For Minnesotans who use Obamacare, the election brought only uncertainty

Kelsey Barkley isn't sure what Donald Trump's election means for the future of Obamacare and health insurance. But she knows it means anxiety for her. Barkley, 25, suffers from a genetic nerve condition that causes numbness in her limbs and, when it flares up, extreme pain.

"When it happens,'' she said, "it's something you need insurance for."

Barkley and people like her have benefited in multiple ways from the Affordable Care Act, also known as Obamacare, and its strategies for increasing access to health insurance. One provision, which Barkley has used, allows children to stay on their parents' coverage until age 26. Another forbids insurance companies from denying coverage because of a person's preexisting medical conditions. Another expanded the state-federal Medicaid program to more low-income childless adults like Barkley.

Which of those provisions will survive — if any — now that Republicans control the White House, Congress and the Minnesota Legislature? The question probably won't be settled for months. That leaves a cloud of questions hanging over the more than 200,000 Minnesotans who have gained coverage during the Obamacare era.

"The Trump election has created a tremendous amount of uncertainty," said Michael Holmes of Scenic Rivers Health Services, which operates six community clinics on the Iron Range — and whose own funding is in question in the 2017 Congress.

High-risk patients

Anxiety is greatest among Minnesotans with preexisting medical conditions. Before the ACA, insurance companies could simply deny them coverage.

Nancy Wagner of Lewiston, Minn., was scheduled to have open-heart surgery Friday and knows that provision well.

In 2014, after being laid off and losing her employer coverage, she was able to buy a policy using the state's MNsure website, despite her heart condition. When her income dropped, she became eligible for the expanded Medicaid program, known in Minnesota as Medical Assistance.

Now self-employed, Wagner, 58, expects to move off state coverage, but wonders if private insurers will take her if the federal law changes.

"It is the whole uncertainty that is so unsettling. This surgery is stressful enough," Wagner said. "I hope they don't just abolish the Affordable Care Act and not have something to replace it. There are some problems with the ACA, but there are some good things that come out of it, too."

Trump has mentioned retaining the provision that requires insurers to cover preexisting conditions; Republican lawmakers have said they would address the problem using public "high-risk" pools for people who can't buy private insurance.

Whether that coverage will prove sufficient is "really going to come down to how these risk pools are structured, and how much funding they get," said Cynthia Cox, a researcher with the nonpartisan Kaiser Family Foundation.

Minnesota had a high-risk pool before Obamacare, and it covered about 25,000 people. It was funded by premiums and an assessment on insurers, but its chronic financing problems required cash infusions from the state three times between 1997 and 2006.

The high-risk pool also featured hefty premiums and deductibles in some of its plans. Yet some who used the old program are now nostalgic for it, given the tight limits on doctor and hospital choices, plus skyrocketing premiums, in Minnesota's individual market today.

After President Obama signed the ACA in 2010, states had broad latitude in the degree to which they embraced it, and Minnesota was among the most aggressive.

Minnesota is one of 32 states, including the District of Columbia, that expanded their Medicaid programs. The state also tapped ACA funds to help finance MinnesotaCare, which insures residents often described as the "working poor." And with the MNsure exchange, Minnesota is in the minority of states running its own online marketplace for individuals to buy coverage with tax credit subsidies.

In all three areas, Minnesotans face uncertainty, Cox said.

What is known is that Minnesota's uninsured rate has dropped to the lowest level in at least 15 years, and more than 200,000 Minnesotans gained coverage.

'It's been a disaster'

That has not, however, endeared the law to the public. MNsure suffered computer glitches, long wait times and, this year, skyrocketing premiums. While they affect only a small share of insured Minnesotans — less than 10 percent — they gave the law a black eye.

"Survey after survey has shown that [health care] has been not just a primary issue in the minds of voters, but a decisive issue," said Rep. Matt Dean, a Republican from Dellwood who chairs a key health care committee in the Minnesota House. "What we had in Minnesota before wasn't perfect by any means, but the ACA in Minnesota — it's been a disaster."

Whether they liked the ACA or hated it, people who used it seemed rattled by the election. On Wednesday, Nov. 9, interest in the federal exchange soared, perhaps from people fearful that they needed to buy coverage before it disappeared. Some Minnesotans seemed to have exactly the opposite reaction — canceling appointments with "navigators" who would help them shop for insurance.

"Should I even apply? We have had a couple people ask that question," said Jaeson Fournier of West Side Community Health Services in St. Paul. "All we can do is tell them, 'Nothing has changed today.' "

Repeal of the ACA would threaten another key provision — tax credits that help lower-income people buy coverage in the private market. About 44,000 Minnesotans were receiving those credits as of October, or a little more than half the total buying coverage through MNsure.

Mike White, 64, of St. Louis Park is among them. White and his wife have purchased individual health insurance for years, and they saved big money when Obamacare's major provisions kicked in for 2014.

Now, with premiums in Minnesota's individual market jumping on average by 50 percent or more next year, White says the tax credits are more important than ever.

"If it wasn't for the subsidy," he said, "we wouldn't be able to afford the insurance."

Republican plans discussed so far include tax credits, and probably would lead to lower premiums in the individual market, particularly for younger and healthier people, Cox said. That's because they would reverse several mandates in the ACA, such as coverage for maternity services and mental health care.

Premiums could also go down as people with preexisting conditions leave the private insurance market for coverage in high-risk pools, Cox said. "If you have skimpier coverage, more healthy people might buy in," Cox said. "The flip side of lower premiums is higher out-of-pocket costs when people use their insurance."

Impact on clinics

Beyond insurance coverage for individuals, the fate of Minnesota's 18 federally designated community health clinics also remains uncertain. Federal grants that subsidize their care for uninsured patients are supposed to be cut by 70 percent next October. Clinic officials are hoping that Congress stays those cuts; the grants received bipartisan support under Obama and George W. Bush. Minnesota clinics receive about $30 million per year in federal grants right now to pay for the care of 51,000 uninsured patients.

The impact on these clinics could be compounded if the new president rolls back Obamacare's huge expansion of Medicaid. Minnesota's community clinics saw a 23 percent drop in uninsured patients over the last two years, said Jonathan Watson of the Minnesota Association of Community Health Centers, and the Medicaid expansion almost certainly played a major role.

Nonetheless, said Holmes at Scenic River, "People expect us to be there. They see the election results but I don't think the impact has trickled down yet, because we don't even know yet what the impact is going to be."