GOP defeats bid to cancel expansion of Obamacare-evading plans

https://www.washingtontimes.com/news/2018/oct/10/gop-defeats-bid-cancel-expansion-obamacare-evading/

Image result for short term health insurance

 

Senate Republicans turned back a Democratic bid Wednesday to kill President Trump’s plan to expand the sale of health plans that fall short of Obamacare’s rules, saying Americans who buy insurance on their own need more options, not fewer.

Sen. Susan Collins, Maine Republican, sided with Democrats in the 50-50 vote, though the resolution needed a majority to advance.

Its defeat was never in doubt, really, though the vote allowed Democrats to paint Republicans as “junk plan” peddlers who don’t care about people with preexisting conditions who might pay more for robust coverage, as healthier people who cross-subsidize their costs ditch Obamacare for skimpier options.

This administration wants to let these junk insurance plans run rampant and let people be duped into thinking they’re having insurance when it covers almost nothing,” Senate Minority Leader Charles E. Schumer said. “They are a massive risk to any family who purchases them, and worse, they cause rates to go up for everyone else.”

Democrats are elevating their defense of health coverage for sicker Americans this mid-term season, citing polling that shows GOP threats to undo Obamacare’s protections for preexisting conditions are unpopular.

Sen. Tammy Baldwin, Wisconsin Democrat facing re-election, pushed Wednesday’s resolution under the Congressional Review Act, which gives Capitol Hill a chance to veto new rules and regulations.

She targeted a Trump rule, finalized in August, that would allow companies to sell “short-term” health plans that fall short of Obamacare’s full coverage menu, and to allow Americans to hold the plans for up to a year.

President Barack Obama himself allowed consumers to hold short-term insurance for a full year until 2016, when he capped short-term plans at three months.

Republicans were quick to point that out, although Mr. Trump’s regulation would let consumers renew for an additional two years.

The administration and its GOP allies say Americans have been priced out of Obamacare’s market, so invalidating Mr. Trump’s attempt to extend a lifeline would be cruel.

“Surely, they must have a better answer than snatching away one of the remaining options that some Americans still prefer,” Senate Majority Leader Mitch McConnell said.

“Our constituents deserve more options, not fewer,” he said. “The last thing we should do is destroy one of the options that still is actually working for American families.”

 

Coverage for pre-existing conditions lives on, even though the Affordable Care Act seemed doomed

https://www.statnews.com/2018/10/10/coverage-preexisting-conditions-lives-on-aca/

The most enduring legacy of the Affordable Care Act may be emerging now in midterm races across the country, and our health care system may never be the same.

For the first time in our history, Americans are agreeing that even if you are sick you should be able to find private health insurance coverage you can afford. Not only do 81 percent of voters now think it should be illegal for insurance companies to deny coverage to people with pre-existing conditions, but both political parties have embraced this central tenet of Obamacare.

Responding to Democratic attacks and polling data, Republicans are backpedaling from opposition to the Affordable Care Act’s guarantees that the more than 50 million Americans with pre-existing conditions should be able to find coverageWriting last month in the Wall Street Journal, Republican strategist Karl Rove urged candidates to embrace the pre-existing condition guarantee, but to find new conservative strategies for securing it.

This development is historic. Before the passage of the Affordable Care Act, Americans broadly embraced a national obligation to insure the elderly, the poor, and the disabled. We’ve now added the sick to this list. If the past is prelude, there will be no retreating from this commitment. Once acknowledged, commitments like Medicare and Medicaid are virtually impossible to claw back.

As policymakers look to respond to this newfound promise to the sick, they will be confronted with the harsh reality of private health insurance markets: The only way insurers can offer affordable coverage to the sick is if they have a substantial number of healthy enrollees.

Many of the ACA’s most controversial provisions are aimed at providing private insurers a steady supply of good risks. This includes the much-vilified individual mandate, as well as restrictions on the sale of skimpier, cheaper policies, such as short-term health plans, that appeal to healthy purchasers and siphon them away from the risk pools that cover less-healthy consumers. The ACA also provided temporary reinsurance that protected private plans against unpredictable, catastrophic losses likely to occur when they cover very sick clients. That provision, however, has expired.

The challenge facing policymakers going forward will be how to execute this new guarantee that the sick have access to private insurance. A wide variety of options spanning the political spectrum exist, but virtually all require some form of government involvement.

The left proposes that, if private companies don’t step up, the federal government should fill in by allowing consumers with pre-existing conditions (or even those without them) to buy into Medicare or Medicaid. As Medicare and Medicaid are among our nation’s most cost-effective insurers, this could be a way of expanding coverage while keeping costs in check.

Another alternative would be to build on the Affordable Care Act’s current provisions that require insurers to cover pre-existing conditions, prevent insurers from charging more for those conditions, and provide strong financial incentives for healthy individuals to purchase private marketplace plans. Despite the repeal of the individual mandate and other attempts to undermine the ACA, private insurance markets created by the ACA have shown considerable resilience, with premiums actually declining this year for the first time since the ACA was enacted.

Republicans have released legislation that would amend the Health Insurance Portability and Accountability Act to require insurance companies to sell plans to people with pre-existing conditions and not charge them more because they have been, or are, sick. Insurers, however, would be able to deny coverage for specific illnesses. In other words, insurers would have to sell coverage plans to people with pre-existing conditions, say diabetes, but would not have to cover their diabetes. Insurance companies could also increase premiums based on age, gender, or occupation.

Another Republican approach, discussed during the “repeal and replace” debate, would make available subsidized plans, such as the ACA, but increase premiums over time if individuals failed to purchase them at the outset. In theory, healthy individuals would jump into the pool to avoid paying a penalty at a later date. This is an approach used under Medicare Part B, a voluntary program that covers outpatient services, that has been fairly effective and politically acceptable.

Whether it would work outside of Medicare and avoid the need for more intrusive government intervention remains to be seen. The elderly are much more likely to feel that they need insurance and to respond to incentives to get it earlier rather than later, while younger, healthier people may be more reluctant to buy and then end up priced out of the insurance market.

These and other routes toward coverage for sick Americans will be fiercely debated in the coming years. As we do so, we shouldn’t lose track of the profound change in attitude and expectations around health insurance for the sick that will animate this debate.

Elected officials should expect to be held accountable this November, and for many Novembers to come.

 

 

 

The Health 202: The rate of people without health insurance is creeping upward

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/09/13/the-health-202-the-rate-of-people-without-health-insurance-is-creeping-upward/5b99569b1b326b47ec95958c/?utm_term=.ae9e8af79dd2

 

THE PROGNOSIS

New Census Bureau data on the number of uninsured Americans is either a testament to the resiliency of the Affordable Care Act or a sign that President Trump’s anti-ACA rhetoric and policies are starting to work.

As our colleague Jeff Stein reported Wednesday, there was a slight uptick in the number of Americans without health insurance in 2017 compared to 2016, even though that number essentially remained statistically flat. Still, the fact that uninsured rate went up at all, by about 400,000 people, marks the first time since the ACA’s implementation that the uninsured rate didn’t drop. 

Supporters of the ACA worry the news marks the beginning of a trend, especially when some of Trump administration policies intended to circumvent the ACA go into effect next year.

Ahead of open enrollment last year, the Trump administration dramatically decreased funding for any Obamacare outreach or advertising, limited resources for “navigators” who help people find an insurance plan, and shortened the window for people to sign up for insurance from three months to six weeks in states that use a federally run marketplace.

“Even with all of that, health coverage stayed steady. But at the same time, we’d like to see further progress in the rate of the uninsured,” said Judith Solomon of the Center on Budget and Policy Priorities.

It’s part of a pattern to weaken the 2010 health-care law known as Obamacare. After the GOP Congress failed to repeal and replace the ACA last summer, the Trump administration moved to dilute the law in other ways: including signing off on a plan to eliminate the individual mandate penalty next year; allowing individuals to buy skimpier, short-term health plans without certain coverage requirements under Obamacare; and seeking to allow states to put conditions on Medicaid coverage.

Some of the most prominent health care organizations in the country came together this morning to voice their disapproval of those short-term plans — including the American Cancer Society Cancer Action Network, the American Heart Association, Planned Parenthood Federation of America, the National Women’s Law Center, the , American Academy of Family Physicians, the American Academy of Pediatrics and Families USA.

“The Administration’s decision to expand short-term health plans will leave cancer patients and survivors with higher premiums and fewer insurance options,” said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

The groups’ statements, compiled and released by Sen. Tammy Baldwin (D-Wis.), are in support of the senator’s effort to have Congress rescind the White House regulation. Nearly every Democratic senator has signed a resolution of disapproval to overturn it.

The census data reflects trends that started last year, when the administration’s policies had yet to be implemented. Fourteen states saw their uninsured populations rise in 2017. The only three states that didn’t see a spike in that number were New York, California and Louisiana. The first two aren’t surprising given those states’ robust efforts to enroll their own residents, while Louisiana expanded Medicaid in June 2016 so its decrease represents those low-income individuals who now have government coverage.

Medicaid expansion in most of the 33 states and D.C. that have done so under the ACA has predictably decreased the number of people without coverage. The uninsured rate last year in states with an expanded Medicaid program was 6.6 percent compared to 12.2 percent in non-expansion states — a gap that has only continued to grow since 2013.

To be fair, as Larry Levitt, senior vice president at the Kaiser Family Foundation, pointed out on Twitter: the uninsured rate started leveling off before the Trump administration started its work. But Levitt suggested the uninsured rate may really rise in 2019 when elimination of the individual mandate penalty takes effect. Moreover, states are increasingly taking the White House up on its suggestion to add work requirements to their Medicaid programs — in just the first three months of it being implemented in Arkansas, more than 4,000 people were jettisoned from the rolls for failure to comply.

Matthew Fiedler, a health-policy expert at the Brookings Institution, agreed with Levitt’s assessment, noting that the bulk of the people who were uninsured pre-ACA have already been enrolled  in the program. He contended that if policy had remained static, there would likely have been a modest decline instead of similar increase in the uninsured rate — though not a dramatic one. The real effects, he said, of the Trump administration’s efforts to chip away at the ACA are still to come. 

“I don’t think the right takeaway is that none of the policy changes will have a negative effect. I think they will going forward, we just haven’t seen that yet,” he said. “I think if your goal is to evaluate the ACA, I think the right takeaway is that there was a lot of progress, but more policy progress to be made.”

Of course, Democrats and Republicans have disparate views on how to get there. Democrats are now pushing for a public option or a universal health care system in which the government would foot the bill for many health-care costs. A lot of them feel  the ACA “got us roughly 40 percent there and established a framework for lawmakers to make that progress going forward,” Fiedler said. That’s why we’re now seeing so many Democratic candidates and lawmakers embracing some iteration of a “Medicare for all” program.  

Republicans still criticize the ACA as vast government overreach and are vowing they will take another stab at repealing it should they maintain the congressional majorities after the November midterms.

“We made an effort to fully repeal and replace ObamaCare and we’ll continue,” Vice President Pence said while campaigning for Baldwin’s opponent, Leah Vukmir, if the GOP performs well in the midterms.

One additional interesting data point from the census is ages at which there was the greatest increases or decreases in the uninsured rate. As highlighted in the chart above, rates of those without insurance rose at ages 18 and 19 — when children are no longer eligible for the Children’s Health Insurance Program; and for those between ages 25 and 26 — when children no longer qualify for their parents’ insurance. The uninsured rate dropped, however, for those aged 64 and 65 — when adults are eligible for Medicare.

The greatest spike in those without insurance was documented for 26 year olds. That’s likely because young adults are typically healthier and feel less urgency to pay for insurance when they lose coverage under their family’s plan.

As noted by the New York Times’ Margot Sanger Katz on Twitter, these stats show just how crucial government programs and laws have been in providing health coverage to Americans:

Is Obamacare Constitutional? The Battle Begins Again

http://www.thefiscaltimes.com/2018/09/05/Obamacare-Constitutional-Battle-Begins-Again

 

The debate over the Affordable Care Act entered a new phase Wednesday as a federal court in Texas began hearing oral arguments in a lawsuit brought by 20 Republican-led states challenging the constitutionality of the 2010 law.

Eighteen Republican state attorneys general and two GOP governors bringing the suit argue that the law’s individual mandate was rendered unconstitutional when Congress lowered the penalty for individuals who don’t buy coverage to zero.

The Supreme Court, in upholding the law in 2012, deemed that penalty a tax and thus a valid and legal exercise of Congress’ power of the purse. The lawsuit claims that the law is no longer constitutional because the zeroed-out penalty can no longer raise revenue. “It’s nothing but a hollow shell because its core has been invalidated,” said Misha Tseytlin, Wisconsin’s solicitor general.

The plaintiffs also claim that this means the entire ACA — and, in particular, its protections for patients with pre-existing conditions looking to buy insurance — must be struck down because the mandate can’t be severed from the rest of the law. The Trump Justice Department decided not to defend the ACA in the case.

What a Kavanaugh Confirmation Might Mean

The case, which legal experts see as a long shot, may still wind up before the Supreme Court — which is why Democrats have brought up Obamacare and its protections for patients with pre-existing conditions in this week’s confirmation hearing for Brett Kavanaugh, President Trump’s nominee to replace Justice Anthony Kennedy.

“Kavanaugh has signaled in private meetings with Senate Democrats that he is skeptical of some of the legal claims being asserted in the latest GOP-led effort to overturn the Affordable Care Act,” the Los Angeles Times’ Jennifer Haberkorn reported last week. Three Democrats in the meetings told the Times that Kavanaugh suggested that if one piece of the law is struck down, the rest of the law doesn’t necessarily have to fall with it.

But that may not be enough to assuage Democratic fears that Kavanaugh could be the deciding Supreme Court vote against Obamacare. “Democrats are more concerned about Kavanaugh’s past writings on expansive presidential powers, which they say could lead to his supporting efforts by the Trump administration to dismantle the health-care law without Congress,” The Washington Post’s Colby Itkowitz notes.

Where Public Opinion Stands

The political debate over Obamacare has shifted as public perception of the law has improved. The latest Kaiser Family Foundation tracking poll, released Wednesday, finds that 50 percent now view the law favorably while 40 percent see it unfavorably, with the divide still falling along partisan lines. Just under 80 percent of Democrats support the law, while a similar percentage of Republicans oppose it.

That may be why Republicans still view repealing the law as a potent issue with their base. Vice President Mike Pence, in Wisconsin last week to campaign for Senate candidate Leah Vukmir, said the GOP push to repeal and replace the health care law was still alive: “We made an effort to fully repeal and replace Obamacare and we’ll continue, with Leah Vukmir in the Senate, we’ll continue to go back to that,” he told reporters. With Sen. Jon Kyl (R-AZ) replacing John McCain, a critical vote against the GOP’s 2017 Obamacare repeal bill, there has been chatter about another potential repeal effort — though Senate Majority Leader Mitch McConnell effectively shot that down on Wednesday.

In the meantime, open enrollment on the ACA exchanges is set to begin on November 1, with the Trump administration once again providing reduced funding for outreach groups that help people enroll. A recent report by the nonpartisan Government Accountability Office criticized the administration’s management of Obamacare signup periods.

Senators Consider Dueling Bills Over Texas Individual Mandate Litigation

https://www.healthaffairs.org/do/10.1377/hblog20180828.283008/full/?utm_term=Read%20More%20%2526gt%3B%2526gt%3B&utm_campaign=Health%20Affairs%20Sunday%20Update&utm_content=email&utm_source=Act-On_2018-08-05&utm_medium=Email&cm_mmc=Act-On%20Software-_-email-_-Individual%20Mandate%20Litigation%3B%20Housing%20And%20Equitable%20Health%20Outcomes%3B%20Simplifying%20The%20Medicare%20Plan%20Finder%20Tool-_-Read%20More%20%2526gt%3B%2526gt%3B

Litigation in Texas over the constitutionality of the individual mandate and, with it, the entire Affordable Care Act (ACA) is receiving more and more attention in Congress. On August 23, 2018, Republican Senators released new legislation that they believe would help blunt the impact of a ruling for the plaintiffs in Texas v. United States. The stated aim of the bill is to “guarantee” equal access to health care coverage regardless of health status or preexisting conditions. However, in the event that the court agrees with the plaintiffs—or even just the Trump administration—the legislation leaves significant gaps.

At the same time, Democratic Senators had their efforts to potentially intervene in the litigation rebuffed during the debate over a recent appropriations bill for the Departments of Labor, Health and Human Services (HHS), Education, and Defense. With a hearing on Texas scheduled for September 5, 2018—the same time as hearings are set to begin in Congress over the confirmation of D.C. Circuit Judge Brett Kavanaugh to the Supreme Court—attention on the case is only likely to increase.

Brief Background On Texas

In Texas, 20 Republican state attorneys general and two individual plaintiffs challenge the constitutionality of the individual mandate, which was zeroed out by Congress beginning in 2019. Without the penalty, the plaintiffs argue that the mandate is unconstitutional. Because the mandate cannot be severed from the rest of the law, they believe the entire ACA should also be struck down.

In June, the Department of Justice (DOJ) declined to defend the constitutionality of the individual mandate alongside the ACA’s provisions on guaranteed issue (42 U.S.C. §§ 300gg-1, 300gg-4(a)), community rating (42 U.S.C. §§ 300gg(a)(1), 300gg-4(b)), and the ban on preexisting condition exclusions and discrimination based on health status (42 U.S.C. § 300gg-3). These provisions collectively ensure that individuals with preexisting conditions cannot be charged more for their coverage or denied coverage or benefits based on health status or other factors.

The plaintiffs have asked Judge Reed O’Connor of the federal district court in the Northern District of Texas to enjoin HHS and the Internal Revenue Service (IRS) from enforcing the ACA and its implementing regulations—or, at a minimum, to strike down the law’s guaranteed issue and community rating provisions alongside the mandate. Judge O’Connor is considering ruling on the merits of the case (instead of issuing a preliminary injunction) and has scheduled a hearing on the motion for a preliminary injunction for September 5.

As noted above, the hearing will coincide with confirmation hearings for Judge Kavanaugh. Texas will likely be a focal point in the Kavanaugh proceedings because of the possibility that the case will reach the Supreme Court and because previous decisions suggest that Judge Kavanaugh believes that a President can decline to enforce laws that he or she believes to be unconstitutional.

The New Republican Legislation

Recognizing the potential impact of the Texas lawsuit, 10 Republican Senators released new legislation on August 23. The bill is sponsored by Senators Thom Tillis (NC), Lamar Alexander (TN), Chuck Grassley (IA), Dean Heller (NV), Bill Cassidy (LA), Lisa Murkowski (AK), Joni Ernst (IA), Lindsey Graham (SC), John Barrasso (WY), and Roger Wicker (MS). It is tied directly to the Texas litigation: Press releases acknowledge the September 5 hearing and state that “protections for patients with pre-existing conditions could be eliminated” if Judge O’Connor rules in favor of the plaintiffs.

The legislation would amend the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Although HIPAA offered significant new protections at the time it was passed, these protections were limited in terms of ensuring that people with preexisting conditions could access affordable, comprehensive coverage, particularly in the individual market. HIPAA established a minimum set of federal protections for certain consumers—for example, those who lost their group coverage—facing certain situations, such as job lock because of a new preexisting condition exclusion period. HIPAA also required guaranteed issue in the small group market and guaranteed renewability in the individual and group markets.

As mentioned, the DOJ has declined to defend the ACA’s provisions on guaranteed issue (42 U.S.C. §§ 300gg-1, 300gg-4(a)) and community rating (42 U.S.C. §§ 300gg(a)(1), 300gg-4(b)), and the ban on preexisting condition exclusions and discrimination based on health status (42 U.S.C. § 300gg-3). Thus, their position in the lawsuit implicates parts of four provisions of federal law: 42 U.S.C. §§ 300gg, 300gg-1, 300gg-3, and 300gg-4.

The legislation introduced by Republican Senators would restore only two of the four provisions that stand to be invalidated in Texas: 42 U.S.C. § 300gg-1 (guaranteed issue) and most of § 300gg-4 (guaranteed issue and rating based on health status). So the bill would prohibit the denial of coverage and rating based on health status, but it would not prohibit preexisting condition exclusions or rating based on other factors, such as age, gender, tobacco use, or occupation. This means that many individuals, including those with preexisting conditions, could still face higher premiums, higher out-of-pocket costs, and the denial of benefits because of a preexisting condition even after paying premiums for many months.

Implications 

The protections offered by the restoration of the two provisions included in the Senate GOP bill, § 300gg-1 and most of § 300gg-4, are largely illusory without the other parts of the ACA—community rating and the ban on preexisting condition exclusions—that are at risk in the lawsuit. Assuming the at-risk provisions are struck down and the new legislation is adopted, consumers would still face significant gaps. For instance, a woman with a history of cancer could purchase a policy under the new bill, but she could be charged more based on her gender and age, potentially pricing her out of the market. In addition, her policy could have a preexisting condition exclusion, meaning that any recurrence of cancer—or any other health condition—might not be covered at all; this could lead to much higher out-of-pocket costs and far less financial protection.

If Congress were to enact this bill today, it would largely be duplicative of existing law (and would do nothing to disturb the ACA). If Congress were to enact this bill in response to the Texas litigation, its effect would depend on how (if at all) a court would invalidate the ACA provisions in Texas. Would a court strike the entire provisions, including what was adopted under HIPAA and other federal laws? Or would a court simply strike the amendments that were made by the ACA?

If the latter, the new legislation might do even less than its authors think, because much of the bill is, in fact, devoted to readopting existing federal law that may not be at issue in Texas. These provisions were adopted before the ACA and touch on, for instance, genetic information nondiscrimination and long-standing exceptions to guaranteed issue.

No Vote On Manchin Resolution To Potentially Intervene In Texas

In July, Democratic Senators led by Joe Manchin (WV) introduced a resolution with the goal of intervening in Texas to defend the ACA’s protections for people with preexisting conditions. The resolution would authorize the Senate Legal Counsel to move to intervene in the case on behalf of the Senate and defend the ACA. During last week’s debate over an HHS appropriations bill, Senate leadership blocked a vote on the amendment.

 

 

The uninsured rate remains plateaued

https://www.cdc.gov/nchs/data/nhis/earlyrelease/Insur201808.pdf?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top-stories

Image result for The uninsured rate remains plateaued

 

The Centers for Disease Control and Prevention is out with its latest health insurance coverage data this morning, and the nation’s uninsured rate isn’t really changing a whole lot.

By the numbers: As of March 2018, 8.8% of all Americans, or about 28.3 million people, had no health insurance.

  • Those numbers are almost identical to the CDC’s 2017 report, when 28.1 million people were uninsured as of March 2017.
  • It’s also worth noting that 47% of people younger than 65 are in a high-deductible plan, up from 42.3% recorded at the same point last year.

The big picture: The federal and state exchanges established by the ACA are treading water when it comes to enrollment, and no new states have expanded Medicaid. (Notably, Maine Gov. Paul LePage is still resisting his state’s voter-approved Medicaid expansion.)

The bottom line: Don’t expect the uninsured rate to fluctuate a lot until more states expand Medicaid or the ACA exchanges get more federal support.

Looking ahead: The U.S. Census Bureau will unveil its 2017 health insurance numbers on Sept. 12.

 

 

Priced Out of Health Insurance, Americans Rig Their Own Safety Nets

https://www.bloomberg.com/news/features/2018-08-22/priced-out-of-health-insurance-americans-rig-their-own-safety-nets

Risking It: Stories From America's Uninsured

Consumers frustrated by high costs are bypassing the bureaucracy with patchwork plans.

When their son Sky was born four years ago, Lindsie and Chris Bergevin were hit with a big surprise: $7,000 in bills for the birth that their health plan didn’t cover. Sky was two when the couple jettisoned their medical insurance, which helped them eventually pay off the debt.

Now that they’re ready to have a second child, they’re not going back to their old coverage, with its premiums of more than $350 a month. Instead, they’ve patched together an alternative through a religious group and a primary-care doctor whom they can visit anytime for a monthly fee.

“I was so jaded with the whole health-care insurance situation,” Lindsie, 35, says. “I just didn’t want to deal with it.”

The Bergevins, who rent a snug little house near downtown Boise, Idaho, are joining a small but growing number of Americans rigging their own medical safety nets. They’re frustrated by the high costs, opaque pricing, and maddening bureaucracy of health insurance.

In their quest for a different way, they’re meeting doctors like Julie Gunther who are also fed up. These physicians have opted to reject insurance, instead charging patients directly in return for more personalized care.

“I like to think we can protect people in vulnerable moments where they’re going to get lost like a widget,” Gunther said, “because they’re not a widget for us.”
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Bloomberg News is following people who are uninsured in a year-long effort to tell the story of Americans struggling to afford the rising costs of health care, and the financial and medical trade-offs they make.

No reliable data exist on how many people are replacing insurance with arrangements like the Bergevins’, but the trend appears to be gaining momentum.
The number of people joining so-called health-care sharing ministries—religion-based cost-sharing plans—rose 74 percent from 2014 to 2016, according to the latest Internal Revenue Service data. An alliance for the groups said that more than 1 million people now participate in such programs. Similarly, primary-care clinics like the one Julie Gunther started in 2014 have grown to almost 900 from just a handful in the early 2000s, according to the Direct Primary Care Coalition, a trade group for the clinics.

The number of people without traditional insurance is expected to increase. The Trump Administration lifted the Affordable Care Act’s penalty for those who go without insurance, while also encouraging the growth of lightly regulated products such as short-term health plans. Proponents of Obamacare fear the administration’s actions will draw healthy people out of the ACA marketplaces, raising costs for those who remain.

Though the ACA expanded coverage to 19 million Americans, some of those gains are reversing. About 28 million remain uninsured. A study by the Kaiser Family Foundation, a health-research nonprofit, determined that most uninsured families simply found health insurance too expensive.

The Bergevins are one of those families.
Lindsie is a freelance graphic designer who focuses on clients in the craft industry. Chris, 34, is a supervisor at the auto shop the Bergevins jointly own with another couple. Though the business is growing, things were tight enough that Chris didn’t draw a salary until last summer. Last year, the couple took home from $40,000 to $50,000, after taxes.

In 2014, when Lindsie was pregnant with Sky, the couple still had coverage through her job at the Idaho Statesman newspaper.
A calculator on her Aetna health plan’s website estimated the Bergevins would need to pay about $3,000 or $4,000 out-of-pocket for Sky’s birth. When the total bill came, the sum for prenatal care, hospital costs, anesthesia, and other care was triple the estimate.

They were still paying off Sky’s birth in 2016 when Lindsie had surgery to remove her tonsils and correct a deviated septum, leaving them with several thousands of dollars more in bills.

She put the sum on a CareCredit medical credit card and is paying $300 each month toward that debt.
As the couple thought more about it, maintaining their coverage made little sense. They were falling deeper into medical debt, despite having insurance which itself cost thousands of dollars a year. In 2016, Lindsie left her newspaper job to devote herself full-time to her thriving freelance design business—and they went uninsured.

“I couldn’t justify it,” she says. The cheapest policy she could find through the Affordable Care Act, she recalls, was $547 a month—more than half the family’s $875 monthly rent at the time. It had a high deductible that could leave them with out-of-pocket costs of more than $10,000.

“If something were to happen to us, we would have been in trouble,” she acknowledges. To hedge, the couple bought an inexpensive accident policy from Aflac that would cover some costs from an injury if, for example, Chris hurt himself working.

A friend told them about a small primary-care clinic called SparkMD less than a mile from their house. The doctors didn’t accept insurance. Instead, they charged a monthly fee of $130 per family. That allowed visits as needed without any limits. When Lindsie went to check it out, a physician began with an in-depth conversation about the family’s health.

“It was amazing. She sat down with me for an hour and talked about everything,” Lindsie says.

Gunther, the Bergevins’ new physician, had long wanted to be a family doctor in her hometown. Working for a large hospital system, though, she was soon chafing under a bureaucracy that seemed to make too many of her clinical decisions for her, down to what tools and equipment she could use. Even worse, Gunther was paid based on her volume of patients and services billed.

She saw patients in 15-minute intervals and says she felt like a factory line worker. She’d later joke that she spent longer waiting in line for her morning coffee than she did with a patient.

“I was saying ‘I’m sorry’ all the time,” Gunther, 42, recalls. “I’m sorry I’m late, I’m sorry this didn’t get called in, I’m sorry this got forgotten, I’m sorry they didn’t give me the message.”

Burned out, she quit her job in 2014 and started her own practice. She borrowed about $200,000 to renovate an old red-brick law office on a leafy corner of downtown Boise, a few blocks from one of the city’s big hospital campuses.

Along with a nurse practitioner and a small office staff, she cares for about 600 patients. A typical primary-care doctor carries at least double or triple that load. More than half of Gunther’s patients have health insurance, often in high-deductible plans. Others are small business owners like the Bergevins. Most are disenchanted with the health-care system.

Last year, Lindsie Bergevin had a bad fever and what she described as “the worst pain I think I ever had in my head.” She called Gunther at 9:30 p.m. on a Saturday. Gunther met her at the clinic 15 minutes later. “She’s like, ‘Girl, you have a double ear infection, and the worst I’ve ever seen.’”

Bergevin walked out with an antibiotic and says that if Gunther hadn’t seen her, she would’ve gone to the emergency room, which could have resulted in a bill for hundreds or thousands of dollars.

Gunther tells her patients that belonging to her practice is not a replacement for having health insurance.

“There’s a whole bunch of things I can’t take care of,” Gunther says. “If you’re not standing upright, or bleeding doesn’t stop, do not call me.”

In April, knowing that they wanted to conceive this year, the Bergevins paid to join a Christian nonprofit called Liberty HealthShare. Organizations like Liberty, sometimes called faith-based plans, help like-minded members share some medical costs. To join, members must pledge to adhere to Christian principles. They are required to make fixed payments each month, and the money is disbursed to cover health-care needs for other families.

Though health-sharing ministries function like insurance in some ways, they aren’t regulated by states, don’t have capital requirements to protect against large losses and don’t have to adhere to rules about minimum benefits. They decline to cover medical expenses that result from behavior they deem immoral. They won’t pay medical costs for a drunk driver in a car crash, for example, or for contraception.

There are other restrictions too: Liberty limits coverage of pre-existing conditions for up to three years, according to its guidelines. Members can also get bounced for “failure to fully disclose known or suspected pre-existing condition information” when they join. Those limits are part of the reason why they’re cheaper—and potentially riskier.

The Bergevins originally expected to pay $450 per month for Liberty. Because Lindsie is overweight, they pay a surcharge of $80 per month—a fee regulated insurers are barred from charging. When they joined, their plan had an “annual unshared amount”—the equivalent of a deductible—of $1,500. Two months later, they learned that amount would increase to $2,250. Lindsie wasn’t thrilled, but she calls it “a ton cheaper than a typical deductible.” And on the plus side, Liberty would reimburse them for some of the cost of membership in SparkMD.

In early June, Lindsie sat at her kitchen table with a stack of medical bills going back four years. Sky ran in from the living room, where Dr. Seuss cartoons played on the TV, looking for dessert before he  finished his dinner.

The Bergevins’ improvised plan has pros and cons. They didn’t have to pay premiums for almost two years while they were uninsured, easing their finances significantly while their businesses grew. They love the personalized care they get from Gunther. And their costs for having another child should be capped at a lower level under the Liberty plan.

But between Liberty and SparkMD, the Bergevins pay more than they did for health coverage through Lindsie’s old job, and, she estimates, about as much as Obamacare insurance would cost. The family is still exposed to considerable risk. Liberty caps reimbursements at $1 million—a limit that insurance companies can’t impose. They have two friends who have had cancer, and, Chris says, “a million’s definitely not enough.”

The Bergevins have their fingers crossed that their choices will allow them to expand their family without incurring the kind of debt that Sky’s birth and Lindsie’s surgery left them with. But they know their improvised approach isn’t for everyone.

“It’s not like I’m trying to say, just go without insurance,” Lindsie says. “You have to find something that’s going to work for you.”