‘It could be Holy Hell for some people’: Fate of the Affordable Care Act, health care for Mississippians in the hands of the U.S. Supreme Court

The Supreme Court is set to hear arguments against the Affordable Care Act this week. If it is struck down, advocates say it will have long-lasting effects on the state, where as many as 450,000 Mississippians will be left without access to affordable healthcare.

By Erica Hensley | November 9, 2020

As a community health worker, Christopher Roby devotes his career to helping folks access health care and support services they need. It’s a lot of paperwork, on-the-ground liaisons with clinics, hospitals and insurers, and time spent earning trust of clients who’ve sometimes gone their whole lives without health care. 

Recently those clients included his parents, who after years of forgoing costly health insurance — and the preventive and primary care that comes with it — enrolled in coverage through the Affordable Care Act’s federal marketplace. Like many, they were hesitant to hand over personal information necessary to enroll, but as a trusted son, Roby connected the logistical dots to coverage.

The McCrays — Roby’s stepfather Stanley, 48, and mother Angie, 58 — have never had employer-based insurance from their various jobs across the Mississippi Delta. Now in Indianola, Stanley McCray does seasonal farming and Angie McCray is a homemaker, cleaning houses for a living — private health insurance was too unaffordable for the couple and they don’t qualify for state-sponsored Medicaid or federal Medicare. 

Like many public health practitioners, Roby is watching from the sidelines as the U.S. Supreme Court hears arguments over the fate of the ACA. Though nothing would change on the ground for some time, the fate of the law has some advocates nervous about the long-standing implications of its removal, which would leave hundreds of thousands of Mississippians uninsured.

The high court this week will hear arguments for California v. Texas brought by 20 Republican governors and attorneys general, including Mississippi’s former Gov. Phil Bryant. Collectively, Texas challenged the constitutionality of the ACA, which provides avenues and tax credits to buy health insurance and broad patient protections for affordability and access. If it is struck down, nearly all Mississippians will be touched in one way or another. 

If the law were to be overturned, more than just Roby’s parents’ access to health care is at stake — the wide-reaching health law touches nearly every American, clinic and medical reimbursement in some way — but they’re foreground in his mind. 

Three years ago, Roby convinced them to try enrolling in the federal marketplace, where their income might qualify for premium tax credits to go toward their monthly insurance payments. It did, and they’ve been enrolled ever since. Once they started seeking regular care, both were diagnosed with pre-existing hypertension that puts them high-risk for COVID-19 and other health complications. But since getting access to regular treatment and meds, they’ve managed their blood pressure and improved their health. 

“My biggest concern is they won’t be able to continue to be covered for things that might emerge as they age. We have to worry about cancer, deteriorating bones, limited mobility,” he said, adding he’s worried that their improved health with better access to preventive care and treatment will reverse course. 

But Roby and his parents are hopeful. For the first time in nearly two decades, last week the McCrays voted and said preserving affordable health care guided their choices on the ballot. 

More than just a way for low- to moderate-income families — anywhere from about $26,000 to $105,000 annual incomes for families of four — to buy health insurance, the law comprises wide-ranging ramifications for insurers, hospitals and patients. 

Currently, 600,000 Missisisippians are protected from being charged more or denied insurance based on previous medical diagnoses, such as heart conditions, cancers and now, COVID-19.

In 2019, nearly 250,000 Mississippians, or about 10% of the state, were eligible for tax credits to help cover insurance premiums through the federal marketplace. With record unemployment due to the COVID-19 pandemic — about 130,000 extra unemployed people as of July — the number of families who will qualify is growing. Projections show the state’s uninsured population ballooning to nearly 450,000 if the ACA is overturned.

All Mississippians are also protected through “essential health benefits” that insurers must cover, such as emergency treatment, preventive services like vaccinations and family planning, and wellness care such as annual cancer screenings.

All of these gains for Mississippians weigh heavily on Maria Morris, a program consultant at the Community Health Center Association of Mississippi.

For 15 years, she’s coordinated public health partnerships across the state to increase Mississippians’ access to affordable health care. For the last decade, she’s focused on helping community health centers prepare for open enrollment on the ACA insurance marketplace. 

Though the fate of the law looms in the background of her training calls this year as open enrollment kicks off, she says she can’t let the potential losses from an overturned ACA distract her and encourages other enrollment counselors to do the same. The necessary switch to virtual training and enrollment this year is enough pressure alone. 

When training other health centers to enroll people in health insurance, her message is clear: correct misinformation you hear and stay focused on getting them the access to health care they need.

“We (counselors) need to get people enrolled,” Morris said. “We need to make sure, especially in light of COVID, that we reach as many people as we can to get them enrolled.”

In 2019 a lower federal court ruled the “individual mandate,” which required people to have health insurance or pay a fine in order to bulk up the country’s pool of insured, unconstitutional. Two years prior, Congress set the penalty fine to $0, effectively negating the tax and paving the way for the Texas lawsuit.

Opponents of the law say the now-unconstitutional mandate is central to the ACA and without it, the whole law must fall. Health care advocates say while the mandate glued the ACA together by aiming to broadly increase coverage — especially for young, healthy people and those who have never had insurance before — it’s disclusion shouldn’t doom the law’s other unrelated protections.

The omnibus ACA created the Healthcare Marketplace, or federal health exchange, which allows consumers to compare and shop for insurance in a single policy-guaranteed web portal. Last year alone, 98,000 Mississippians signed up for health insurance through the marketplace. Of those final enrollees, 98% percent qualified for tax subsidies to help pay for monthly premiums, another key feature of the ACA. This is where counselor Morris and others come in — helping folks meet eligibility requirements and enrolling in the insurance.

The health centers she works with train staff to identify un- and under-insured patients, and get them connected with counselors who can help them enroll in insurance plans. Insurance policies not only help the patients with specialty costs and meds, but also benefit the clinics, by increasing their reimbursements.

Most of the centers work on sliding scale fees and provide primary and preventive care to people who otherwise don’t have a medical home. Enrollment assistance has long been a key part of the ACA, and will continue to be until patients stop needing the help or the access is pulled out from under them, Morris says.

She and other health advocates worry about the backslide in individuals’ health gains who have become healthier through access to preventive and wellness care, but risk losing those gains if their health insurance goes away. 

“…(New insurance consumers) see the benefit out there of having access to the hospital and getting your prescription medication. And then too, people have aged in such a way that they’ve been able to improve their health standards. And then now, they (potentially) can’t get access to it? It would be totally devastating,” Morris said. “And then you’re talking about stress and depression and anxiety on top of COVID. I would hate to have to live through a time like that. It would be totally catastrophic.”

Despite slashed budgets under the Trump Administration for enrollment assistance, counselors like Morris have steadily increased ACA marketplace enrollment every year since 2017, when enrollment took a hit across the U.S. Policy experts hypothesize the dive in enrollment was due to market instability fostered by President Donald Trump’s “repeal and replace” rhetoric that confused many who, if they ended up with navigators’ help, asked, “We still have Obamacare?

But despite the enrollment dip then, Mississippians are still actively using the marketplace to access health insurance. Enrollment has increased by nearly 20% and is on track to meet or surpass it’s peak 2016 enrollment of 109,000. In 2018, Mississippi was one of only five states to see enrollment gains.

In other words, the marketplace is a popular provision of the ACA in Mississippi. But it’s not the only benefit the state has seen.

Since 2014, an average of 91,000 Mississippians a year have gained health insurance, putting a dent in the state’s high uninsurance rate, and with it, reimbursing clinics and hospitals for previously uncompensated care. 

But far more — about a third of the state’s population — were protected from losing health insurance based on their medical histories. Under the ACA’s protections, insurers have to cover the 600,000 Mississippians with pre-existing conditions. 

The marketplace in Mississippi saw a rocky start and suffered from limited competition over the years, with insurers dropping out over time. But for the first time since 2017, Mississippi’s marketplace will see two insurers, Ambetter and Molina. For average plans, costs are down 6%.

Still, healthcare costs continue to rise in the U.S. — though slower than previous decades — particularly for employer-based plans. The ACA purposefully avoided interfering with employer-based health insurance, other than requiring employers with 50 or more workers to offer it and ensuring certain patient protections. 

About 40% of Mississippians get their healthcare this way — fewer than almost any other state. As COVID-19 caused record numbers of workers to lose jobs and health insurance, more will qualify for insurance and tax credits under the ACA this year, which tells experts it’s a dangerous time to pull the lifeline

Enrollment counselor Morris is especially worried about new insurance consumers — a major enrollment target of the ACA — who have bought health insurance for the first time in their lives over recent years. Uninsurance rates have plummeted in Mississippi since the ACA passed, especially for people of color. Black Mississippians’ uninsured rate dropped by 35% since 2008, compared to a 27% drop for the state. 

Those gains could all disappear with the fate of the wide-reaching health law in the balance, though advocates reiterate that nothing would likely change within the year and encourage people to seek enrollment.

Mississippi has one of the nation’s highest rates of pre-existing conditions — such as high blood pressure, heart conditions and now, COVID-19 — netting more built-in protections under the ACA here. 

The COVID-19 pandemic not only puts individuals’ healthcare and insurance under increased use, but it at the same time has gutted hospitals and clinics operating revenues. Public health advocates tend to favor increasing access to care and insurance, but say now more than ever overturning the ACA could upend years of progress expanding insurance rolls, and with that, funding safety-net trauma hospitals, like Jackson’s University of Mississippi Medical Center.

“If (ACA) goes away with nothing to replace it, it could be totally devastating because you’re talking about the elimination of the pre-existing conditions (protections). And so that puts it back into place. We talked about expanding coverage up to the age of 26, that goes away,” Morris, the enrollment counselor, said.

She recalls helping a man in his late fifties enroll for the first time and worries what will happen if he loses the coverage. 

“It’s his first time ever getting health insurance in his life, and to go back to not having coverage because he can’t afford it? Those are just a small number of things that could cause devastation and tragedy to people that … need health insurance now more than ever,” Morris said. “It could be just like Holy Hell for some people. I mean, because you’re talking about giving somebody access to something that they needed all this time and then you’re coming back and taking it … that’s where the stress and the devastation and hopelessness come in.”

Open enrollment on the federal marketplace runs through Dec. 15, 2020 for 2021 coverage. Visit healthcare.gov for more information, or get help from certified community counselors and navigators.

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Erica Hensley, a native of Atlanta, has been working as an investigative reporter focusing on public health for Mississippi Today since May 2018. She is a Knight Foundation fellow for our newsroom’s collaboration with local TV station WLBT and curates The Inform[H]er, our monthly women and girls’ newsletter. She is the 2019 recipient of the Doris O'Donnell Innovations in Investigative Journalism Fellowship. Erica received a bachelor’s in print journalism and political science from the University of Southern California Annenberg School for Communication and Journalism and a master’s in health and medical journalism from the University of Georgia Grady College for Journalism and Mass Communication.