Virginians face coverage woes

HEALTH CARE INSURANCE

RICHMOND — The only thing that Susan Swan, Lucas Fritz and Melissa Greenfield know for sure about their health care insurance next year is that their current policies won't exist on Jan. 1. Swan, of Midlothian, and Fritz and Greenfield, both from Richmond, currently have health coverage under policies issued by Aetna on Virginia's affordable care insurance marketplace. Aetna, now owned by CVS Health Corp., is pulling out of that market in Virginia and the rest of the United States after this year.

But even if they find another comparable policy on Virginia's insurance exchange, they might not be able to afford monthly premiums that are rising by an average of nearly 21% — unless Congress extends enhanced federal subsidies that are scheduled to expire on Dec. 31.

"At this rate right now, I probably will not have health insurance," said Greenfield, a self-employed small-business owner. She said she and her husband pay about $500 a month with the enhanced subsidies. Swan, Fritz and Greenfield were among eight Virginians who shared their stories and concerns about health care coverage in an online roundtable discussion that Sen. Mark Warner, D-Va., led on Friday. Warner and Sen. Tim Kaine, D-Va., are among Senate Democrats who have refused to back a Republican short-term funding bill to reopen the shuttered federal government unless the deal includes a plan for extending the premium enhanced tax credits.

"We've got to get the government reopened, but we've also got to recognize that the health care cliff is real," Warner said.

Swan, Fritz and Greenfield will be able to shop for new insurance policies on the marketplace, which began open enrollment on Saturday for nearly 400,000 Virginians who already buy health coverage through the state exchange, as well as potential new customers seeking affordable health care at a time of rising household costs and shrinking government programs.

Right now, the outlook is not good.

Swan and her husband are 62 years old, retired and living with chronic health concerns that require daily medications and extensive preventive care. He's a cancer survivor and she carries an extensive family history of breast and pancreatic cancer that require close monitoring.

With their Aetna policy expiring, they hired an outside consultant to help them find other options. What they learned is that instead of paying $492 a month under their current policy, they may have to pay $1,950 a month, without enhanced subsidies — or almost half of their monthly income.

"If we do have premium tax credits, it would make a big difference," Swan said.

Fritz, owner of The Broadberry music venue and booking promotion company, is looking for health insurance options primarily for his 10 full-time and 56 part-time, year-round employees, many of whom can't afford coverage without help. The company said it does not offer health coverage as a benefit, but provides employees a stipend to help them pay for coverage. All but one of his full-time employees currently has health insurance.

Personally, he said he pays about $400 a month for the Aetna policy he's had for five years, but he does not yet know what to expect with the plan disappearing.

"I'm going to have to go back and find new insurance for myself," Fritz said. "It's kind of a bad situation all around for everybody."

Doug Gray, executive director of the Virginia Association of Health Plans, acknowledged that current Aetna customers in the state marketplace are "kind of stuck in between" until they have a chance to compare options during open enrollment.

Gray said health insurance premiums are rising this year because more people are using their benefits for medical care and the people in the insurance pool generally are sicker, which causes prices to rise. He said costs also are rising because of increasing challenges that health care providers face, which include impending cuts in reimbursements they receive for care under the Medicaid program that the federal government shares with states.

CVS, the new owner of Aetna, is getting out of all the state and federal affordable care markets, and focusing instead on Medicare health plans. "They were losing money because the population is getting sicker," Gray said.

The insurance pool is likely to get sicker yet, if relatively healthy people drop their insurance because they can't afford it, he said. A higher percentage of the people who remain would be those with medical conditions who can't risk being without insurance to pay for medications and care.

The Virginia Health Benefit Exchange, which runs the state marketplace at the State Corporation Commission, estimates that 106,000 Virginians will drop their insurance coverage entirely, or more than a quarter of the roughly 388,000 people who hold marketplace policies now.

If Congress does not extend the enhanced subsidies, the pain would be worst at the top and the bottom of the income scale. The enhanced premium tax credits, enacted during the COVID-19 pandemic, provided subsidies for the first time to middle-class families earning more than 400% of the federal poverty limit — $84,600 for a family of two — who still cannot afford to buy insurance on the individual private market.

In Virginia, 27,624 people at that income level hold auto-renewable policies on the marketplace, with an average household income of $144,771 a year. Their premiums will rise to $1,388 per month, a net increase of $526 a month or 61%, according to the exchange.

Legal immigrants in a bind

At the bottom, people who earn less than 100% of the federal poverty limit also will lose all subsidies under the budget reconciliation act that President Donald Trump signed into law in July. In Virginia, that will affect 19,853 people, with an average household income of $13,322 a year, the exchange estimated. Almost all of them are immigrants legally present in the United States, predominantly people who hold green cards as lawful permanent residents.

They would have to pay an average premium of $999 a month, an increase of more than 2,000%, to keep their insurance.

The new law excludes them from tax credits because of their income. People who earn up to 138% of the federal poverty level are eligible for coverage under Medicaid, but lawful permanent residents must wait for five years after receiving their green cards before they are eligible for Medicaid in Virginia.

"This is the first time that any legally present immigrant has been denied a federal tax credit," said Ben D'Avanzo, senior strategist for health policy at the National Immigration Law Center.

Nationally, the Congressional Budget Office estimated that the restriction affects about 300,000 people, but KFF, formerly known as Kaiser Family Foundation, puts the number closer to 550,000.

Deepak Madala, director of the Center for Healthy Communities at the Virginia Poverty Law Center in Richmond, said the federal law "created this new Medicaid gap for immigrants. They can still get a plan, but they have to pay full price."

Madala also oversees Enroll Virginia, which operates a statewide network of "navigators" who help people find health insurance, whether through the state marketplace or Medicaid.

With the combination of higher premiums and no or lower federal subsidies, free clinics are bracing for a surge in demand for their services.

"If the subsidies go away and they can't afford to purchase insurance, then they're uninsured," said Julie Bilodeau, CEO at CrossOver Healthcare Ministry, which runs two medical clinics in Richmond to provide health care to people who have no health insurance or rely on Medicaid.

CrossOver is preparing for "a big increase in need," Bilodeau said. "We expect to see newly uninsured who need our services."

Julie Trombley-Shapiro Jonas, at the Legal Aid Justice Center, also expects that people will have fewer places to turn for health care.

"They're going to rely on the free clinics," Jonas said. "The free clinics are already overwhelmed and will only be more so."

Michael Martz, (804) 649-6964 mmartz@timesdispatch.com