Sweeping provisions of the ACA on the table as High Court hears case

Arguments to save or kill wide-ranging Obamacare law set for Nov. 10
Jill Henning was diagnosed with an aggressive cancer just a couple years after the Affordable Care Act became law.  Henning has group insurance under her employer, and because of the ACA, the screening that caught her cancer was free.  Henning, a reverend with the Evangelical Lutheran Church in America, is seen here working from home. (PHOTO by Alyssa Pointer / Alyssa.Pointer@ajc.com)

Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com

Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com

Jill Henning was diagnosed with an aggressive cancer just a couple years after the Affordable Care Act became law. Henning has group insurance under her employer, and because of the ACA, the screening that caught her cancer was free. Henning, a reverend with the Evangelical Lutheran Church in America, is seen here working from home. (PHOTO by Alyssa Pointer / Alyssa.Pointer@ajc.com)

Like millions of Georgians, the Rev. Jill Henning has health insurance through her job and doesn’t shop the Affordable Care Act’s marketplace. But her job’s plan gave her the cancer screening that saved her life for free because the ACA required it.

The ACA, also known as Obamacare, is best known for the health insurance exchange marketplace where individuals can buy subsidized plans. And when it comes before the U.S. Supreme Court Nov. 10, that will be on the table. So will countless other changes that altered far corners of the U.S. health care system.

For the 160 million Americans with group insurance like Henning, the law required that insurance fully pay for doctor-ordered preventive cancer screens. It changed safety rules for nursing homes. It broadened prescription coverage for Medicare, the government insurance for the elderly, and it changed membership for Medicaid, the government insurance for the poor. It levied new taxes. It prohibited gender discrimination in a variety of healthcare programs.

That’s just a sampling of the law’s 900-plus pages of changes. A lawsuit brought by Texas, Georgia Attorney General Chris Carr and other Republican-led states and supported by the Trump administration seeks to unravel every piece of it.

That “would be a very, very massive undertaking,” said Alina Salganicoff, senior vice president of the Kaiser Family Foundation research center and its director of women’s health policy.

“I mean, the Affordable Care Act has now been in place for 10 years,” she said: It would change things for many who are uninsured, and many on government insurance programs. And “it would affect nearly every individual who has private insurance coverage.”

A broad swath

The ACA attracted big groups as supporters or opponents. It attracted opponents from free-market groups who feared that healthier people with lower risk would be forced to buy meaty insurance they didn’t want. They were right.

It also attracted support from several patient groups. One was women’s groups, who decried insurance companies' practice of charging women more for insurance on the basis of their gender. There were also reports of insurers' treating domestic violence as a pre-existing condition, because victims were more likely to wind up in the emergency room.

Another group that supports the ACA is the AARP, which advocates for older Americans. AARP cites gains in the ACA that helped older people afford prescription drugs, since older people are strong consumers of them.

The process for the Food and Drug Administration to encourage and approve more affordable competitors to brand-name “biologic” drugs is encoded in the ACA. Repealing the entire law would erase that. Biologics are expensive, an AARP official said, and they need competition.

“We are just starting to see more robust biosimilar competition now, 10 years after the ACA,” said Leigh Purvis, director of health care costs and access at the AARP’s Public Policy Institute. “What happens to those products that got on the market?”

In addition, Medicare’s Part D plans used to have a “donut hole” where people would suddenly find their drug coverage had stopped. For a time, they would have to pay for all drugs out-of-pocket. After several thousand dollars' worth of spending, the plan would pick up costs again.

If the ACA goes away, “Every year you’d have potentially millions of people who’d be paying thousands of dollars more than they were paying before,” Purvis said. The AARP has called the potential dismantling of the ACA a “catastrophe.”

Kyle Wingfield is president and CEO of the libertarian-leaning Georgia Public Policy Foundation, which opposed the ACA and the government interference in the insurance industry that it brought with it.

If the law is overturned, he said, “It’s pretty inconceivable to me that any court would say, well it’s gone tomorrow.”

Just as Congress wrote years of transition into the ACA law, the courts would surely give states and the federal government time to undo it, if they overturn it, he said.

“It’s not going to be like, ‘I just got my plan ripped under me,’" Wingfield said. “There’s going to be time for people to prepare.”

Not perfect

Critics like the Foundation denounced the ACA as a broad government intrusion into insurance companies' market.

From Wingfield’s perspective, the law took problems that affected a few million people—a small number compared to the number who were satisfied with their insurance—and used it to bring regulation of insurance into the federal bureaucracy.

Advocates acknowledge its failings, too, but say that’s because the law didn’t go far enough.

The two sides generally acknowledge both positive and negative trends since its enactment. Patients with private policies, for example, increasingly see network lists from their insurance companies with not enough doctors on them. And the price of insurance premiums and out-of-pocket costs have continued to spike.

On the other hand, insurance companies are still making profits in the billions. And nationwide, the level of people with health insurance has soared.

Flecia Brown of Summerville is a supporter of the ACA because it mandates some help for people who get experimental cancer treatments like she did. But she has an acquaintance whom it doesn’t help.

Friends and family took up a collection to get the woman an initial cancer screening, which indicated she needs a biopsy, Brown said. But because she doesn’t have an ACA-compliant insurance plan and is poor, and because Georgia has opted not to expand Medicaid to all adults who make less than $12,000 a year, the woman would have to pay out of pocket. She’s hiding from the situation, though Brown thinks she’d go if the cost issue was moot.

“Now we’re just holding our breath,” Brown says.

Uncharted territory

Following the ACA’s passage in 2010, Henning was healthy with no reason to worry about cancer and overdue for her routine mammogram. But then she felt a lump in her breast and made sure to attend the next mammogram she had scheduled.

That lump turned out to be a rare, wildly aggressive cancer. Doctors got it all out, but it has transformed her life.

It can replant itself anywhere and spring to life at any time, so she gets screened every 12 weeks. She and her husband have bought a new home with the bedroom on the ground floor in case she winds up needing hospice care. She’s had one recurrence, a slight cough she thought was allergies but turned out to be cancer spread throughout her esophagus. They gave her six months to live, three years ago.

The ACA makes sure her preventive scans are paid for, so there is never a monetary choice for her about skipping one. And the ACA eliminated the lifetime cap on coverage that policies often included to protect insurance companies from patients with expensive conditions that have no cure.

“My scan on Monday is going to be $15,000,” Henning said. “I would have maxed out my employer lifetime cap if that wasn’t a protection under the ACA...We would have liquidated my retirement, my husband’s retirement, and our house to pay for treatment within six months.”

Back when she was first diagnosed, her co-workers and friends immediately jumped to suggest a fundraiser for her. They knew she had benefits through her job with the Evangelical Lutheran Church in America. They were just used to insurance giving out along the way.

“I said, ‘I don’t need that,”' Henning recalls. “’I have insurance.'”

They donated to cancer research instead.

Why it matters

The Affordable Care Act, also known as Obamacare, did more than just create the Marketplace for individual insurance plans. It regulates coverage by employer-sponsored plans, prescription drug development, experimental treatment coverage, Medicare drug coverage and more. On Nov. 10, the U.S. Supreme Court will hear arguments on the ACA as Georgia, Texas, and other GOP-led states attempt to overturn the entire law, supported by the Trump administration. The court could do that, or just strike down part of it, or leave the whole thing intact.

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