Obamacare's Tennessee inroads tenuous under Trump

From the "reddest part of a red state," Tracy Pate has been helping people buy Affordable Care Act marketplace plans since they were first available in 2014.

In that time, she's seen the opinions and emotions around Obamacare fluctuate wildly — shaped by cost, the benefits of having insurance, and the cultural mindset of a state largely set against anything that bears the Democratic president's name. 

Now, the arrival of a new administration in Washington is bringing fresh uncertainty to Tennessee's shrinking uninsured rate. 

For many, their opinion on whether Obamacare is working comes down to dollars and cents. And that's led to nuanced views on the federal policy, which is the target of reform in 2017, from people who have seen premiums jump but also watched medical bills roll in.

Tennessee, even without Medicaid expansion, saw a 4 percent decrease in uninsured people from 2010 to now, according to a variety of sources, including the U.S. Department of Health and Human Services, the University of Tennessee at Knoxville, WalletHub and the Urban Institute.

The biggest decrease came between 2013 and 2016, said LeeAnn Luna, author of the UTK UT report. In addition to 268,000 people buying insurance on the exchange, some people realized they were eligible for TennCare and enrolled. An improved economy led to others landing jobs with insurance, Luna said.

"Tennesseans should realize the percentages are dropping, but there are still lots of people who don't have insurance," said Luna, professor with UT's Boyd Center for Business and Economic Research.

Estimates of how many Tennesseans are currently uninsured vary wildly. Federal data puts the number of uninsured Tennesseans at about 650,000. UT's estimate, around 365,000, is much lower than most estimates of at least 600,000. 

The progress in getting people into some sort of insurance coverage, which is the gatekeeper to most of the country's health-care facilities, could be in jeopardy as President-elect Donald Trump and the incoming U.S. Congress have said they're preparing to repeal and replace the Affordable Care Act early in 2017, although details for an alternative are vague. 

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U.S. Rep. Phil Roe, a physician and Republican who represents the Tri-Cities and authored a repeal bill, said he wants to "seek bipartisan solutions" to advance some central tenets of the ACA: lower costs and increased access. However, the flaws of the ACA, such as the 10 essential benefits and mandates, have to go, Roe said. 

U.S. Sen. Lamar Alexander, R-Tenn., wants to repeal and replace at the same time. 

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There is likely to be a two-year delay before the repeal takes a repeal would take effect, but many are dubious that Congress could reach an agreement on an alternative in the interim.

Using the budget reconciliation process to repeal the law is a huge risk because drafting a replacement that can make it through the House and Senate will take time, said Matt Buettgens, co-author of the Urban Institute report.

“You could easily end up in a situation that is much worse than where we were before, Buettgens said. "(It’s) an outcome that few, if any, people actually want, but it’s one that could happen.”

The prospect of repeal without a replacement has advocates of coverage shuddering. The impact could be profound and has the potential to leave more people uninsured than before the ACA was implemented.

Repeal without replacing could be particularly detrimental to those who must buy their own policies, rather than relying on employer-sponsored insurance, as well as others who don't yet realize how they would be affected by the disappearance of Obamacare.

As many as 1.19 million Tennesseans, including children, could be left uninsured if the ACA is repealed during the budget reconciliation process without finding a consensus on an alternative, according to the nonpartisan Urban Institute, which evaluated the impact on Medicaid, the Children's Health Insurance Program and some small group employer-sponsored plans.

That’s roughly 500,000 more people than were uninsured before ACA.

State lawmakers are still pushing forward on a pilot to expand TennCare using Medicaid expansion funding under a program that prioritizes mental health and substance abuse treatment, and treatment for veterans. Medicaid expansion, however, probably would be among the first ACA tenets to be repealed, Buettgens said.

The ideas being tossed around now are "Band-Aids, some of which are helpful but none of which solve America’s health problems," said U.S. Rep. Jim Cooper, a Democrat who represents Nashville and supports efforts to fix or improve upon the existing legislation. 

“That effort by Republicans would be welcome," Cooper said. "Our job should be to fix the problem, and call it something else if you need to."

Strides seen

In the Tri-Cities area of Upper East Tennessee, Pate had trouble finding a place to hold enrollment events in the fall of 2013 — thanks in large part to the stigma of Obamacare in the overwhelmingly conservative state. A public library thought she was a "scam artist," and restaurant owners would tell her to leave when she told them what she wanted to talk about, she recalled.

It’s gotten easier in her area, and around the state, as more people heard about marketplace plans and their affordability from friends or family. Pate tells of her own experience of being able to afford a couple of surgeries after purchasing a plan on the exchange.

Initially, Pate tried putting "ACA" instead of "Obamacare" in the title of her events, but no one knew what she was talking about. Even now when she helps people pick a plan, it sometimes doesn’t dawn on them that it’s "Obamacare."

“They would just look at you like, 'What in the world are you talking about?' ” Pate said. “They still don’t. You’ll be halfway through, and they say, ‘Is this that Obamacare?’ ”

Then she tells them, “Now see, isn’t that a whole lot better than what you thought?”

Claude Wills, 63, is holding out until he turns 65 and qualifies for Medicare — although the 51-year-old program could be reformed. Pushing back the qualification age to 67 by 2020 is one of the proposals from House Speaker Paul Ryan, R-Wis.

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After years of working at a now-shuttered Magnavox plant in Greene County, Wills and his wife have been largely self-employed since the plant closed.

They paid for COBRA for several years, even as it crept above $900 a month. They were afraid to be without insurance, Wills said. But at $1,200, it was unmanageable. The Wills Willses were delighted when they were able to buy a BlueCross BlueShield of Tennessee plan in the first year of the federally run marketplace. The premiums were less than $100 a month after a tax credit.

The plan has been a blessing, Wills said, even with staggering increases. In 2017, they will be paying $400 a month after tax credit.

Wills knows that he’s been an expensive patient over the past 22 months — and he also knows that the care he received was possible because of his coverage. He got a staph infection that ate away at some of his artificial joints, and they had to be replaced. He’s not been able to work, and his wife has been supporting them both.

“You’re talking to somebody who is a $1 million patient,” Wills said. “That doesn’t sound good to somebody, but I sure didn’t get sick on purpose. A little bit of bad luck.”

His youngest son, 27, also buys insurance on the exchange, and the two know that it’s a balance. Premiums are costly, but so is getting sick.

The elder Wills is concerned that the premium increases will be a harbinger for the years until he gets to Medicare. 

“Once again, it’s about the money,” he said.

Pate's territory — Carter, Greene, Hancock, Hawkins, Johnson, Sullivan, Unicoi and Washington counties — is a place where $30,000 is a good living and jobs with insurance are scarce, she said. 

Half of the people in Greene County made less than $35,000 in 2015, according to census data. Pate helped one man select a plan for which he would pay $12.40 for the entire year of premiums.

Going uncovered is something Wills isn’t willing to do, and he’s been pushing people, particularly those close to his age, to shop for a plan.

“I didn’t care where I was at — Lowe’s, McDonald’s, the gas station — I ran my mouth about it and told them how pleased I was,” Wills said.  

Tales and first-time shoppers

A self-described fence straggler who votes for the person over political parties, Wills embraced Obamacare from the onset yet is dismayed by some of its progression.

Rumors and tales persist.

One man was chauffeured to an enrollment event in 2013, Pate said, because he thought he’d lose his driver’s license if he didn’t get insurance, and came in with the conviction he wouldn’t be able to afford it.

This month, a woman went to an event in Knoxville and insisted that she was told she’d be fined if she didn’t buy a marketplace plan — despite being covered by Medicare, said Carl Wheeler, a volunteer coordinator.

“I told her, if you have Medicare, you already have insurance — you won’t be fined,” Wheeler said. “I think the confusion comes from what people hear from other people, and it’s not fact-based.”

Navigators around the state are trying to dispel fears that an immediate repeal will leave 2017 plans null and void.

Pate sometimes feels like a civics teacher this year.

“It’s been crazy. I honestly thought people thought that (the ACA) was going to go away with the election, and they don’t realize how the government works,” Pate said. “They didn’t realize he’s not actually president until Jan. 20.”

The exchange, meanwhile, is still getting first-time shoppers.

Margaret Chambers of Nashville bought a plan this year, even though the premium with a tax credit will be a stretch, because her mother pressured her into getting coverage. She came to the Bellevue Public Library for help with healthcare.gov.

It's been a "long, long, long time" since she's had insurance, and she thinks — thanks, in part, to her mom — that in the long run paying the monthly premiums and deductibles will be a better financially than shouldering all the costs of care.

Melinda Hmielewski enrolled in a plan to start Jan. 1 that will replace her $554-a-month Cobra payment with a premium of zero. She expects the incoming administration to take what has worked and make it better. 

The ACA, for all of its flaws, which supporters acknowledge, has become ingrained in the fabric of U.S. health care. An HCA executive said at a conference last month that even though hospitals didn’t get everything for which they bargained, they are “happy to have reform and pleased with the direction.”

Alan Hall, a navigator with Family and Children's Service, who is working to assure people that coverage will be around even after two years from now, hopes that D.C. will find a way to make improvements without scrapping coverage. 

Reversing course is more like "turning around an ocean liner — it's not a speed boat. It has to be done very gradually and very carefully,” Cooper said.

Knoxville News Sentinel reporter Kristi Nelson contributed.

Reach Holly Fletcher at 615-259-8287 and on Twitter @hollyfletcher.