Nueces County residents sound off on future of ‘Obamacare’

March 05--When Carol Elliott was 6 years old, she learned how to play Beethoven's "Fur Elise" on the piano.

"I just remember the first time I heard someone playing that song ... I was just transported," said Elliott, 64. "I just love music. It just made me happy. I love to dance, love rhythm. I believe everybody has gifts, and I think I got a gift for music and poetry."

In Nashville, she was paid $1,000 a month to pen a certain number of songs a year as a professional songwriter for Sony Records. During her career, she self-produced five albums, which she sold at gigs, and experienced some popularity in the German music market in the early 2000s.

"But I never got famous," she said.

Though she always worked side jobs, Elliott never made enough money to afford insurance. She didn't do annual checkups and would go years between mammograms, which are recommended annually for women starting at age 45.

"I was taking risks. I look back on that now and think I suffered for my art and took great risks, so I could do what I felt was the most important thing to me," the Port Aransas resident said.

Elliott was 60 when she finally got insurance through the Affordable Care Act, commonly known as Obamacare, which mandated new rules for Americans' health care, one being that everyone be on an insurance plan.

A few months before purchasing insurance on the government exchange, she had a mammogram. It had been four years since her last one.

Looking at the 3-D scan of her breast, Elliott remembers, the tumor looked like the constellation Cassiopeia. "It wasn't smooth. It was jagged."

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In October, she was diagnosed with breast cancer. By the next February, she had a lumpectomy.

"I just decided I was going to take the world's most positive attitude about this," she said. "I had gotten Obamacare. It covered everything -- surgery, anesthesia, post-operative doctor's visits. Then it covered all my medication. It was paying 100 percent of all medication, antidepressants, thyroid medication, pain killers. Then I had radiation."

Elliott believes her story is not uncommon, and she's worried about what will happen if the Republican-controlled Congress keeps its promise to repeal, or dismantle, the Affordable Care Act.

Though now in remission, there is a chance it could come back. If the ACA is repealed, but not replaced, Elliott said she may not be able to afford coverage or won't qualify for insurance because of her history with cancer.

"I had my six month appointment in October, but I don't try to keep track," she said. "The doctor wants me to exercise 45 minutes a day, five days a week, to decrease the chance of recurrence by 20 percent. It's got me walking on the beach more."

What is 'Obamacare'?

Since the controversial Patient Protection and Affordable Care Act was signed into law in March 2010, there has been debate about who it helps and who it hurts.

The act mandated several rules but the most contested has been that everyone have health insurance -- even people who don't want it.

It also created a way for parents to keep their adult children on their plan until age 26 and became one of the first effective ways for people with preexisting health conditions to qualify for insurance. The act also prohibits lifetime maximums for benefits.

People with low incomes can buy insurance on an exchange and afford to pay for it through government subsidies and tax credits for which they have to qualify. The qualifications are based on modified adjusted gross income.

Another part of the act expanded Medicaid coverage in states that opted in. Texas declined to expand the federal program.

A county's needs

In Nueces County, 12,798 people were insured through the ACA last year. This is about 3.5 percent of the county's population, said Jonny Hipp, chief administrator/CEO of the Nueces County Hospital District.

The hospital district, which is funded by county taxes, pays for health care for the county's indigent population through the Nueces Aid Program.

Since 2014, Hipp estimates about 250 people have left Nueces Aid and bought insurance through the government's health care exchange.

Roughly 90 percent of the people who still use that county aid would have been able to have insurance had Texas expanded its Medicaid coverage. However, people are not required to disclose why they leave the aid program or why they re-enroll, Hipp pointed out.

"Texas has taken the position that if the federal government was willing to give them the funds that would have been needed to expand Medicaid, then they should let the state come up with its own expansion program," Hipp said.

Of the nearly 13,000 people who have insurance through the ACA in the county, about half qualify for cost-sharing reduction subsidies. How people qualify for subsidies is based on income level, but not necessarily resources, said Dena Bruni, the hospital district's assistant administrator.

Nueces Aid covers people from zero to 138 percent over the federal poverty level. There are nearly 4,000 people in the county who have insurance through the ACA who are between 138 and 150 percent over the poverty level.

"We went ahead and made the change that anyone between 138-150 percent who should have qualified for subsidies, but didn't, we would let them in if they could provide an exemption on why they didn't get it," Bruni said.

There's a disparity between how the federal government counts income (modified adjusted gross income) and how the county does. If a person has assets valued at more than $4,147, he or she does not qualify for county aid.

Household size also is computed differently. In the county, a household oftwo adults and two children is considered a household of two, because the children would qualify for Children's Medicaid.

"The ACA is not an indigent care program," Hipp said. "It's designed to get people covered who were uninsured. All people enrolled in our program are uninsured, but not all uninsured are indigent. That means there's a whole layer of people income-wise that are out of our program that are uninsured."

Seeking alternatives

Dr. Keith Rose said there are more uninsured or underinsured people today because of the ACA's mandates.

"There were about 12 million people without insurance in the country. Many of those people were young people who chose not to buy insurance," Rose said. "The fact that no one could get insurance is an outright lie. There have always been high-risk pools in Texas."

Rose, who owns The Doctor's Center Urgent Care on South Padre Island Drive, said the ACA is a disaster.

"It's just more regulation. For average people, insurance has doubled in costs, tripled in some places," Rose said. "Deductibles are $7,000 out-of-pocket before the plan takes over for some."

Before the act, Rose said he paid $450 a month for his family of four and had a $2,500 deductible to meet before insurance would kick in. Now it's $1,400 a month with a $7,500 deductible.

In an analysis conducted in 2015, USA Today found there were fewer choices on the national health care exchange for low deductible plans, and the minimum deductible cost increased significantly in some parts of the country, including Texas.

Before the ACA, health insurance premiums for people buying individual coverage grew only about 10 percent between 2008-2010, according to USA Today.

"You didn't do anything to help people," Rose said. "President (Barack Obama) lied to us. We couldn't keep our doctors and health care costs more now. Those are two indisputable facts."

Health care, especially health insurance, tops the list as one of the country's most debated topics.

As Republicans look at ways to replace the ACA, they are faced with how to continue a way of providing coverage for the thousands who get it through the exchange.

Congressman Blake Farenthold, R-Corpus Christi, has long decried the drawbacks of Obamacare.

In a 2016 news release after President Barack Obama's final State of the Union speech, Farenthold said the healthcare system needed to be changed.

"I have listened to (Obama) tout Obamacare while I've watched good, hard working people pay triple for their insurance premiums, and seen their deductibles skyrocket," he said.

A spokeswoman with Farenthold's office directed an inquiry last month seeking comment about his stance and the local effects of the ACA to his official website.

In late February, Farenthold spoke to area Tea Party members at a public meeting. He said plans are in motion to repeal the ACA by March 31.

"At the bare minimum, I'm 100 percent for repealing Obamacare," Farenthold said on a video streamed on Facebook by an attendee. "We are going to repeal easily the penalties, employer penalties, the mandates, all of the taxes, all of the financial related stuff."

Farenthold laid out how Congress was going to move the bill through the Senate to ensure it's placed on President Donald Trump's desk to sign. He also said they were in the budget resolution process, which has a deadline of the end of March.

Obamacare is failing financially, he said, and many insurers have stopped offering plans on the exchange. The policies are so expensive because of the mandates insurance companies have to follow, such as coverage for preexisting conditions, mental health and substance use disorder services, prescription drugs, and pregnancy, maternity and newborn care.

READ THE TRANSCRIPT OF FARENTHOLD'S REMARKS

"The Republican plan wants to cover preexisting conditions, but we don't want to cover preexisting conditions forever," Farenthold said at the meeting. "We want to say 'if you got a preexisting condition, you can buy insurance, but you gotta buy it by such-and-such date.' The insurance only works if you have it when you're healthy, too."

Rather than let the ACA fail on its own, Farenthold said they are working on an alternative that would not leave people who need insurance uncovered. He described something Republicans are developing called a "health insurance backpack," which will include rules about insurance after retirement or moving to a new job and tax-free health savings accounts.

The unknowns

The repeal of the act, just like its inception, would affect the hospital industry in a multitude of ways.

And a repeal without an immediate replacement is not a scenario that Christus Spohn Health System supports.

Gabriela Saenz, the system's vice president of advocacy and public policy, worked in Austin and Washington, D.C., throughout February to stress the need to keep the ACA. She said Spohn was one of the first to jump onto the act at the federal level because it strongly believed the national healthcare system needed to be reformed.

"Access to care is the core of our mission," Saenz said. "If it is repealed, there needs to be a replacement mechanism for that to occur."

Saenz said if the act is repealed, millions would lose their insurance. But those people are still going to use hospital services and the cost for uncompensated healthcare will rise to a level that Christus Spohn cannot afford.

"None of those people were eligible for Medicaid or (Nueces Aid)," she said. "The uninsured will be coming to the emergency department (when they are the most sick) with the highest costs in an inappropriate setting."

Without health insurance, people tend to ignore a small problem until it's a much bigger one, and that's when they seek emergency services. Since hospitals cannot refuse to treat anyone, they are often left to foot the bill. Through the ACA, much of the uncompensated care costs are reimbursed to the hospital by the government.

Saenz said Spohn's No. 1 priority is to push the congressional delegation on making sure there is a replacement with an adequate level of access to care before anything is repealed.

"Without Obamacare, (the gap population) would have nothing," she said.

Clinics that exist solely to serve uninsured populations would also be affected by a repeal.

Women's and Men's Health Services would be impacted if the part of the ACA which requires birth control be provided at no cost is eliminated, executive director Amanda Stukenberg said in an email.

"We would be inundated with women who have private insurance, but who could not afford to buy their contraceptives, especially the ones that are most effective," Stuckenberg said. "Since (the clinic) is funded entirely with state funds, the elimination or changes to ACA would not affect the women we serve with this funding stream."

The business side

According to USA Today, freelancers and small business owners in the country number in the millions. The National Association for the Self-Employed has offered insurance in the past, but has no current plans to do so again.

About 80 percent of nearly 29 million small companies do not have the requisite number (51) of employees to be mandated to provide group health insurance coverage, according to USA Today.

The National Small Business Association opposes the ACA because of the increased costs that have resulted from compliance.

Seventy percent of about 600 small business owners surveyed by Wells Fargo believe that changing the ACA requirements for small companies would help them grow in the long run.

A waiting game

Ross Bernhardt, a music professor at Texas A&M University-Corpus Christi, said he is disheartened by the political attitude that people protesting the repeal of the ACA are a "vocal minority" as Farenthold has described.

"By far, the majority of people want to not repeal the ACA, but improve it," said Bernhardt, a member of the Coastal Bend for Bernie Sanders group. "What he is proposing is not improving it at all, especially for the poorest in our community."

Hearing proposals about tax-free health savings accounts does not impress him because of the minimum wage.

"People who are making starvation wages don't have money to put aside for anything, much less healthcare," Berhardt said. "People are living paycheck to paycheck and don't have disposable income."

Hipp knows that the 13,000 people with insurance through ACA would not return to the Nueces Aid rolls, and he said there would be a local economic impact.

"The first people getting paid by them are doctors that weren't getting paid before when they saw them," Hipp said. "The next layer is the hospitals and outpatient facilities. They now have income to buy prescription drugs. They have their insurance to get things they couldn't get before."

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