- doesn't see anyone like that.

His issues include reimbursement changes that he said allow doctors to maintain their revenue only if they see far more patients, spending less time with each.

He worries about bundled payments that pay fixed sums for different types of care, sometimes in packages split between hospitals and doctors. He thinks it means less control and less money.

Lum contends the pressures are pushing doctors to partner with hospitals or medical corporations in an effort to ease the financial burden. He predicts the trend will grow.

"I think there's a lot of doctors who feel they will not be able to stay in business," he said, adding that he wonders about his own future. "We are definitely in a time of great uncertainty, more than we've ever been."

PRE-EXISTING DEBT

For some, questions about cost miss the mark. To them, the Affordable Care Act is not about the wallet; it's about the heart, lungs and liver.

When Lisa Safaeinili's husband died of cancer seven years ago, her insurance coverage shifted to a government-mandated program called COBRA. The coverage lasted three years.

Afterward, she couldn't find private insurance because of lumps under her skin in a condition called lipoma. She was deemed uninsurable.

Her health care came from the free clinic she directs at a Methodist church in Thousand Oaks every Wednesday night.

The Affordable Care Act changed all that. It meant insurers no longer could turn away people because of pre-existing conditions. Safaeinili pays $936 a month to cover herself and her 17-year-old daughter. She said the cost is about the same as her COBRA insurance.

"I have access," she said. "It gives you the security."

Safaeinili is middle class. The 100 people every week who see doctors, receive medication or gain other services from the Westminster Free Clinic clean windows for a living or serve as nannies or work in restaurants.

Emma Morrow, of Agoura Hills, earns about $13 an hour working in a preschool. Her three children qualify for Medi-Cal. She does not. Her husband is covered through his job as a furniture salesman, but it would cost far more than she can afford to join the coverage.

She found insurance in the Covered California marketplace. But after a half-year of paying $117 a month, she dropped the plan. She couldn't afford it.

She's not sure which presidential candidate she supports. She knows what she needs: health care totally covered by the government.

"Financially, it would be better," she said.

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ABOUT THIS SERIES

This is the third in a series of stories looking at how policies proposed during the presidential campaign could impact Ventura County.

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AFFORDABLE CARE ACT

The Affordable Care Act created a new insurance marketplace and the expansion of government Medicaid insurance in 2014 that have brought health coverage to 20 million Americans, 4.8 million Californians and 88,0000 Ventura County residents.

The programs drew criticism from inception, blamed for rising insurance premiums, problems in finding doctors and cuts in revenues for some providers.

Republican presidential candidate Donald Trump said he would immediately call for the repeal of all of the Affordable Care Act and replace it with a program based on free-market principles. Democratic candidate Bernie Sanders has called for a single-payer system that would provide government health care to all. Democrat Hillary Clinton defends Obamacare and has also proposed allowing some people to buy into government Medicare.

Presidential candidates healthcare proposals (PDFs)-

Hillary Rodham Clinton

Bernie Sanders

Donald Trump

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