Terry Brewster’s years of construction work have begun to take their toll on his 5-foot, 4-inch, 118-pound body.
A torn rotator cuff that requires surgery and nagging rheumatoid arthritis have left Brewster, 56, of Little River, S.C., in near-constant pain.
Fortunately, his marketplace health coverage under the Affordable Care Act allows Brewster to get arthritis medication, pain pills and even his high blood pressure medicine for about $20 per month.
Federal subsidies, in the form of tax credits, pay roughly $400 toward his monthly premium, leaving Brewster with a payment of just $119 per month for coverage.
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“It’s been a blessing to me,” he said of the financial assistance. “I’ve been able to go to specialists that I desperately need to go to. Other people can knock it, or whatever, but for $119, I’ve got coverage.”
At least for now.
The U.S. Supreme Court will soon decide whether the subsidies can continue for 6.4 million people in 34 states who use the federal insurance marketplace at HealthCare.gov.
Plainfiffs argue the subsidies should only go to people in the 16 states that operate their own marketplaces.
More than 4.1 million people, or nearly two out of three who could lose their subsidies in the case this year, live in just 13 Southern states – Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia.
These are many of the nation’s most impoverished states, where public policy decisions, unhealthy individual choices and a lack of education and resources have fostered a legacy of poor health outcomes throughout the Southeast and the Deep South.
“It’s a less healthy part of the country,” said Dr. Kenneth Thorpe, who chairs the Department of Health Policy and Management at Emory University in Atlanta. “The obesity rates are higher. The diabetes rates are higher. There’s high blood pressure. The (incidence) of chronic disease is substantially higher. The magnitude of health problems is substantial.”
In fact, eight of those 13 Southern states were among the bottom nine in last year’s America’s Health Rankings, which charts the health status of each state’s residents. Only Virginia, Texas and Florida finished higher, ranking 21st, 31st and 32nd, respectively, in the annual report compiled by the United Health Foundation, a charitable arm of insurer UnitedHealthcare.
Yet none of the 13 Southern states, except Arkansas, has used the Affordable Care Act to expand Medicaid eligibility for its low-income residents. So the marketplace subsidies have provided a “transformational opportunity to improve the health status of populations, particularly in the South, that really never had expansive state Medicaid programs in the first place,” Dr. Thorpe said.
If the Supreme Court terminates the subsidies, and most of the 4.1 million Southern plan members drop their coverage as experts predict, it could reverse the largest net increase in Southern health coverage since enactment of Medicare and Medicaid some 50 years ago.
“The cruelest thing is to give someone something and then take it back,” said Dr. Gary Wiltz, CEO of the Teche Action Clinic, a community health center in rural Franklin, La. “You’re talking about people who now have the ease of mind of knowing that they have health coverage and they’re not one accident or illness away from bankruptcy or financial devastation, which happened to a lot of our (uninsured) patients. They got ill and had to go to the emergency room and they got stuck with $10,000 or $20,000 medical bills.”
Brewster didn’t know about the upcoming court decision that will determine whether he gets the shoulder surgery he needs. But he does know he can’t afford his insurance or the operation if the court strips him of his subsidies.
“My life will be ruined, wrecked, totally wrecked,” Brewster said of possibly losing coverage. “You go through all these procedures, you get what you need, you do what your doctor says, what the specialist says, everything like that. You get down to the bottom line of being able to get something done. And then this? It’s very scary.”
The plaintiffs in the King case cite a section of the Affordable Care Act that says the subsidies can only be used toward coverage purchased “through an exchange established by the State.” Only 16 states and the District of Columbia currently operate their own marketplaces. The Obama administration argues that a full reading of the health care law makes clear that Congress intended to provide the tax credits in all states.
Nationally, 87 percent of marketplace plan members receive the tax credits, but in impoverished Southern states, the rates are higher. Mississippi leads the nation with subsidies going to more than 94 percent of people with marketplace coverage. Florida’s next at 93.5 percent, followed by North Carolina at 93.2 percent. Louisiana, Arkansas, Georgia, Alabama and South Carolina all top the 90 percent mark.
At Teche Action Clinic, about half of the 20,000 annual patients are uninsured. Most were expected to get coverage through Medicaid expansion, but when that didn’t happen in Louisiana, the clinic helped many enroll into marketplace coverage. If those patients lose their subsidies and can’t afford coverage, the clinic would still provide care, but the charges – $10 to $20 depending on a patient’s income –wouldn’t cover the cost of care.
”If you’re paying me $20 for a visit that costs us $120, and we’re not being reimbursed for our costs, that’s very difficult to sustain,” said Wiltz, board chairman of the National Association of Community Health Centers. “If this gets repealed, I’m going to have to make some hard decisions.”
As nonprofit organizations prepare for the upcoming marketplace enrollment season, the specter of King v. Burwell looms large.
After explaining the ins and outs of coverage to thousands of people for the last two years, the possible loss of subsidies and coverage in the South would be like going back in time, said Shelli Quenga, director of programs for the Palmetto Project, a nonprofit organization in South Carolina that helps enroll people into marketplace coverage.
“We would be back where we were years ago when we were piecing together parts of care through free clinics, prescription assistance programs and the community health centers,” Quenga said.
Without the subsidies, Quenga envisions hospital emergency rooms overrun with people who lost their coverage but had gotten used to their improved health.
“At first we had people who didn’t understand how to use their coverage. Now we have people who have their medicine and see what a difference it makes,” Quenga said. “Those people would most likely want to be able to continue feeling that good, being able to work and being able to care for themselves and their families.”