Affordable health insurance has been the difference between having a life and just scraping by for Bruce Ario, a Minneapolis man with schizophrenia and diabetes.

A low-income worker who supervises mailrooms for two federal agencies, he was spending $1,000 a month for medical coverage before Congress passed the Affordable Care Act in 2010. Today he pays $300.

"As an individual with pre-existing conditions, [the ACA] has helped save me thousands of dollars and given me a better lifestyle — free to give to charity and my church, to take trips, to eat out at a restaurant."

So the 63-year-old worries whenever he hears about a new threat to the law, like the recent ruling by a federal judge in Texas that the ACA is unconstitutional.

Like Ario, thousands of other Minnesotans who have benefited from the law's far-reaching provisions found the ruling a reminder that, even eight years later, its survival is not something to be taken for granted.

"I feel like it will constantly keep coming up," said Amy Zellmer, who has needed the Medicaid benefits she gained under the ACA to cover the medical costs of a brain injury she suffered when she slipped on an icy driveway. "It is incredibly stressful for people who are on it and rely on it."

Whether the ACA is the right solution for the nation's health care challenges remains in dispute. But it has become so embedded in clinics, hospitals and insurance markets over the past decade that eliminating it would affect the medical care of millions of people.

Senior citizens with numerous prescriptions would be affected, because the law eliminated an expensive "doughnut hole" gap in Medicare drug benefits. Young adults would be affected, because the law allows them to remain on their parents' insurance until age 26. And low-income Minnesotans would be affected because the law expanded Medicaid eligibility to cover 200,000 more state residents.

"The ACA affects everybody," said Jim Showalter of the Minnesota Council of Health Plans, which represents the state's nonprofit health insurers. "We haven't yet, but we will have to start looking over the cliff to understand what could change if this ruling were upheld."

Delaney McCarthy, a 19-year-old college student, is awaiting test results to see if she carries the same genetic trait that predisposed several of her relatives to breast cancer. Any threat to the ACA concerns her because the law mandated that health plans cover recommended mammogram screenings.

Katherine Paylor of Minneapolis is trying to regain financial independence after diabetes complications forced her out of her job. For now, she's covered by a low-income government program that would continue if the ACA went away. But she worries that any income from a part-time job could disqualify her for that coverage, and that she would struggle to find private insurance without the ACA's protections for people with pre-existing conditions.

Zellmer, 44, qualifies for Medicaid only because the ACA raised the income limits to be eligible for the state program for the poor and those with disabilities. She had 73 doctor visits in the first year after her head injury, and she doubts she would have received that much care without good insurance.

"I would never have gotten in to see a neurologist. Without insurance, they wouldn't even have looked at you," she said.

Zellmer became an advocate for people with brain injuries and traveled to Washington, D.C., to oppose prior legislative attempts to repeal or replace the ACA.

"It was personal. It affected me directly, and it affected millions of Americans," she said.

Back to the future?

The Texas ruling was sought by a group of Republican governors and attorneys general who filed suit to challenge the ACA's constitutionality and was welcomed by other conservatives, who felt the law represented government overreach into U.S. health care. The judge — appointed to the bench by President George W. Bush — stayed his order, allowing the ACA to remain in place pending an appeal and potentially a review by the U.S. Supreme Court,

Many members of the U.S. House's new Democratic majority have called for an appeal of the ruling while acknowledging that the law could be improved.

"We should fix the ACA, which we can do," said Rep. Dean Phillips, a newly elected Democrat from suburban Hennepin County. "It's imperfect, but a good beginning."

That could be tough with a Republican-led Senate buoyed by President Donald Trump, who campaigned to repeal the ACA and has sought administrative strategies to weaken it since taking office in 2017.

Newly elected Rep. Jim Hagedorn, a southern Minnesota Republican, said the solution is to put states back in control.

"If you eliminated Obamacare today and sent it back to the state of Minnesota, we'd effectively have the exact same thing we had in Minnesota, which was fine," he said. "We had 94 percent with health insurance ... and we had a pool for people with pre-existing, expensive medical needs."

Going back, however, wouldn't be simple. State legislation would be needed to recreate two of the pillars of the previous system: MinnesotaCare, which covers the working poor, and the Minnesota Comprehensive Health Association (MCHA), which covered a pool of sick people who had been denied private insurance.

The VanDerPol farming family in Chippewa County relied on MinnesotaCare even before the ACA, although some years they went without insurance because they made too much to qualify. The current income limit for a family of four is about $50,000.

"If it went away, it would be awfully tough for us," said Josh VanDerPol, who has primarily grown organic crops and raised hogs and grass-fed cattle. "The cost of [private] insurance would probably consume most of our income, especially in years when you have a poorer crop or other problems and cash flow is pretty low."

More than half of Minnesotans get their health insurance through group plans sponsored by employers, though that rate has been declining. But they too could be affected by the loss of the ACA, which among other things eliminated caps on lifetime benefits, which in many workplace plans had been set at around $1 million.

If the law were abolished, employers could revert to previous policies, which also allowed them to deny workers health benefits for their first years of employment if they had been uninsured for more than two months when they were unemployed.

"I don't anticipate that many large employers would take a restrictive approach, but smaller employers might," said Roger Feldman, a University of Minnesota health economist.

A degree of stability

Ario was a longtime beneficiary of MCHA due to his chronic diseases, but he was spending $1,000 per month for coverage. Now, subsidies afforded by the ACA and new insurance options have reduced his monthly premium costs to around $300.

His plan under the ACA hasn't been perfect, he said. It considers his psychiatrist to be out-of-network, so he pays extra to keep seeing her. But it has introduced an element of stability to his life, including familiar doctors, that, along with peer support and employment through the Tasks Unlimited program, is critical to his management of schizophrenia, he said. Loss of ACA protections could threaten that stability, he said.

"I wouldn't say it's been keeping me up at night, because I think they are going to be able to overturn [the ruling]. But if they aren't able to overturn it, it definitely would be keeping me up at night."

Staff writer Patrick Condon contributed to this report.

Jeremy Olson • 612-673-7744

Glenn Howatt • 612-673-7192