Before President Biden signed the American Relief Plan Act (ARPA) on March 11, Bri Dehlinger was considering giving up her health insurance.
This wasn’t a decision she’d make lightly. Dehlinger, 36, a self-employed digital marketing consultant from Charlotte, N.C., takes a daily cocktail of medications and regularly sees a psychiatrist to treat the depression she was diagnosed with a decade ago. Without insurance, that alone would cost thousands of dollars a year. And that’s if nothing else went wrong.
Dehlinger knew she needed insurance. But her premiums had gotten too expensive.
Before 2016, she got coverage through work. Then she had what she called a “quarter-life crisis.” She quit her corporate job, sold her things and moved to London. Since returning three years ago, Dehlinger has purchased insurance on an Affordable Care Act (ACA) exchange.
It was, in fact, affordable at first. In 2020, she had a Blue Cross Blue Shield plan that, after the ACA’s income-based subsidies, cost her just $80 a month. But when she went to re-enroll at the end of the year, she discovered that her plan had ballooned to $290 a month.
She searched for something cheaper. But the best she could find, from a provider called Bright Health, came with a $250 monthly premium. She took it but soon began to second-guess herself. Then in February, after Biden opened a special enrollment period—it runs through August—Dehlinger called Bright Health in search of a less-expensive plan. When she got off the phone, she’d shaved $14 off her premium.
That wasn’t good enough. Her expenses were fixed and unavoidable. She viewed health insurance more like a bet on whether or not she’d use it.
She was still weighing her options in early March when she learned—via the podcast Pod Save America—that the just-passed ARPA would significantly expand ACA subsidies.
“I like to think I’m pretty well-informed on things,” Dehlinger said. “I was like, ‘So why didn’t you know this, Bri?’”
As it turns out, many other people didn’t, either. Attention to the $1.9 trillion ARPA’s higher-profile provisions—$1,400 stimulus payments, child tax credits, unemployment supplements—tended to obscure its more generous healthcare subsidies and other reforms.
Dehlinger eagerly awaited April 1, when the new subsidies kicked in. It was worth the wait. She got a zero-deductible plan with a $140 monthly premium, a savings of $96 a month.
Dehlinger was one of about 528,000 Americans—and 32,577 North Carolinians—who bought an insurance plan on healthcare.gov between Feb. 15 and March 31, in the first six weeks of the special enrollment period, before the expanded subsidies took effect, according to the Centers for Medicare & Medicaid Services (CMS). (Another half-million applied for coverage but hadn’t yet selected a plan by the end of March; about 149,000 of them were eligible for Medicaid.)
All told, almost 1 million Americans signed up for ACA covered in the first three months, about half of them in April alone, when the expanded subsidies were in place, the Centers for Medicare and Medicaid Services said.
The U.S. Department of Health and Human Services estimates that under ARPA, nearly three-quarters of the 11 million uninsured Americans who qualify for coverage on healthcare.gov will pay premiums of less than $50 a month. More than 60 percent will pay nothing. Many of them will have plans with low or no deductibles, meaning it will be insurance they can actually use.
For those who thought Obamacare—as the ACA is commonly known—was unaffordable, Bidencare asks for a second look.
Jeremy Smith calls ARPA a “game-changer.” The project director for First Choice Services, one of 30 certified Navigator programs that received federal funds in 2020 to help people sign up for ACA plans, Smith said, “It’s really going to bring the price ranges into an affordable level for thousands of new people.”
First Choice is based in West Virginia—it also operates in Iowa, New Hampshire and Montana—where the risk pool created by the state’s older, sicker population led to a steep rise in ACA premiums. Thousands fled the marketplace, either forgoing insurance or turning to cheaper, unregulated plans. Smith says he thinks ARPA’s subsidies will lure them back.
At least until 2023, when they disappear.
Without congressional intervention, ARPA’s healthcare changes will be temporary. They only apply to this year and next. After that, millions of people will see their premiums and deductibles reset; for some of them, health insurance will again become unaffordable.
American healthcare is at an inflection point.
During his presidential campaign, Joe Biden promised to build on his predecessor’s achievement. ARPA lays the groundwork to do just that. It’s a proof of concept, a demonstration of what a more robust version of Obamacare would look like if the country spent an additional $23 billion a year.
But since it was designed as an emergency response to the pandemic, ARPA has few permanent features, including for healthcare. Some provisions were tailored to issues that arose from the turbulent COVID economy.
For example, ARPA erases the tax debts of those, like Jim Thornton of Scottsdale, Ariz., who received too-large ACA subsidies because they underestimated their 2020 incomes when they signed up for healthcare plans. Thornton was laid off from his job as chief revenue officer at AV Concepts, which runs audio/visuals for corporate events, when the pandemic struck in March. His premium to cover his family of four was $2,100 a month, but with no income, he only had to pay $300 after subsidies.
By October, however, he’d started his own business and his wife had gotten a job. Their good fortune became a sort of bad luck. Together, their income, combined with what he’d made in the first three months of the year, meant that they’d gotten more subsidies than they were entitled to. The IRS wanted $12,000 back.
“This is the type of stuff where people look at it and go, ‘Oh, maybe it’s just easier not to take the job,’” Thornton said.
But ARPA altered the equation. “To me, that type of legislation is really what helps people,” he said.
Other changes attempt to patch various ACA holes.
ARPA eliminates the subsidy cliff—the cutoff, at 400 percent of the federal poverty line, after which a consumer pays full freight. Instead, ARPA subsidizes premiums so that no one pays more than 8.5 percent of their income for what’s known as a benchmark—or middle-tier—plan. KFF estimates that this will help eight million Americans.
ARPA also boosts subsidy amounts, meaning almost everyone in the marketplace will pay less for premiums, on average saving about $70 a month. At least 5.2 million people are now eligible for a zero-premium plan that—factoring in cost-sharing reductions that lower out-of-pocket costs—has an average deductible of $177.
In addition, ARPA dangles billions of dollars in front of the 12 states that haven’t expanded their Medicaid programs. When the ACA passed in 2010, Medicaid expansion was a mandate, but a 2012 Supreme Court ruling made it optional, and several conservative states resisted on ideological grounds.
Because the ACA planned for Medicaid to cover the very poor, it did not provide subsidies for those earning below the poverty line. In the states that haven’t expanded Medicaid, that’s left 4 million people without affordable healthcare coverage.
So far, no state has taken up the White House on its offer.
Craig Hoffman made what he thought was a safe bet. In February 2020, he left his reporting job at 106.7 The Fan, a Washington, D.C., sports-talk radio station, to join the Washington Spirit, a women’s professional soccer team, as executive producer of media.
A new owner had purchased the team in 2018, and the franchise had “startup tendencies,” said Hoffman, 31. While the team had set up insurance for its players, it hadn’t done so for the front office. So when Hoffman negotiated his salary, he worked in an allowance to buy insurance on Virginia’s exchange.
He purchased a Bronze-tier plan through Anthem Health with a $4,900 deductible and $6,850 out-of-pocket max that cost about $350 a month.
“At that point, I wasn’t, like, killing it financially, but I was making enough money that I could afford decent healthcare, and I didn’t want to skate on it,” Hoffman said.
He’d barely settled in before the sports world cratered due to the pandemic. While women’s soccer played some games without fans, without fans, the teams had little revenue coming in.
Almost exactly a year after he started, Hoffman lost his job.
He still pieced together an income. The Spirit offered him contract work, he picked up a few freelance hours at the radio station, and as more people got vaccinated, he worked as a personal trainer. But the $350 a month he paid for health insurance loomed large.
As soon as the new subsidies became available, he went shopping on healthcare.gov and found another plan—a Silver plan, a tier better than what he had before—also through Anthem.
“It’s costing me, like, legitimately, $200 less per month,” Hoffman said. “That’s at least a couple of extra clients a month I’d have to train to make up that gap. The money’s able to go a lot further. And I’m not nearly as nervous about paying rent.”
By February, Victoria Evans-Thomas was stressed. A Houston tax preparer, she was laid off in October—after which, she said, she “retired” from corporate life, though she still works independently—and her insurance had expired at the end of December. She sees five different specialists, and costs were mounting.
“I canceled so many appointments,” said Evans-Thomas, 54. “Because the day of, a few days prior to the appointment, I realized, ‘Hey, I’m not sure I have $220 [for a specialist]. My health is important, but I’m not gonna have it.’”
Then she saw a Facebook post by Stacey Thompson, who runs the Navigator program for the Houston nonprofit Change Happens!, that mentioned the special enrollment period. To Evans-Thomas, that was a godsend. She reached out.
“I didn’t expect to pay $3 for a policy,” she said. “But I did want something that was affordable for me and covered my needs.”
In an interview a week after ARPA passed, Evans-Thomas said she didn’t know how the new law would affect her. But it would almost certainly save her money.
Unless something changes, however, the expanded subsidies will go away at the end of 2022 for millions of people, including Dehlinger and Hoffman.
A decade into its existence, the ACA has weathered political attacks and outright sabotage. It nearly imploded at launch, then saw premiums skyrocket and insurance providers flee its exchanges. Yet for the conservatives who pledged its repeal, the ACA proved to be a dragon they could not slay.
It not only survived but became popular. Thanks to the ACA, there are 18 million fewer uninsured Americans now than in 2010. The protections it introduced—banning insurers from discriminating against people with preexisting conditions or capping lifetime or annual coverage amounts—have almost become expectations. Perhaps most important, by many measures, it has improved health outcomes.
Still, 30 million people remain uninsured. Healthcare is still expensive, with high copays and deductibles often rendering insurance effectively unusable; 40 percent of all bankruptcies involve medical debt. And some states and counties have few options on the marketplace. In 2015, states averaged six providers; by 2018, that number had dropped to 3.5, according to a Kaiser Family Foundation (KFF) study.
Democrats, including House Speaker Nancy Pelosi, want to make the expanded subsidies permanent. In his first congressional address on April 29, Biden urged Congress to do just that: “The American Rescue Plan lowered health care premiums for 9 million Americans who buy their coverage under the Affordable Care Act,” he said. “Let’s make that provision permanent so their premiums don’t go back up.”
But any expensive legislation will have difficulty passing a divided Congress, and even the Democratic Party is split on its next healthcare move. Sen. Bernie Sanders is pushing to expand Medicare. There’s probably not enough money to do both.
There are political considerations ahead of the 2022 midterm elections: Seniors comprise a vital voting bloc, but providing low-cost healthcare and then taking it away could invite blowback.
“The thing is, government should be a force for good,” Hoffman said. “This affects people’s lives, and this legislation affected my life in a meaningful way, and I think that’s a story that people need to understand.”
Jeffrey Billman is an award-winning investigative journalist based in North Carolina.
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