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Still Standing: Taking the Affordable Care Act's vital signs after a tumultuous year

Open enrollment closes December 15

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When I first meet Jennifer Saxton, she's brimming with excitement and apologizes for speaking so quickly. "I feel so, so relieved," she says, "you have no idea." The 23-year old had just finished enrolling in the Oregon Health Plan—a process which she says took about one and a half hours— and says she feels an immense sense of comfort knowing that from Jan. 1, she'll be covered.

"Between my rent, utilities, car payment and student loan debt, there's no way I could afford health care. Before this year, I hadn't been to the doctor, since, well, I don't even know when." Saxton suffered a severe kidney infection in July this year that left her hospitalized after she failed to go to the doctor.

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"I just kept thinking the pain, the fever, would go away and I'd be able to fight it off," she says. "In hindsight it was stupid, but I just kept telling myself I couldn't afford the $250 they wanted for new patient fees to see the doctor." Saddled with the steep price of a two-day hospital visit, stretching into the thousands, the young Central Oregonian took the advice of a nurse and signed up for OHP. "For some reason, I guess being young, I didn't think I needed it. Or that I would qualify."

Not on the Radar

Such misinformation can be common, especially at a time when the Trump Administration has slashed the advertising budget for the Affordable Care Act by 90 percent—from $100 million to $10 million. A September 2017 research study published by The Incidental Economist blog examined healthcare advertising in previous years, showing a correlation between increased advertising and increased enrollment. The study showed that providing information on such a complex and ever-changing subject can do wonders for "enrollment confidence."

Still, Oregonians are being proactive, getting informed and reapplying. There have been 51,882 individual market plan selections in Oregon since Nov. 29, according to the Centers for Medicare and Medicaid Services. That's on par with states with similar population sizes, such as Arizona, with 51,615 plan selectors and Oklahoma with 43,253. The state with the largest enrollment thus far is Florida with 626,144 (pop. 20 million) and Texas with 344,328 (pop. 27 million).

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Roy and Jeannine Hawthorne are among those who could be dubbed savvy individual health insurance buyers. They're typical in that they've gone through three different insurance companies with three separate plans. They've lost their primary care physician because he was "out of network" and "too costly," and have seen prices and deductibles rise and benefits shrink. Yet, the family of two—he's a mechanic and she works part-time in sales—qualifies for a federal tax credit. Their combined monthly premium after such credits comes down to what they say is a "reasonable" $230 a month. They say they're relieved they're covered.

Shawn Houghton, who lives in Terrebonne, is another example. He enrolled a few weeks back over the phone. "It went very smooth," he said. He too gets a tax credit and this is his third year using it. "My payment went up by 14 dollars," he says, "I was able to stay with my same insurance company (and) only a few things changed in the plan (but) nothing drastic." Houghton pays $90 a month after the applied credits, which he says is "cheap," considering he has a "chronic illness" and uses his insurance a lot.

Broken, Battered But Still Standing

With the Affordable Healthcare Act safe from repeal—for now, and the effects of the Republican tax plan yet unclear—the federal marketplace used for health insurance by 39 states is open for business for another year. A quick surge in enrollment around Nov. 1 had quickly dropped off by Thanksgiving weekend, according to stats released by CMMS. As the deadline for open enrollment through the HealthCare.gov website nears its Dec. 15 deadline, more than 2.7 million customers have signed up for health insurance as of Nov. 29. Of those, 504,181 were new to the system.

Experts say this is surprising considering the Trump Administration slashed the enrollment period this year to just 45 days, half of last year's enrollment period. The Oregon Health Plan reported that, last year, a third of Oregonians enrolled on HealthCare.gov in the final 13 days of open enrollment, from Dec.18 to Jan 31, 2017. Some policy experts worry Oregonians may not be aware they're quickly running out of time to find or renew coverage.

"I would tell folks to get started on enrollment right away," says Beckah Moore who specializes in healthcare insurance plans. "We've definitely been busy with enrollment despite the lack of ads, and I think it'll just get more chaotic as Dec. 15 nears."

With many worried about the increase in rates and decrease in available insurance providers, community partners like Taylor, who are well versed in the health insurance options, can be critical advisors for those daunted by the federal marketplace and who don't receive health insurance from their employers. Some even opting to forgo insurance altogether, citing "it's too expensive."

In an effort to combat vague information, the Oregon Health Insurance Marketplace released financial aid figures, stating that on average, an Oregonian in 2017 received $346 per month in financial aid, if they bought the plan through the federal marketplace.

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These breaks can be available to those who make as much as $48,240 per year (single family), $64,960 (2 persons) or up to $98,400 per year for four individuals. In addition, adults who "make up 138 percent of the Federal Poverty Level" qualify for OHP, according to the Oregon Health Authority. That means those who make approximately $16,100 per year (one person) or $32,900 per year for a family of four may qualify for free healthcare.

Liz Hagan, the associate director of policy at the National Association of Health Assisters, in an interview with the Washington Post says she was "encouraged by what we've seen thus far," in regard to enrollment. "Thankfully, people sharing the facts about coverage and open enrollment have cut through the noise and rhetoric by the Trump administration."

But as Moore notes from her past experience, the litmus test isn't the first few weeks of enrollment, but the last few days. She reminds younger, healthy Oregonians who may think they don't need coverage, such as the case with Saxton, to sign up. "They balance out the system, and without them playing their part, the entire plan is in jeopardy of collapsing."

MEASURE 101: On the Ballot this January

The cost of health care in Oregon is again up for debate next year when Measure 101— due for a vote Jan. 23 — goes before voters. Campaigners for the YES vote say the measure would safeguard healthcare for more Oregonians by instilling a 1.5 percent tax on certain health care insurance providers and hospitals. The additional money would funnel into the Oregon Health Plan, the state's version of Medicaid. Supporters say that if the tax is repealed, up to 350,000 people may lose health care.

Citing the potential of some health insurers dropping out or health care providers raising prices, some experts believe taxing health care providers will not make services more affordable. As reported in the Source Weekly Oct. 18, the largest employer in Central Oregon, St. Charles Health System, is facing a $35 million shortfall next year, laying off 30 caregivers to close the gap in the 2018 operating budget. It also offered 72 employees "voluntary separation offers."

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Hospital officials said that the impending tax (if not repealed) is one reason for the shortfall—as is the fragmented insurance reimbursement scheme. "A new 0.7 percent real tax is coming off the net revenue, so for us, that translates to about $3 million annually," said St. Charles' President and CEO Joe Sluka.

Sluka also blamed the rising trend of patients buying high-deductible plans as a reason for the changing landscape. "On a nationwide scale, the cost of healthcare has gotten to the point where people can't afford their insurance anymore. What we're seeing is patients buying high deductible plans—anywhere from $2,000-$10,000—and it's creating a scenario where people are either not seeking care or can't pay."

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Oregon voters will decide on whether to overturn this new tax just as the state faces a budget shortfall of more than $1 billion. Three Republican state representatives—Julie Parrish, Sal Esquivel and Cedric Hayden—gathered more than 85,000 signatures to force the vote, which normally would take place in the 2018 primary election, but was moved up because it may impact the 2018 state budget. Opponents of the tax say it will put pressure on lawmakers to "get more creative" and find other ways to cut costs for low-income Oregonians.

In a recent health care forum hosted by the Bend Chamber, a representative of PacificSource, a nonprofit insurance provider, acknowledged the strain on state and federal funding. "We have a history of building a nation on the premise of really clearly delineating what the government shouldn't be able to do," said Lindsey Hopper, vice president of Medicaid Programs at PacificSource. "We have a few rights that are expressed and the rest of history is pretty much about protecting ourselves from the federal government which we feared is too strong. That is a really weird platform to launch a big shift. And some of this is just really ugly growing pains."

Sluka noted that Central Oregon seemed to be in a unique position to navigate tough funding. "I've worked in health care for 20 years and what we are doing in Central Oregon is really unique. It is having everyone at the table, and sitting with dental health, mental health, education now, physical health, the county commissioners... and there's a discussion going on, not only about health care but about the care we deliver. I think we're pioneering here, and I couldn't agree more, I think the allocation and investment impact health overall."

Local physician and President of High Lakes Healthcare, Dr. Stephen Mann, notes that lowering the cost of care across the board so that patients will seek preventative and primary care is critical to ensure the system next year will still be operational. "There has got to be work on lowering the cost of care across the board, in order to take care of everybody," Mann said. Though on what scale remains to be seen.



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