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If he can stay healthy for six more years, Victor Genao figures, then he can qualify for Medicare — and a lifetime of struggling with health insurance coverage will be over.
It won’t be easy getting there, Genao said. He has Type 2 diabetes and high blood pressure, conditions that he manages with prescription drugs and regular doctor visits. But at 59, Genao’s body cannot tolerate skipping medications like it once did.
“When you’re my age,” he said, “the only thing you worry about is getting sick and not being able to get better.”
These days, Genao worries about getting sick more than he has the last few years. He is part of a group of low-income Floridians over 50 who have been able to rely on the Affordable Care Act’s financial aid for coverage as they enter a stage in life when many begin to confront chronic illnesses at the same time that their economic prospects dim, experts say.
For all the relief Genao said he felt last week after Congress canceled a vote on the Republican plan to repeal and replace the ACA, coverage remains worrisome for him and millions of Americans who receive financial aid under the health law known as Obamacare.
That’s because a lawsuit filed by House Republicans against the Obama administration in 2014, challenging the legitimacy of certain financial aid payments without a congressional appropriation, is still unresolved after a federal judge decided in favor of the plaintiffs in May 2016.
The judge stayed her order while the Obama administration appealed. But after Donald Trump won the White House in November, the new administration and House Republicans asked for more time to resolve the issue.
The Trump administration can decide to stop defending the case — letting the judge’s ruling stand — or it may choose to stop the payments, which are known as cost sharing reductions.
The out-of-pocket spending limit for an Affordable Care Act plan is $7,150 for an individual plan and $14,300 for a family plan. For eligible Americans with low incomes, the spending limits are less.
The payments are offered to consumers who purchased coverage on the ACA exchange and don’t make much money — less than $30,000 for an individual or $51,000 for a family of three.
The subsidies reduce out-of-pocket costs such as deductibles and co-payments for doctor visits and prescription drugs. About 1.1 million Floridians with an ACA plan, or 73 percent of those enrolled, received the subsidies in 2016, according to the Centers for Medicare and Medicaid Services, which regulates the Obamacare exchange at healthcare.gov.
Without those subsidies, Genao said, he and his wife, Nany Almanzar, 54, could not afford their coverage. The Genaos live in Sweetwater. He is a self-employed electronics repairman, and sometimes goes weeks without getting paid. His wife works in retail sales. Together they earned a household income of less than $2,000 a month in 2016, he said.
Their income qualified the Genaos for coverage by Ambetter from Sunshine Health that costs them less than $60 a month in premiums. They have no co-payments for doctor visits or the emergency room. They pay $5 to see specialists, and $25 for prescription drugs. Their annual deductible is $600.
323,000 Floridians ages 50- to 64-years-old receiving cost sharing reductions for ACA coverage
It’s affordable, but Obamacare coverage hasn’t been perfect. Genao said his last doctor was dropped from the plan’s provider network, and he’s having difficulty finding a new one who will accept his insurance.
But the health law put coverage within financial reach for Genao and his wife, an ovarian cancer survivor, for the first time since they immigrated to Florida from the Dominican Republic in 1990. Without the cost sharing reductions, Genao said, they likely will have to seek out charity care or risk an emergency to get the medical attention they need.
“It’s reassuring to know that I can still get my medications, whether I have money or not,” he said.
About 323,000 Floridians ages 50 to 64 received cost sharing reductions in 2016, according to AARP Florida, part of a national nonprofit that advocates for people 50 and older.
Low-income Floridians in that age group tend to have fewer job prospects and more family responsibilities, whether it’s children in school or elderly parents who need care, said Jeff Johnson, president of AARP Florida.
“It’s really a precarious time in a lot of ways,” he said.
It’s also a stage when chronic health conditions can begin to emerge, raising the risks of going uninsured.
“A lot of folks in that age group are experiencing lifetime wear and tear,” Johnson said. “So if they don’t do anything about that for 10 years or 15 years, then by the time they get to Medicare they have more healthcare needs.”
Cost sharing reductions lower deductibles, co-payments and co-insurance, reducing out-of-pocket costs for eligible low-income Americans.
Helping low-income Americans afford healthcare — and not just health insurance — is precisely what the ACA’s cost sharing reductions were designed to do, said Gary Claxton, a vice president for the Kaiser Family Foundation, a nonprofit health policy think tank.
The health law’s financial aid lowers monthly premiums for millions of Americans, including about 1.4 million in Florida. But the ACA’s architects recognized that those with low incomes would need more help, Claxton said.
“Most of the people who don’t have health insurance don’t have it because they’re low income,” he said. “Just helping with premiums doesn’t do much good if they have to spend thousands of dollars [on deductibles and co-payments] before they get care.”
In 2016, the federal government paid about $7 billion in cost sharing reductions, covering nearly 6 million Americans. Nearly $1.5 billion went to Floridians with ACA plans in 2016, according to the nonprofit Center for Budget and Policy Priorities.
In Florida, cost sharing reductions are available only to people with standard ACA plans and incomes between 100 and 250 percent of the federal poverty level, or about $11,880 to $29,700 for individuals.
If the Trump administration stops defending against the House’s lawsuit challenging the cost sharing reductions or otherwise eliminates the subsidies, then the low-income Americans who receive them likely would not be able to keep their ACA coverage.
“If you start unraveling that, then it’s not going to be a program that helps low-income people anymore,” Claxton said, “and you’re going to go back to having a lot of people who don’t have insurance.”
For insurers, the elimination of cost sharing reductions would force them into difficult choices: absorb the extra expense, raise premiums or leave the ACA exchange, according to a recent report from the left-leaning Commonwealth Fund, a private foundation that advocates for healthcare access for the low-income and uninsured.
Just helping with premiums doesn’t do much good if they have to spend thousands of dollars before they get care.
Gary Claxton, Kaiser Family Foundation
J. Mario Molina, a physician and chief executive of Molina Healthcare, said he knows what his company would do. Molina sells coverage on the ACA exchange, and covers about 362,000 Floridians in 2017.
“We might drop out of the marketplace if the cost sharing reductions go away this year,” Molina said. “Getting that issue resolved is really important.”
For Floridians like the Genaos, the payments are key to staying insured. Before the ACA insurance exchanges launched in 2014, Victor Genao said the couple looked for coverage but could not afford the monthly premiums of $1,000, much less the deductibles, co-payments and other out-of pocket costs.
When his wife was diagnosed with ovarian cancer about 10 years ago, he said, they traveled to Santo Domingo in the Dominican Republic for her to get surgery, which he said cost about $3,000.
“We couldn’t afford it here,” he said. “That was the only solution.”
As he watches the debate over the ACA’s fate, Genao said he has felt the return of a familiar sense of insecurity.
What will he have to give up in order to afford his prescription drugs? Will he and his wife be able to afford her routine visits with the gynecologist? Will he be able to barter his skills repairing electronics for medical care from a charitable doctor?
Most importantly, he wondered aloud, can they keep themselves healthy long enough to qualify for Medicare at age 65?
“I’m scared about the future,” he said. “Who knows what can happen.”