Healing Healthcare: New law is saving lives, sowing doubts

By on April 15, 2014
Affordable Care Act
Affordable Care Act

Affordable Care Act

JACKSON, WYO – Julia Heemstra never imagined that the Affordable Care Act would ever get this far.

“I’ve been following universal healthcare since it was an idea of Hillary Clinton’s way back when,” said Heemstra, director of the Wellness Department at St. John’s Medical Center.

“When Obama started talking about a healthcare overhaul, I was like ‘That’s another thing I hope he does, but I don’t think it’s going to happen.’”

In March 2010, President Obama signed The Affordable Care Act into law. Almost four years later, the law is finally becoming a reality as millions of Americans gain healthcare coverage through the controversial law.

In Teton County, Heemstra has the tough task of making sense of the nuanced and ever-evolving set of policies since enrollment opened in October. She is part of a state-funded collaboration between Teton County Library and St. John’s Medical Center, which offers free help sifting through the online marketplace.

“This was one of the most complicated things that I have ever done,” Heemstra said. “The deadlines and policies were changing on a regular basis. There were days where I felt like my brain could not function after working with multiple clients, problem solving for unique situations and all of the loopholes and exemptions that exist.

On January 1, the first ACA healthcare plans went into effect. “It’s been so amazing to see it come to life,” Heemstra said.

No one understands that metaphor better than Kelly (name changed to protect privacy). Her newborn son was one of the first in Teton County to be born under Affordable Care Act coverage.

Kelly’s previous private insurance wouldn’t cover pregnancy, so she shopped around on the marketplace, where she found plans that covered maternity. Her due date was January 16, which would have been perfect timing if she had not started dilating at the end of December.

“I put myself on self-imposed bed rest, to keep that baby in until the first of the year when we could get coverage,” she said. “He came on January 11, and we were pretty psyched that we had Obamacare.”

The pregnancy bills totaled more than $20,000. “Our plan covered the majority of that,” Kelly said. “It was pretty great.”

Like Kelly’s son, the ACA is in its infancy, and we are only just beginning to understand its personality.

“We are, of course, fans of Obamacare, but ya know, it wasn’t all easy. Getting our newborn son on the plan was a lot more complicated than signing up ourselves. It was like they were not equipped to deal with anything out of the ordinary. It was kind of a pain, but I couldn’t really get mad because we are all figuring this out together. The whole thing is just so new for everyone,” Kelly said.

Eric Lovely on the road to recovery – minus his spleen

Eric Lovely on the road to recovery – minus his spleen

The ACA in action
Eric Lovely signed up for a healthcare plan through the ACA on Christmas Eve. His coverage started on January 1. About a month later, he was unexpectedly utilizing his new plan after being caught in a small avalanche that pinned him against a tree.

He felt a little shaken, but he managed to ski down the mountain and skin back to the car a full two miles. As a precaution, his ski partners convinced him to head to the hospital.

“We had a discussion, and everyone said ‘You have health insurance, you should go. You hit a tree pretty hard,’” said Lovely.
One life flight and a several hours later, surgeons were removing his ruptured spleen in emergency surgery at Eastern Idaho Regional Medical Center.

“Everyone was totally surprised. You don’t necessarily feel your spleen,” Lovely said. “They told me I was bleeding internally. I didn’t realize how imminent the danger was. I would have died that night had I not gone to the hospital.”

Lovely woke up the morning after his operation hoping to start his road to recovery with his first physical therapy session. As he inched toward the nurse, everything went black. He awoke to the sounds of panicked doctors.

“I heard them say, ‘we’re losing vitals. We don’t have a pulse,’” Lovely said.

Doctors had removed his spleen in the first surgery, but the remaining artery had ruptured, prompting another emergency surgery.
“I felt like I was dying on the table,” Lovely said. “I was in and out of consciousness, but I was pleading with them to open me back up. They saved my life.”

After nine days in the hospital, Lovely was happy to just be able to process food properly. Health care coverage was the last thing on Lovely’s mind.

That’s when his first bill arrived.
The total cost of his hospital stay was $105,506. Under his new ACA healthcare plan, Lovely owed just $100.

“This is the best health insurance that I’ve had,” he said. “I thought it looked good on paper, but in reality, it’s turning out to be a good plan.”

Lovely could be the poster child for who can most benefit from the ACA. He has already saved thousands of dollars only three and half months after getting coverage. His pre-existing conditions from past injuries are covered, and he is paying a third of what he would pay for premiums on the private market because his annual income falls into the healthcare “sweet spot.”

Finding the ‘sweet spot’
Healthcare navigator, Julia Heemstra says ‘the sweet spot’ is where the financial assistance gets really good.

The first thing Heemstra does during her one-on-one healthcare consultations is pull out a chart that breaks down the federal poverty level.

“My book just opens right to this page, because I use it so much,” Heemstra said.

Those with an income between 100 and 400 percent of the federal poverty level qualify for financial assistance through the health insurance marketplace.

People like Lovely, whose projected income falls into the more limited range between 100 and 250 percent of the federal poverty line are situated in the “sweet spot.” In other words, a single individual making between $11,460 and $28,725 a year is poised to receive the most substantial subsidies toward a healthcare plan.

The closer someone gets to the low end of that range, the better the assistance gets.

Take, for example, Matthew Lovely (Eric’s brother), who makes just slightly more than the federal poverty level. This puts him in the sweetest of the sweet spots, paying only $2.50 a month for his healthcare plan.

“This was maybe the only time these people thought it was a good thing to make so little,” Heemstra said. “I would say, just anecdotally, for probably 75 percent of the people I saw, the marketplace really worked for them.”

Those on margins left out
For those whose incomes fall outside the range of eligibility for financial assistance, the ACA becomes a misnomer.

“The problem is that once you get past those ranges, it was kind of like falling off a financial cliff. The premiums went up significantly and not in proportion to income,” Heemstra said.

An individual who makes more than $45,960 is subject to paying full price on plans inside the marketplace.

“In those cases, I told them, it’s time to shop around,” Heemstra said. “Often a private plan will be cheaper.”

On the flip side, a person with an income that falls below the poverty level is in the odd position of falling off a similar financial cliff as their wealthier outliers.

“The people that I was worried about were those people on the low end of the income spectrum who fell into the Medicaid gap,” Heemstra said.

These are people who make less than $11,460, for whom shopping around for private insurance may not be an option. Heemstra said she only saw a few clients that fell into the Medicaid gap. Her advice was to utilize options like the free clinic and public health.

“These were the truly heartbreaking stories,” she said. “This is what makes you feel like the system is broken, but the problem is not with the ACA. The problem is that the ACA was presupposed on the assumption that all states would expand Medicaid.”

When the health care law was passed it was expected that states would pick up Medicaid coverage where the ACA left off. The Supreme Court later ruled that the Medicaid expansion should be left to states discretion. Twenty-one states, including Wyoming, opted not to expand their Medicaid coverage, leaving the poor with few options for health insurance.

“In the end we left the poorest of the poor without assistance. Those people were not supposed to be left behind, but they were,” Heemstra said.

Perhaps the only recourse for folks who fall in the Medicaid gap is that they are exempt from the tax that most people face if they opt out of health insurance.

Healthcare navigators used this chart to pinpoint their clients’ assistance level. Incomes between 100-250 percent of the poverty level fall into the ‘sweet spot

Healthcare navigators used this chart to pinpoint their clients’ assistance level. Incomes between 100-250 percent of the poverty level fall into the ‘sweet spot

What’s my income?
Often, when Heemstra pulls out her federal poverty level chart and asked her clients what they expected to make next year, they would return blank stares.

“I would say that 95 percent of the people that I worked with were like ‘I don’t know what I am going to make in 2014,’” Heemstra said. “That’s one of the unique things about Teton County.”

The majority of people Heemstra helped had at least two jobs and sometimes more with variable and unpredictable levels of income.
For people like Emilee Walker, pinpointing next year’s income is not always a simple task. She works as a massage therapist and barista, and her income varies depending on workflow and seasonality.

“I’m nervous that I guessed my income bracket wrong. I think I might have guessed low,” Walker said.

If she underestimated her salary, she could be forced to pay back a portion of her subsidies at the end of the year.

“People would show up with a stack of W2s,” Heemstra said. “And then they’d be like, ‘I think I am going to have this job again next year, but I’m not sure.’ And it was really scary for people to feel like they were locked in financially.”

Heemstra tried to allay enrollees’ fears by explaining that you can change your income level at any point when you realize you misjudged or something changes. That information helped ease any anxiety that Walker was feeling.

“I was told by a healthcare consultant ‘this is new for everyone. We are all figuring this out as we go and you can always change your projected income.”

Alternatively, Heemstra suggests playing it safe and taking a lesser subsidy. That leaves her clients with a little bit of padding, and in the best-case scenario they could end up with a check in the amount of a leftover subsidy at tax time.

“But you know, of all the people I worked with, there was only one person who only used only a portion of his subsidy. Everyone else took the full subsidy,” she said.

Opting out
Trae Christopher is a prime candidate for a plan through the ACA, but he chooses to opt out entirely.

Choosing to remain uninsured means that he will face a fee of $95 or 1 percent of his income, whichever is greater. For Christopher, that means a couple hundred dollars on his tax return for 2014.

“That’s the part that gets me. I think it’s illegal to tax me because I don’t buy something,” he said. “But I’m just going to pay the fine. It makes more financial sense for me.”

Also, Christopher says he doesn’t think the ACA will last long.

“I appreciate the effort to change the healthcare system, but we have so many other fundamental issues to fix before we can even get to healthcare. It’ll be two to three more years of ‘experimentation’ and then the Republicans are going to repeal the act and the whole thing anyway and it’s going to be a giant nightmare,” Christopher said.

Mike Sherwood shares Christopher’s hesitancy to jump into untested territory. He has been insured privately for years. As someone who is privately insured through a Qualified Healthcare Plan, he is exempt from the fee. Sherwood says he would probably be paying less through the marketplace, but prefers to stick with his $500 per month plan because he doesn’t quite trust the system yet.

“It’s just so new. I want to see it tested,” he said. “Maybe I’ll switch in two or three years after we see how it goes.”

Growing pains
Through all the challenges, dissenters and upheaval, Heemstra remains positive about the future of the ACA.

“There were a lot of bumps and bruises along the way, but I’ve believed in the ACA since it was just a concept, so I will take the bumps and the bruises,” Heemstra said. “This system might be cumbersome and broken in its own ways, but it’s working in the most important ways.”

Lovely, who has experienced the benefits of the new system firsthand, has more nuanced opinions.

“I feel that it is my responsibility to be insured, and the marketplace was my best financial option. It ends up working really well for me, but the real problem is the inflated cost of medical care in this country. I think the ACA is like a Band-Aid on a much bigger wound. It’s just putting off the problem for future generations to deal with.”

Four months after implementation of the ACA, we’re starting to get a glimpse of the scale of the new law.

“I think we are literally just seeing the tip of the iceberg when it comes to the disruption that this law will cause,” Heemstra said. “And in my opinion a disruption was needed.”

About Christie Koriakin

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