If there was anything certain coming out of Election Day it was this: Obamacare was doomed.
The 7-year-old health care law has been in Republican crosshairs since its birth. But now that the GOP has actually taken power, the consequences of the Affordable Care Act's demise no longer are mere political campaign promises but a near-term reality that will play out in the lives of millions of Americans.
In the Quad-Cities, thousands of people gained coverage because of the law. Nationwide, the figure is 20 million.
They’re either on expanded Medicaid programs, or they have used government subsidies to buy private insurance plans. Others, who had insurance, have been forced to buy greater levels of coverage. And for those not fortunate enough to qualify for subsidies, they’ve shouldered big premium increases, particularly this year.
Hospitals have seen a boost in patient numbers and revenues, and the amount of unpaid-for care they have been forced to provide has dramatically declined.
Offsetting some of the charity-care savings are reduced federal reimbursements in other areas, such as Medicare.
Community health care centers have seen an expansion in the number of patients, as their lower-income clientele has eagerly sought to get family members to the doctor.
But now that the time for repeal is at hand — and with little clarity on when the Republicans may produce the replacement they have promised — there is a mountain of uncertainty over what’s to come.
What follows is a peek into the different corners of the Affordable Care Act’s impact in the Quad-Cities and worries — as well as hopes — for what could be on the horizon.
Premiums going up
Connie Mangler was shocked.
Last month, she got a letter from an insurance company that said she was being enrolled in an insurance plan that carries a premium of $1,735 per month.
Mangler's previous insurer, UnitedHealthcare, decided to exit the ACA marketplace in Iowa. And, Mangler said, the letter offered a plan that was similar to one she had previously.
"I thought, 'You've got to be kidding,'" Mangler said.
Mangler posted a copy of the insurance letter to her Facebook page and got a torrent of response from others who also saw sharply higher premium costs.
"Something's got to be put in place better than what's being done," she said.
Mangler qualifies for tax credits, so she and her agent went shopping. After weeks of research, they came up with a plan that they estimate will cost her $648 per month, almost $90 higher than what she paid last year. However, the deductibles that went with the plan are more than with her previous coverage.
On average, premiums for mid-range Affordable Care Act plans jumped 25 percent this year. In Iowa, the rise was less stark. But premiums for plans sold on the marketplace still jumped on average 12 percent, according to data from the Iowa Insurance Division.
The tax credits, which rise with premiums, can offset some of the additional cost. But the Obama administration estimates that of the 18 million people in the individual (non-employer) insurance market, 7 million buy coverage off the exchange. There, premium costs for individual policies in Iowa rose even more.
Theresa Felger, an insurance agent who works on both sides of the river, said, "I've had several people tell me, 'I'm just going to take the penalty.' And I had one kid tell me, 'You can't get blood out of a turnip.'"
Obamacare critics have lambasted the premium increases, and even Democrats said something needed to be done. Hillary Clinton proposed expanding the availability of a "public option," or government-administered insurance plan, that would compete with private plans.
Republicans have not offered an alternative yet, but Iowa GOP lawmakers say they hear constant complaints about affordability.
"Throughout my 99-county tour across Iowa, I hear countless stories from Iowans facing premium increases, as well as skyrocketing out-of-pocket costs like deductibles and co-pays that they simply cannot afford," Sen. Joni Ernst, R-Iowa, said recently.
On a conference call earlier this month, Obama administration officials say despite the premium increases — which they predict will moderate next year — marketplace enrollment still is higher than it was the year before, adding that claims the marketplace is in a death spiral are false.
"These data show that this market is not just stable, it's currently on track for growth," said Aviva Aron-Dine, an economist and senior counselor to Health and Human Services Secretary Sylvia Mathews Burwell.
In the Quad-Cities, 5,770 people had signed up for or renewed their marketplace plans through Dec. 24. That's slightly higher than the 5,753 who had done so through the first nine days of January 2016.
Fearing coverage loss
It didn't take long for Republicans to begin acting to repeal Obamacare. Nine days after going into session, the U.S. Senate passed a budget resolution that puts repeal into motion. The House passed its own resolution a day later.
As is often the case in Washington, however, it's more complicated than that.
Republicans are promising swift action to repeal and say it won’t lead to widespread calamity. They say they will come up with a replacement plan. At the same time, Democrats are warning that repeal, without a clear plan for replacement, is a recipe for disaster.
For most, the technicalities of repeal — along with the politics — are less important than the implications. Kellie Sharp, a para-educator in the Davenport school system, is worried the Medicaid coverage she now qualifies for will be lost if the law is repealed.
Twenty-eight years old, Sharp said she was born with a condition called hydrocephalus, an accumulation of fluid on the brain. Sharp said she had a device put in to relieve the pressure, called a shunt. However, it requires monitoring.
"If I lost that insurance, I wouldn't be able to be monitored," she said. She added she also has expensive medications to treat the migraines that result from her condition.
Critics of the repeal effort say what's at stake is the health of millions of Americans who will lose coverage.
Rep. Cheri Bustos, D-Ill., argued on the House floor this month, "Again and again, we've heard that repealing Obamacare will make America great again. Well, I say it will make America sick again."
The Urban Institute estimated that, in 2019, 230,000 Iowans would lose coverage under repeal. In Illinois, it's 1.1 million people.
Sen. Chuck Grassley, R-Iowa, said on a conference call about a week ago that, regardless of how quickly a replacement plan is approved, people won't be abandoned.
"Either way, I think the idea is to make sure that people on the exchange now continue on the exchange through the transition period," he said.
Republicans have indicated that elimination of the subsidies that lower the cost of care would not happen immediately.
Critics of the repeal effort, however, fear that insurers concerned about the unpredictability of the situation will simply bail out of the marketplaces. Already, companies have left the exchanges because of big losses. Last year, UnitedHealthcare announced it would reduce its Obamacare offerings, including in Iowa.
Currently, Wellmark Blue Cross & Blue Shield, Coventry and Medica sell policies on the marketplace statewide.
Insurers are scheduled to submit rates to state regulators this spring. And although companies have not yet given an indication what they will do, Marylin Tavenner, president of America's Health Insurance Plans, the main industry trade association, wrote in an opinion piece last month that subsidies for consumers, as well as help for insurers that enroll "high cost individuals,” should continue through Jan. 1, 2019.
Putting in place clear "rules of the road” will be important to insurance executives who are, by nature, risk averse, said Nick Gerhart, the former insurance commissioner in Iowa.
"That’s the key: Sending a message of predictability to the industry," he said.
Gerhart has said Congress should keep a reinsurance program in place, which would assist insurers with high-cost claims.
Grassley said there is sentiment in the Senate toward providing some help for insurers to keep them in the marketplaces. He didn't say definitively whether he would support it but added, "I see a problem that's got to be dealt with.”
Hospitals wait for change
With 20 million new people gaining insurance coverage nationwide, it would follow that more people are getting care.
And for health care providers, such as hospitals and health clinics, it has meant more patients who can pay.
Both Genesis Health System and UnityPoint Trinity saw significant drops in the charity care they provided.
At Genesis, for example, that number shrunk from $17.8 million the year before the Affordable Care Act took full effect to $8.8 million last year.
Some of that was offset by lower federal funding in other areas, such as Medicare. But the decreases, hospital officials say, have allowed them to put more money into programs that seek to educate people about how to better manage their health.
That’s meant hiring people to help patients navigate their way through the health system and coach them on their care. The money that was freed up by lower charity care is only part of the funding that goes into the programs, but it has helped, officials say.
At Community Health Care, the share of its patients without coverage dropped to 10 percent. Tom Bowman, chief executive at CHC, said that when he started, in 2007, that figure was about 35 percent. Most of that decline was driven by the ACA, he said.
“That’s had a big impact for us,” he said.
The moves toward repeal now have hospital and CHC officials wondering what will happen with people who gained coverage, especially through an expanded Medicaid program.
Hospital officials say they’re fairly confident those people won’t simply be dropped.
Congress is moving swiftly to pass legislation repealing the ACA, but Republicans have said they expect revocation of the funding, such as what pays for the expanded Medicaid program, will be delayed while a replacement is put together. They also have tried to assure people they won’t just yank away their coverage, although Democrats have warned it’s a promise they might not be able to keep.
“I certainly hope, and I don’t believe, the government is going to turn its back and go in a different direction,” said Doug Cropper, Genesis’ chief executive officer.
Cropper and a representative for UnityPoint Health said repeal and replace may mean Medicaid patients paying more for their coverage. But “I’m optimistic that in Iowa, that they’re not going to drop people off of coverage,” said Sabra Rosener, vice president for governmental and executive affairs at UnityPoint.
When she was in the Quad-Cities last week, Lt. Gov. Kim Reynolds said the state’s intent is to make sure that people on Iowa’s expanded Medicaid program will maintain coverage.
Still, that doesn’t mean the current uncertainty isn’t disconcerting for hospitals and other providers.
"The biggest problem for us right now is uncertainty,” Rosener said. "The uncertainty that is caused by not knowing what your reimbursement structure is going to be in six months is a big problem.”
At CHC, Bowman said the organization is putting money into reserves that it otherwise would have used to hire people or expand.
“It makes us very uneasy about expanding the services we currently provide,” he said.
The Affordable Care Act, in addition to trying to increase coverage, also took some modest steps aimed at changing the way care is delivered and paid for. And the move toward repeal has created questions about just how much of the law’s provisions will be thrown overboard.
UnityPoint is part of what is called Next Generation ACO, a program that seeks to test whether strong financial incentives, coupled with better patient engagement and care management, results in better health outcomes and lower costs.
About 75,000 Medicare patients at UnityPoint, including in the Quad-Cities, are part of the model, whose management falls under a federal agency created by the ACA.
Killing the effort and moving back toward a fee-for-service method would be a step backward, Rosener said.
“It’s a pretty big deal to our health system,” she said.
This is expected to be an important week in the health care debate. The resolutions that were passed in the Senate and House on Jan. 12 and 13 instructed committees in both bodies to come up with a repeal bill by Jan. 27, which is Friday.
This process, called “reconciliation,” prevents Senate Democrats from using a filibuster to stop the repeal. That means a simple majority vote, not 60 votes, are needed to kill the law.
The key question is what will happen next and how fast. The “reconciliation” process can revoke only the parts of the law dealing with spending and taxes. So, killing other parts of the law — such as the requirement that individuals buy insurance and coming up with a replacement — will not be as easy.
Meanwhile, President Donald Trump, not long after being sworn in on Friday, signed an executive order giving federal agencies the power to make changes, to the extent that they're permitted by law.
The potential impact of the one-page order is still being sorted out.