With the possibility of the U.S. Supreme Court overturning the Affordable Care Act, many political candidates are addressing a topic Obamacare was supposed to fix: insurance protection for the sick and disabled.
The premise of Obamacare was built on “guaranteed issue,” allowing those with preexisting conditions to get insurance at any time. The ACA also mandated enrollees be rated equally, regardless of risk or age.
Both of these provisions, however, put pressure on premiums to the point where many healthy enrollees ended up dropping coverage. Even the mandate to purchase insurance or face a fine was not enough to stop the exodus. Insurers were left with the most expensive pool of enrollees to cover. Many enrollees who have remained in the exchanges do so with the help of government subsidies to help pay for premiums.
The issue of “pre-existing” conditions surfaced during the September 29 Presidential Debate. President Trump defended his September 24 executive order to “ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates” by saying it was not just symbolic and he’s done more to cut prescription drug prices than the Obama Administration.
Democratic candidate Joe Biden stated Trump “is not for any help for people needing health care,” and regarding Obamacare, “he wants to take it away.” Trump responded, “Obamacare is no good, I made it better,” and “[my advisors] said the problem is, no matter how well you run Obamacare, it’s a disaster.”
Obamacare Upends Care for the Disabled
When the ACA went into effect in 2014, the insurance plan for Melissa Davert’s disabled twin children was canceled because it did not meet Obamacare requirements. The twins, like their mother, face significant disabilities from a life-threatening disorder known as brittle bone disease. Ken Davert, Melissa’s husband and the twins’ father, has cerebral palsy.
Melissa Davert’s experience was featured in the Republican Study Committee’s (RSC) 2019 report, “A Framework for Personalized, Affordable Care.” To find a replacement plan on the exchange would have cost the family $10,200 out of pocket, a hardship for the family because Ken and Melissa were limited to how much they could earn to receive Medicare coverage.
The children, now young adults, have enrolled in Medicare (through Social Security Disability) because they could not afford plans on the individual exchange and do not have employer insurance.
“They are forced to take government-sponsored insurance with a huge out-of-pocket medical cost liability and awful prescription coverage, said Davert.”
Davert says the twins, who were finishing college at the time, want to work and save.
“[My daughter] has considered signing up for Medicaid, but due to her assets she does not qualify,” Davert told Health Care News. “In order to qualify, she would have to transfer most of her small savings to a government-approved savings account (in Michigan, called ‘MiAble’) where she would lose her right to spend that money how she pleases and would incur a fee every time she would make a withdrawal.”
In the RSC report, Davert wrote, “we feel people like us with disabilities and pre-existing conditions have been forgotten and left behind in the current system.”
ACA Like Medicaid, with Higher Premiums
Obamacare has been problematic for individuals with less significant disabilities, says John Goodman, co-publisher of Health Care News. Goodman, along with health economist, Devon Herrick, published February 21 by The Daily Signal, “How Obamacare Made Things Worse for Patients with Pre-existing Conditions” and Herrick discussed the problem on The Heartland Daily Podcast and for an article in Health Care News.
Goodman and Herrick explain that before Obamacare upended the market, states had insurance risk-pools for the disabled. Employees who were sick and lost their employer coverage could be covered under COBRA, which was the case at one point for Melissa Davert.
When insurers struggled with costs with their plans on the exchanges, their solution was to limit networks. ACA plans are like Medicaid, with higher premiums, Goodman says.
“Many of the best doctors refuse to see Medicaid managed care patients and many of the best hospitals won’t admit them,” Goodman said. “They exclude ACA patients for the same reasons.”
Healthy People Crowd Out Disabled
Medicaid has long been an option for disabled people, but now that states have been able to expand their programs to healthy people, disabled people are being “crowded out.”
A 2018 report by Linda Gorman, director of health policy at the Independence Institute and a senior fellow of the Goodman Institute, states that 423,745 intellectually or developmentally disabled people were on waiting lists for home care and community services in 47 states. Gorman offered an explanation.
“The people in the expanded Medicaid population tended to be less expensive than the people already enrolled in Medicaid,” Gorman writes in the report.
Gorman states one big cost drain for Medicaid has been managed care setups where states pay a flat fee to cover healthy enrollees who may never use services.
“In traditional Medicaid, people do not generate spending unless they get medical care,” Gorman stated.
Unemployment caused by lockdowns in response to the pandemic could make the situation worse because it will put more healthy people on the rolls, Gorman told Health Care News.
“If scarce public money is to be spent on individual health care, then the first people in line should be those who need medical care but cannot help themselves,” Gorman said.
“Rather than providing health care for poor disabled people on state waiting lists for long-term care services, Obamacare architects wanted ‘coverage,’” Gorman said. “They expanded Medicaid to cover healthy people like college students even though seriously disabled children and adults continued to languish on waiting lists for lack of funding.”
Thirty-nine states have expanded their Medicaid programs.
AnneMarie Schieber (email@example.com) is managing editor of Health Care News
Linda Gorman, “What Are We Getting for Our Obamacare Dollars,” August 6, 2018, The Goodman Institute: http://www.goodmaninstitute.org/wp-content/uploads/2018/11/BA-126-What-Are-We-Getting-for-Our-Obamacare-Dollars-for-web.pdf
Republican Study Committee, “A Framework for Personalized, Affordable Care,” October 2019: https://www.heartland.org/publications-resources/publications/a-framework-for-personalized-affordable-health-care