For Margie Ohmer, there is no debate. The federal health care law helped save her life. It certainly saved her hair salon business.
Just before Thanksgiving in 2015, the owner of Bella Gente Salone in Baton Rouge was diagnosed with cancer; doctors removed her right kidney three weeks later.
"Without health insurance, I would have lost my business. At the time, I had six people working there," said Ohmer, who bought health insurance through the federal health insurance marketplace four years ago with subsidies that make it affordable.
Zachary certified public accountant Dennis Maciasz, on the other hand, said he feels he has been left out of the affordability discussions from the beginning. Maciasz does not qualify for federal subsidies because of his income and saw his premiums jump from $750 a month on a policy he had before the Affordable Care Act, commonly referred to as "Obamacare," to $1,700 after it kicked in.
He now pays $1,000 a month for a short-term policy with a $5,000 deductible. Because it's a short-term policy, he also pays a federally mandated penalty as uninsured — the greater of $695 per adult or 2.5 percent of household income.
It isn't the plan he wanted, but it's what he could afford, Maciasz said.
The vast gulf between Maciasz's and Ohmer's experiences help illustrate the promise and the problems of the President Barack Obama's health care law as the marketplace enters its fifth year. It covers more than 143,000 people in Louisiana.
Lately, more uncertainty surrounds the law than when the it originally passed. A Republican-majority Congress has tried and repeatedly failed in recent weeks to repeal or replace the law, and President Donald Trump on Friday said "let 'Obamacare' implode, then deal." His health secretary then said the Trump administration would pursue its health care goals through regulation.
With no idea what, if anything, will emerge from Washington, D.C., insurers already have had to incorporate guesswork that pushed their 2018 Affordable Care Act policy rates higher. The White House has threatened to halt payments to insurers for providing discounts that reduce low-income policyholders' costs like deductibles. Blue Cross and Blue Shield of Louisiana says that decision alone pushed its rate increase from single to double digits.
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The ambiguity means more stress for Louisiana consumers concerned about whether they will lose coverage.
"Now I'm sweating because I have to get scans every six months. If they do away with the ACA and then we go back to where we were ... I may never get the scans," Ohmer said.
Those like Maciasz who earn too much to qualify for subsidies face another escalation in premiums that have spiraled ever higher since 2014.
In Louisiana, Affordable Care Act-compliant plans increased premiums on average between 10 percent to 20 percent in 2015; 6 percent to 30 percent in 2016; and 23 percent to 41 percent in 2017, according to filings with the state Department of Insurance. The preliminary increases for 2018 range from 12 percent to 36 percent, with the enrollment period that begins Nov. 1 and ends Dec. 15.
Close to 102,000 Louisiana residents enrolled in Affordable Care Act plans for 2014. Enrollment peaked at more than 214,000 in 2016. After the state expanded its Medicaid program for the poor in 2016, more than 70,000 people eligible for marketplace coverage moved to Medicaid from the federal health insurance exchanges.
Blue Cross and Blue Shield of Louisiana and Vantage Health Plan — the only Louisiana insurance companies offering marketplace plans — have said the 2018 rate increases facing the state's Affordable Care Act policyholders reflect the uncertainty in Washington and would have been limited to single digits if not for actions of the federal government.
Ohmer has seen her share of the premiums grow from about $200 a month to a little more than $380 in the past four years. Without subsidies, her cost would have risen from $500 a month to $700.
"I've been hoping this would level out," Ohmer said. "I think if this country would have supported it, it had a much better chance of working and it would have leveled out."
Ohmer said she is frustrated that members of Congress would rather fight over ideology than help people and that so many in Louisiana believe people with Affordable Care Act coverage are freeloaders.
"I'm not looking for a handout. I'm just looking for affordable health care," she said.
Looking back, experts have varying ideas about the health care law's successes and failures over the past four years, ranging from whether the law helped contain health costs, was too lenient on people breaking enrollment periods or amounted to an ill-fated experiment in social engineering. Others see the potential for fixing the law.
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In a "Straight Talk" blogpost, Blue Cross and Blue Shield of Louisiana economist Michael Bertaut said in trying to extend coverage to as many people as possible, the health care law federalized the individual markets, which were regulated by each state and entirely unsuited for that purpose. The then-Democrat-controlled Congress rammed the law through with zero Republican support. Not surprisingly, the law generated lots of unhappiness, he said.
The law also allows people to jump in and out of the market at will, so a big chunk of individual policyholders bought coverage when they needed care and dropped it after being treated.
"When the ACA was passed, they did not address the huge problem of the cost of health care," said B. Ronnell Nolan, president and CEO for Health Agents for America. "That hasn't been addressed and it doesn't look like it's going to be addressed, and that's the driving force of health insurance premiums."
Rate increases averaging from 12 percent to 36 percent are on tap in 2018 for many Louisiani…
So although more people in Louisiana have health insurance, rapidly rising premiums make it harder for people to find an affordable plan, she said. Some people, especially those who enrolled in Medicaid after the state expanded the insurance program for the poor, also are having a hard time finding doctors.
"I think we're kind of in an uphill battle with trying to help the citizens of Louisiana be able to pick a plan … a plan that they can afford and includes their doctors and hospitals," Nolan said.
Supporters of the health care law argue that it has helped control health spending. A 2016 report from the Urban Institute and the Robert Wood Johnson Foundation — nonpartisan think tanks focused on economic and health issues — projected health spending for 2014 to 2019 would be $2.6 trillion less than federal forecasts made back in 2010, just after the law passed.
The report says the law and Medicaid expansion, the recession and the sluggish economic recovery contributed to the reduced spending projections. Spending growth peaked in the fourth quarter of 2014 at a 6.2 percent rate, then slowed to less than 5 percent in 2015, suggesting that other factors, including the health care law, are contributing to sustained health care cost containment.
Jonathan Gruber, a key architect of the law, said although some have estimated the law is responsible for as much as two-thirds of the spending slowdown, no one knows the exact amount.
"It's got to get at least 10 percent of the credit. It probably is less than 50 percent of the credit. That's probably about as far as we can narrow it," Gruber said.
But the health care spending numbers are so huge that even a third amounts to hundreds of billions of dollars, he said.
Brian Burton, who heads the Southwest Louisiana Area Health Education Center, said the law's biggest impact in Louisiana hasn't been the marketplace but the expansion of Medicaid.
It opened up health coverage to so many Louisiana residents, he said. More than 433,000 low-income adults in Louisiana qualified for Medicaid under the expansion.
Although many people talk about how important Medicaid is and saving the program, there's not a lot of talk about saving the federal health insurance marketplace, Burton said.
"I have to remind people that there are 140,000 people in our state who don't have access to employer-based insurance."
Despite the huge increase in the number of people with health insurance, even the Affordable Care Act's most ardent supporters believe the law needs fixing.
Business groups maintain the continued rate hikes, mandated coverage and taxes are crippling for small companies.
Burton said Congress should increase the level of subsidies to include people earning more than 400 percent of the federal poverty level, rather than reducing the amount of financial assistance.
He said the navigators who help people sign up for insurance coverage see a lot of consumers whose income falls just above cut off for subsidies, 400 percent of poverty level, or $98,400 for a family of four in 2017. That makes it "extremely cost-prohibitive" for some of these folks.
Jack Duvernay, president-elect of the Louisiana Association of Health Underwriters, said there was a much simpler solution than the health care law.
The federal government could have bolstered high-risk pools, which existed before the law and covered people who couldn't find conventional insurance, he said. The individual markets should have been left alone, he said.
The reason high-risk pools weren't strengthened then and won't return now is purely political, Duvernay said. Even though a separate high-risk pool would function more efficiently, it's bad politics: "Because then people can point at you and say 'Oh, denying coverage for pre-existing conditions,' ” Duvernay said.
Louisiana capped high-risk pool rates at 200 percent of market rates. The plans covered fewer than 2,000 people and most paid 155 percent of the market rate and picked plans with a $5,000 deductible.
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The plans required a waiting period for people with pre-existing conditions, capped prescription benefits and lifetime health benefits, and operated at a loss. Premiums covered a little less than half the $20 million costs. About a third of the program's costs came from fees charged to private insurers, with the rest from the state's general fund.
Nolan said she and her association think changes are needed to the health care law, whether people want to call it repeal, replace or reform.
The premiums have gone up so much that not everybody is getting help, she said.
Burton said the whole system is riddled with things that can be fixed so it's easy to cherry-pick the people who have had issues under the law.
"But I can definitely give you a lot more stories of people who have benefited from it than who have been hurt by it," he said.