Inside Uninsured America — How Obamacare's Retreat Is Hurting Trump Country

Inside Uninsured America — How Obamacare's Retreat Is Hurting Trump Country

The U.S. Capitol is seen in a reflection on the side of an ambulance in Washington on Monday, June 26, 2017, as the Senate grapples with health care legislation.

SourceBill Clark/CQ Roll Call via Getty Images

Why you should care

Because there’s an immediate human cost to Washington’s wrangling.

When Cortney Guelker, health initiatives manager and marketplace navigator for the Ohio Association of Food Banks, talks to clients these days, she implores them “not to panic.” It’s easier said than done for the more than 10,000 Ohioans who, for now, don’t have health insurance options for next year on the Affordable Care Act exchanges because no insurers are willing to offer plans in 20 mostly rural counties.

The food bank association is the biggest “navigator” for the law in Ohio, helping enroll people on the exchanges, a complex job that seems to become more fraught by the day. Guelker and Erinn Garrison, a fellow navigator, say that most of their clients are a smidge younger than the Medicare age of 65, and they need a bridge to get there. They may have retired early, have a spouse on Medicare or are working part-time retail jobs that don’t provide insurance. Without federal subsidies, there is little chance they can afford a private plan. They’re researching what it would cost to pay for checkups and medications out of pocket next year, while they remain befuddled about what’s going on with the law known as Obamacare — and the potential rewrites ping-ponging around Congress.

An OZY analysis shows that … all 38 counties across three states without health exchange insurers next year voted for Trump.

With Republicans struggling to find consensus on a new health care law amid projections about how many millions of people will lose health care coverage in future years, tens of thousands are on the brink of losing their care under the current law — in part because of what the Trump administration is doing and not doing to undermine it.

In early June, Anthem Blue Cross Blue Shield Ohio announced that it would not participate in the Affordable Care Act exchanges next year because of “the shrinking individual market as well as continual changes in federal operations, rules and guidance.” The ACA has not enrolled as many people on state-based exchanges as analysts projected, in part because millions have opted to pay a fine — $695 per adult, or 2.5 percent of household income, whichever is higher — rather than buy costly health insurance.

The Trump administration has continued to pay “cost-sharing” subsidies, one of the ways to help people buy insurance plans on the exchanges, but has not signaled whether it will continue do so beyond the summer. (House Republicans sued the Obama administration over these payments, which will total about $7 billion this year, claiming they were illegal, because Congress didn’t appropriate money for them. The Trump administration inherited the case, which is still pending.) In January the administration also scaled back Obamacare advertisements, a critical tool for encouraging more desirable young and healthy customers to buy plans.

And then there’s the rhetorical barrage. Trump often muses about allowing the law to “implode” as a negotiating ploy to get Democrats to help repeal and replace it. When the Department of Health and Human Services put out a map highlighting counties with zero or just one exchange insurer, Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, labeled it as “another failing report card for the exchanges.”

When pressed by Democrats at a recent Senate hearing, HHS Secretary Tom Price — a chief Obamacare foil when he was in the U.S. House — insisted, “Nobody is interested in sabotaging the system. Nobody is cheering the challenges that we have in the system.” While pressing for a new law, HHS says it’s working with states to fill in coverage gaps and points to actions it says will improve and stabilize the marketplace, such as allowing insurers to offer plans with slightly lower premiums and higher cost-sharing.

Trump country hurts most from the uncertainty. An OZY analysis of election results and insurance data from the nonpartisan Kaiser Family Foundation shows that, as of June 30, all 38 counties across three states without health exchange insurers next year voted for Trump — usually by large margins. The 20 “zero counties” in Ohio gave 68 percent of their votes to Trump, compared to 52 percent statewide.

Anthem remains in talks with Ohio, leaving the door open for a comeback, and another insurer could jump in — as happened recently in Missouri. The Ohio Insurance Department is “working to identify coverage options for consumers, but that process will take some time,” according to Chris Brock, the assistant director of public affairs. Among its options is a waiver from the federal government so people could get subsidies to help buy insurance on the less-regulated private market outside the exchanges — but it’s still unclear if any private plans will be available in those counties.

Companies are now locking in rates and coverage for next year, while Congress continues to wrestle with health care. The Senate returns this week expecting to debate a divisive replacement. “If the Senate bill fails, I think there’s tremendous uncertainty about what the Trump administration will do in running the marketplaces for 2018,” says Larry Levitt, senior vice president for the Kaiser Family Foundation. “And we certainly could see more insurers pull out or raise rates significantly because of that.”

Meanwhile in rural Ohio, caregivers and patients talk of fear and confusion. Stress is rising, whether or not it is a pre-existing condition.

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