Esquire

Thoughts From a Hospital Bed

And what it means to be healthy, or unhealthy, in the United States of 2017.

By Charles P. Pierce    May 3, 2017

I wasn’t awake for 30 minutes Wednesday morning before the panel on MSNBC’s Morning Zoo Crew made me wish that there was a procedure by which they could put my gallbladder back, just so they could take it out again. The subject was Hillary Rodham Clinton’s appearance at a woman’s conference on Tuesday. First, Harold Ford came on—and who’s more of an expert of losing winnable elections than Harold Ford, Jr.?—and said that, instead of talking about the election just passed, HRC should be out there talking about “what she would be doing as president.”

Just thinking about the reactions in many quarters, from this bunch, from The New York Times’ Washington Bureau, if she actually did this—She’s Delusional! She Thinks She’s President!—made me long to be back on Toradol again. (By the way, if you know anyone who wonders why NFL players do what they call “riding the T train” before every game, send that person to me. Toradol is very good at its job.) Then, Mika informed us that one of the major blunders of the Clinton campaign was that it didn’t realize that the arrival of Donald Trump “changed the moral calculus” of the race and would sideline Bill Clinton as a political asset. That got me longing to start the whole process again, perhaps with a rusty lawnmower blade.

I can’t leave you alone for a minute, America.

So anyway, this happened. Last Tuesday, I awoke in the middle of the night feeling as though I’d swallowed an ankylosaurus, spiked tail and all. (It was a good day for dinosaur news, because it’s always a good day for dinosaur news, but it wasn’t a good day for metaphorical dinosaur news.) That brought me to the emergency room. The next afternoon, I felt as though someone was pounding a railroad spike into my right side. After a series of tests that covered 14 hours and included an endoscopy, an ultrasound, an MRI, and a more elaborate MRI, it was determined that the ol’ gallbladder had run the race, that it had to come out, but that it had not made the argument for its removal in a conventional way. I had, as they said, “an atypical presentation of a common condition.”

New title for the memoirs!

So, anyway, this happened. Before relieving me of the offending organ, the surgeon and I were chatting, and he mentioned that, in college, he’d played defensive tackle at Trinity College in Connecticut, in which capacity he annually ran into a plucky offensive lineman named…Bill Belichick. So that was weird.

The staff at Newton-Wellesley Hospital, all of them, will always have my thanks and prayers. But although Jimmy Kimmel beat me to this by a couple of days, what continued to strike me over the past week was the fact that the critical element in my care was that I could afford it.

The critical element in my care was that I could afford it.

After a while, the Toradol and I conjured up a guy in Mississippi who worked in a plastics plant. (He also works at the local Piggly Wiggly to make ends meet.) Last Tuesday, he wakes up in the middle of the night with the anklyosaurus in his gullet. He probably downs an over-the-counter stomach medicine. The next day, at work, he feels the railroad spike’s being driven in. He has to make calculations in currencies with which I am not familiar and in which I am not fluent. Antibiotics exchanged for food, school fees bartered for an ultrasound. Or maybe he just soldiers through, day after day, until a chronic condition becomes catastrophic and the ankylosaurus breaks through into his life like the critter from Alien leaping from John Hurt’s chest. I really got to like this guy. I wished him well.

From this standpoint, with my Mississippi plastics worker hanging out at the side of my bed, I watched the Republicans fall all over themselves trying to destroy the Affordable Care Act while pretending they weren’t doing that very thing. (An atypical presentation of a common condition.) For a good, long, healthy while, I was completely one of The American People, my privileged view of our democratic follies clouded for a moment by more than just the pharmaceuticals. I was looking through a haze of frustration and pain, and considerable anger, for me and for my phantom pal from the plastics plant. Human health is not a commodity, to be bargained and sold and traded as though it were any other consumer good.

I was lying in a hospital, doped to the gills, chatting in my mind with an imaginary fellow citizen, and I could figure that out. Why in bloody hell can’t they? They’re out to wreck the only piece of effective legislation that made this a little easier for me and for my pal that has emerged in the last half-century. Everything about the proposed replacement is cruelly inadequate, because that’s what it was designed to be. The pre-existing conditions protections are cheesecloth; the high-risk pools are guaranteed to bring us back to the days of generally unaffordable premiums. It’s still a tax bill dressed up as healthcare reform, which is like calling a crop subsidy a law enforcement measure.

And hand things back to the states? To Sam Brownback’s Kansas, or Scott Walker’s Wisconsin, or even my phantom companion’s Mississippi? Somehow, doing this, bringing millions of Americans back to the brink of a cliff they’d almost forgotten over eight years, makes those Americans more free? This is crazy. I turned on the hockey game.

Human health is not a commodity, to be bargained and sold and traded as though it were any other consumer good.

The debate on the essential American political identity—which I contend began in all modern contexts with the belated acknowledgement of the rights granted to African-American citizens in the wake of the Civil War—has not even half-begun. The question of who we are as a nation is as unresolved as it ever has been. The value of the political commons—and the distribution of the benefits thereof—is still in a perilous place. The notion that the American republic is an ongoing experiment in self-government is one to which I still subscribe, but, dammit, these days, we seem to be closer than ever to the moment when that experiment turns to one of complete devolution, as we walk the republic back through all the mistakes of the past from which we’d thought we learned. Hell, the Greeks knew that social inequality was the route through which democracy turns to oligarchy. We were supposed to have learned that in 1787.

Also, in case you haven’t noticed, the president* of the United States is bughouse bananas and he’s getting worse.

So, anyway, all this happened. My family and I would like to thank you magnificent bastids, one and all, for the great outpouring of thoughts, prayers, good wishes, and raisings of the glass that came to us from all across the Intertoobz. There’s something stirring out in the land, I swear to god there is, and I’m glad we’re all here in this thing called life together.

So, anyway, that all happened. The shebeen is open again, praise be. God bless all here!

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A look at the House Republican health care bill

Associated Press May 4, 2017

WASHINGTON (AP) — House Republicans on Thursday passed legislation to roll back much of former President Barack Obama’s health care law. The legislation would rework subsidies for private insurance, limit federal spending on Medicaid for low-income people and cut taxes on upper-income individuals used to finance Obama’s overhaul.

The nonpartisan Congressional Budget Office estimates that the Republican bill would result in 24 million fewer people having health insurance by 2026, compared to Obama’s 2010 statute.

Here are key elements of the bill:

__Ends tax penalties Obama’s law imposes on individuals who don’t purchase health insurance and on larger employers who don’t offer coverage to workers.

__Halts extra payments Washington sends states to expand Medicaid to additional poorer Americans, and forbids states that haven’t already expanded Medicaid to do so. Changes Medicaid from an open-ended program that covers beneficiaries’ costs to one that gives states fixed amounts of money annually.

__Erases Obama’s subsidies for people buying individual policies based mostly on consumers’ incomes and premium costs. Replaces them with tax credits that grow with age that must be used to defray premiums. The credits are refundable, which means they can go to people with little or no tax liability. Credits may not be used to buy policies that provide abortion coverage.

__Repeals Obama’s taxes on people with higher incomes and on insurance companies, prescription drugmakers, some medical devices, expensive employer-provided insurance plans and tanning salons. Obama’s law has used the revenue to help pay for expanded coverage.

__Requires insurers to apply 30 percent surcharges to customers who’ve let coverage lapse for more than 63 days in the past year. This would include people with pre-existing medical conditions.

__Lets states get federal waivers allowing insurers to charge older customers higher premiums than younger ones by as much as they’d like. Obama’s law limits the difference to a 3-1 ratio.

__States can get waivers exempting insurers from providing consumers with required coverage of specified health services, including hospital and outpatient care, pregnancy and mental health treatment.

__States can get waivers from Obama’s prohibition against insurers charging higher premiums to people with pre-existing health problems, but only if the person has had a gap in insurance coverage. States could get those waivers if they have mechanisms like high-risk pools that are supposed to help cover people with serious, expensive-to-treat diseases. Critics say these pools are often under-funded and ineffective.

___Provides $8 billion over five years to help states finance their high-risk pools. This late addition, aimed at winning over votes, is on top of $130 billion over a decade in the bill for states to help people afford coverage.

__Retains Obama’s requirement that family policies cover grown children to age 26, and its prohibition against varying premiums because of a customer’s gender.

___

Sources: U.S. Congress, The Associated Press, Kaiser Family Foundation

NPR Politics

GOP Health Care Bill Would Cut About $765 Billion In Taxes Over 10 Years

Scott Horsley   May 4, 2017  

The Affordable Care Act took money from the rich to help pay for health insurance for the poor. The repeal bill passed by House Republicans would do the opposite. The health care bill passed by the House on Thursday is a win for the wealthy, in terms of taxes.

While the Affordable Care Act raised taxes on the rich to subsidize health insurance for the poor, the repeal-and-replace bill passed by House Republicans would redistribute hundreds of billions of dollars in the opposite direction. It would deliver a sizable tax cut to the rich, while reducing government subsidies for Medicaid recipients and those buying coverage on the individual market.

Tax hikes reversed

The Affordable Care Act, also known as Obamacare, is funded in part through higher taxes on the rich, including a 3.8 percent tax on investment income and a 0.9 percent payroll tax. Both of these taxes apply only to people earning more than $200,000 (or couples making more than $250,000). The GOP replacement bill would eliminate these taxes, although the latest version leaves the payroll tax in place through 2023.

The House bill would also repeal the tax penalty for those who fail to buy insurance as well as various taxes on insurance companies, drug companies and medical device makers. The GOP bill also delays the so-called “Cadillac tax” on high-end insurance policies from 2020 to 2025.

All told, the bill would cut taxes by about $765 billion over the next decade.

The lion’s share of the tax savings would go to the wealthy and very wealthy. According to the Tax Policy Center, the top 20 percent of earners would receive 64 percent of the savings and the top 1 percent of earners (those making more than $772,000 in 2022) would receive 40 percent of the savings.

Help for the poor reduced

Over time, the GOP bill would limit the federal contribution to Medicaid, while shifting control of the program to states. Depending on what happens to costs, states may be forced to provide skimpier coverage, reduce their Medicaid rolls, or both. The Congressional Budget Office estimated that an earlier version of the bill would leave about 14 million fewer people covered by Medicaid by 2026. (The House voted on the current bill without an updated CBO report.)

CBO also anticipated fewer people would buy insurance through the individual market. With no tax penalty for going without coverage, some people would voluntarily stop buying insurance. Others would find coverage prohibitively expensive, as a result of changing rules governing insurance pricing and subsidies.

The GOP bill would allow insurance companies to charge older customers up to five times more than younger customers — up from a maximum 3-to-1 ratio under the current health law. The maximum subsidy for older customers in the GOP plan, however, is only twice what is offered to the young.

The bill also allows insurance companies to offer more bare-bones policies. As a result, young, healthy people could find more affordable coverage options. But older, sicker people would likely have to pay more.

In addition, because the subsidies offered in the Republican plan don’t vary with local insurance prices the way subsidies do in Obamacare, residents of high-cost, rural areas would also suffer. That could include a large number of Trump voters.

DailyKos

A Vote To “Harm Millions of Americans:” Study Released Today Predicts Disaster With TrumpCare.

By Dartagnan    May 04, 2017

Republicans working hard to screw millions of Americans out of their health care

David Leonhardt of the New York Times draws our attention to a Harvard study being released today that reveals just how harmful a “health care” package the Republican House and Donald Trump are about to foist on the American public. It is one that will raise premiums and prompt millions to opt instead to go uninsured, further driving prices up for everyone.

The study is based on an analysis of Massachusetts’ subsidized exchange health insurance system system. Put simply, it shows that when even relatively modest premium cost increases are imposed on lower income individuals, they tend to choose to go uninsured, preferring to stick to “emergency room” treatment.

The Massachusetts method allocates subsidies to lower-income people by separating them into categories of income—a family making  $ 44,701 per year, for example, can end up paying several hundred dollars more per year then someone making $44,699.  It’s not a perfect or even wholly equitable system, but it has the virtue of being well-studied. The clear-cut thresholds of income-based premium costs that result from the Massachusetts system provide an opportunity to analyze people’s behavior in a more straightforward way, with fewer variables and more reliable results.

What the Harvard study clearly shows is even a slight price increase in premiums will make lower-income folks disinclined to sign up. And if that sounds obvious, it should. All this new study does is back it up with hard data:

Why? Partly because people know that they have an alternative. They can instead rely on last-minute emergency-room care, in which hospitals typically treat them even if they lack insurance. Such care is problematic: It tends to be expensive, raising costs for other patients, and it’s often not as good as preventive care. But many poorer families choose E.R. care over taking money from their stretched budgets for health insurance.

The Republican plan being voted on today will increase costs to low income individuals not just a little, but significantly. Most affected will be lower-income, older Americans because of the way the system is designed—tax credits based primarily on age, not geographic area or ability to pay. That is a major distinction between the Republican plan and The Affordable Care Act (“Obamacare”), and its impact will be staggering, because for low-income, aged individuals only the very sick (and desperate) will be willing to pay those premiums. According to the three authors of the Harvard study—one of whom, Amy Finkelstein of MIT, is regularly touted by such conservative outlets as the Wall Street Journal– the rest will largely opt out of the entire system:

“When premiums go up, it’s the healthier enrollees who drop out,” said Amy Finkelstein of M.I.T., another author of the study.

The implications of the Harvard study on what the Republicans are voting on today are even more ominous than the already damning analysis of the Congressional Budget Office, which predicted that the Republican plan will kick 24 million people off of their health insurance:

[T]he magnitude of the new results suggests the C.B.O. estimates of insurance losses were conservative. Nathaniel Hendren of Harvard, the paper’s third author, said that the Republican proposal would effectively end enrollment in the insurance markets for families that make less than $75,000 a year.

So this is what the Republicans are voting to do to the American public today. Their prime—indeed their only– motivation for this is to cut the same taxes on multimillionaires that permitted Obamacare’s success in providing millions of Americans with good health care coverage . As Leonhardt notes:

The Republican health bill is simply a bad bill. It’s been blasted by conservative and liberal health experts, as well as groups representing patients, doctors, nurses and hospitals. Above all, the bill cuts health benefits for the poor, the middle class, the elderly and the sick, and it funnels the savings to tax cuts for the rich.

The Republican health care bill is a recipe for disastrous, out-of control premium hikes for millions.  Unfortunately for all of us, the GOP Party leadership has secured just enough “yes” votes to make its passage probable today, while sparing so-called “moderate” members of their caucus the political consequences and allowing them to vote “no.”

But those “moderate” Republicans own this as much as their colleagues, because this act of violence against Americans in taking away a system (“Obamacare”) already proven to work has been the longstanding, explicit policy of their Party leaders, whom they eagerly voted into that position.  And the pain it causes will affect all Americans, including ones who live in so-called “moderate” Republican Districts:

The bill could cause more people to lose insurance than previously predicted and do more damage to insurance markets. The $8 billion sweetener that Republicans added to the bill on Wednesday would do nothing to change this reality. President Trump and Speaker Paul Ryan are continuing to push a policy that would harm millions of Americans.

Americans must remember that in 2018, when it will be time to pay back the GOP for what it did today.

House Republicans are hell-bent on ripping away our health insurance. Call your member of Congress at 202-224-3121, and demand they vote NO on a renewed Trumpcare that is worse than the one before. Remind them they work for you.

If you have trouble getting through or their “mailbox is full,” you can work through AARP (which vehemently opposes this Bill) to connect you to a live person to answer: AARP’s #: 844-259-9352.

DailyKos

After announcing her retirement, one GOP congresswomen is torching the GOP health care plan.

By Jen Hayden    May 04, 2017

U.S. Rep. Ileana Ros-Lehtinen (FL-27) recently made a surprise announcement that she will be retiring, not seeking re-election in 2018. Perhaps that has freed her up to speak the truth about the impending disaster of a massive tax cut for the wealthy, stealthily disguised as a health care plan , because today she issued a statement saying she intends to vote against the Trumpcare AHCA bill. Rep. Ros-Lehtinen plainly says this bill “fails to prove for the needs of my constituents” and has the “potential to severely harm the health and lives of people in South Florida.” Read her statement and see why she isn’t just a no, she’s a HELL NO:

“Despite amendments and changes, the AHCA still fails to provide for the needs of my constituents. I will not support a bill that has the potential to severely harm the health and lives of people in South Florida and therefore I remain steadfast in my commitment to vote NO on the AHCA. The recent addition of further funds to high risk pools continues to be inadequate and fails to cover those who need it most. If enacted, the older and poorer South Floridians will be worse off and will find it more difficult to obtain quality healthcare. My constituents should not have to take a step backward in their ability to obtain treatment for any illness and thus, I will vote NO.”

Too bad her colleagues are caving right and left, ignoring the will and the needs of their constituents. The midterm elections take place on November 6, 2018. We have 551 days to get these bums out of Congress and restore our health care protections.

Consumer Reports

How the Affordable Care Act Drove Down Personal Bankruptcy

Allen St. John, April 24, 2017

As legislators and the executive branch renew their efforts to repeal and replace the Affordable Care Act this week, they might want to keep in mind a little-known financial consequence of the ACA: Since its adoption, far fewer Americans have taken the extreme step of filing for personal bankruptcy.

Filings have dropped about 50 percent, from 1,536,799 in 2010 to 770,846 in 2016 (see chart below). Those years also represent the time frame when the ACA took effect. Although courts never ask people to declare why they’re filing, many bankruptcy and legal experts agree that medical bills had been a leading cause of personal bankruptcy before public healthcare coverage expanded under the ACA. Unlike other causes of debt, medical bills are often unexpected, involuntary, and large.

“If you’re uninsured or underinsured, you can run up a huge debt in a short period of time,” says Lois Lupica, a bankruptcy expert and Maine Law Foundation Professor of Law at the University of Maine School of Law.

So did the rise of the ACA—which helped some 20 million more Americans get health insurance—cause the decline in bankruptcies?

The many experts we interviewed also pointed to two other contributing factors: an improving economy and changes to bankruptcy laws in 2005 that made it more difficult and costly to file. However, they almost all agreed that expanded health coverage played a major role in the marked, recent decline.

Some of the most important financial protections of the ACA apply to all consumers, whether they get their coverage through ACA exchanges or the private insurance marketplace. These provisions include mandated coverage for preexisting conditions and, on most covered benefits, an end to annual and lifetime coverage caps. Aspects of the law, including provisions for young people to be covered by a family policy until age 26, went into effect in 2010 and 2011, before the full rollout of the ACA in 2014.

“It’s absolutely remarkable,” says Jim Molleur, a Maine-based bankruptcy attorney with 20 years of experience. “We’re not getting people with big medical bills, chronically sick people who would hit those lifetime caps or be denied because of pre-existing conditions. They seemed to disappear almost overnight once ACA kicked in.”

The first attempt to repeal and replace the ACA, in March, failed to gain enough Congressional support and never came to a vote.

Then in April, details of a new replacement plan were released. Although President Donald Trump has said that this new version, like the first bill that was pulled from consideration, will cover pre-existing conditions, the revised law gives states broad latitude to allow insurance companies to increase rates for consumers with an existing illness.

Since the start of the year, more than 2,000 consumers have answered an online questionnaire from Consumer Reports’ advocacy and mobilization team, sharing their experiences with the ACA. Katie Weber of Seattle was one of them.

In 2011, she had just landed her first job out of college, as a teacher with AmeriCorps, she explains in a phone interview. That’s when the unusual numbness in her hand began, which she—and her doctor—at first mistook for a pinched nerve. Then came debilitating headaches and nausea and, ultimately, a diagnosis of medulloblastoma, a fast-growing cancerous brain tumor.

The treatment for her tumor was straightforward: surgery, radiation, then chemotherapy. Figuring out how to pay for it was much less clear. She worried that the insurance she had through AmeriCorps wouldn’t cover enough of her bills.

“My dad said to me, ‘Your health is the most important thing. If you have to declare bankruptcy at age 23, it’s no big deal,’” Weber says.

Because of the ACA, she says, it never came to that. After her year with AmeriCorps, the new healthcare law enabled her to get coverage under her parents’ insurance plan.

The ACA provisions required that the family’s insurance company cover her even though she had already been diagnosed with cancer. That would not have been the case before the ACA, which mandates the coverage of pre-existing conditions for all consumers.

Later, when she aged out of her parents’ insurance, Weber was able to enroll in Apple Health, Washington state’s version of Medicaid, a program that was expanded once the ACA was passed. That coverage, she says, has been crucial to her financial and medical well-being, especially once the cancer returned last fall.

Weber says she now spends more time discussing treatment options and less time worrying how she’ll pay for MRIs and drugs. These are covered in full under her Apple Health policy.

“Cancer is really expensive,” she says. “My insurance saved my life.”

Numbers Plummet

If you want further testimony about how much personal bankruptcies have dropped over the past decade, talk to Susan Grossberg, a Springfield, Mass., attorney.

For more than 20 years she has helped consumers push the financial reset button when debt triggered by divorce, unemployment, or a costly illness or medical episode became too much to handle. “Medical debt can get really big really quickly,” Grossberg says. “When you’re in the emergency room they’re not checking your credit score while they’re caring for you.”

With the advent of the ACA—and before that, expanded state healthcare in Massachusetts—she says fewer clients with large medical debts walked through her door.

Grossberg adds that her bankruptcy business has slowed so much that she has been forced to take on other kinds of legal work—landlord-tenant and housing discrimination cases—to cover her own bills.

The American Bankruptcy Institute suggested that veteran Chicago bankruptcy attorney and trustee David Leibowitz could also help parse the reasons for the decade long decline.

First, he says, the Bankruptcy Abuse Prevention and Consumer Protection Act of 2005 made it more difficult for consumers to file for bankruptcy. The law required credit counseling and income verification and forced many consumers to seek protection under Chapter 13, which restructures, but does not eliminate, most debt. The piles of paperwork also meant most filers needed a lawyer, which made bankruptcy more costly and therefore not an option for many poor consumers.

Then there was the economy. After a slow and steady recovery following the housing crisis of 2008, Leibowitz explains that American consumers generally had fewer problems with their mortgages, better employment prospects, and greater access to credit, which made them less likely to file.

The final factor, according to Leibowitz, has been the ACA, which afforded health coverage to many more consumers and expanded protections for all.

Of course, not everyone sees such a direct connection between the decline in bankruptcies and the emergence of the ACA.

Thomas P. Miller, resident fellow at the American Enterprise Institute and co-author of “Why ObamaCare is Wrong for America” (HarperCollins, 2011), cautioned against “reaching broad conclusions” because the subject is so complex.

“Certainly there are fewer people declaring bankruptcy, and certainly fewer are declaring bankruptcy because of healthcare spending,” he says. But his earlier research suggested that some studies exaggerated the degree to which high healthcare bills cause bankruptcies. “They tended to reflect other problems with credit card balances well beyond healthcare,” he says. “It stems from multiple causes.”

Figuring Out Why

Over the past decade, determining the cause-and-effect relationship between medical debt and bankruptcy has become a political football, particularly during the years the Obama administration was trying to pass the ACA through Congress.

The truth is that it’s not that easy to determine how many bankruptcies are caused by medical debt. Examining the paperwork doesn’t always offer insight because debtors often juggle their indebtedness, for example, using a credit card to pay an outstanding medical bill while leaving other debts unpaid.

But a 2014 study from Daniel Austin, a bankruptcy attorney and, at the time, a professor at the Northeastern University School of Law, offers some of the most in-depth research to date.

Austin and his team selected a nationwide group of 100 bankruptcy filers meant to represent a cross-section of the U.S. population, studied their paperwork, then followed up with a survey asking filers, basically, “Why?”

His team’s research found that medical debt is the single largest factor in personal bankruptcy. First, Austin analyzed the paperwork of individual case files, which suggested that medical bills were a factor in 18 percent of filings. But when he directly asked the same filers, in a survey, the number was even higher, with 25 percent citing medical bills as a factor in their decision to file bankruptcy.

In addition to the nationwide group, Austin isolated a group of 100 bankruptcy filers from Massachusetts. Why Massachusetts? Because its citizens, starting in 2006, had been covered by a comprehensive state healthcare program similar to the ACA known as Romneycare, after the state’s former governor, Mitt Romney.

The differences between the two groups were striking. Even though the Massachusetts filers owed substantially more in unsecured debt (that is, debt not backed by a home, a car, or another asset) than their counterparts in other states, they reported less than half as much medical debt, which is also unsecured.

“The average medical debt in Massachusetts in 2013 was relatively low at just $3,041 (6 percent of total unsecured debt) compared to $8,594 (20 percent of total unsecured debt) nationwide,” Austin writes in his 2014 study, portions of which were published in the Maine Law Review.

“Only about 9 percent of Massachusetts debtors felt their bankruptcy filing was a result of medical bills,” Austin explains. “This compares to 25 percent for debtors from [other] jurisdictions.” Austin’s research found that comprehensive medical coverage in Massachusetts had all but eliminated medical bills as a cause for bankruptcy.

“Not only in absolute numbers—they had much smaller medical debt—but psychologically, medical debt did not loom nearly as large for people in Massachusetts as it did for other people in other states.” And in 2010, four years after Romneycare began, the state had a bankruptcy rate that was about 30 percent lower than that of other states.

In Search of Certainty, Consistency

At its most basic level, health insurance allows consumers to pay for the medical care they need. Each year, the Centers for Disease Control and Prevention determines how well the system is working by surveying Americans and asking a simple but powerful question: Did you have problems paying medical bills in the last 12 months?

The percentage of those reporting problems has dropped from 21.3 percent of households when they first asked the question in 2011 to 16.2 percent in 2016. That’s almost 13 million fewer Americans no longer facing collection notices from a doctor or hospital.

“It’s been happening across the board, by race, by age, by insurance status, by gender,” says Robin Cohen, the study’s lead author.

But insurance is also about peace of mind. And judging from the consumers who have shared their stories with Consumer Reports, that certainty is in short supply as the fate of the ACA is decided. People are wondering what comes next: Repeal? Replace? Improve? Retain and neglect? No one really knows the answer. Americans are concerned about how the future of healthcare will affect them and their families.

In CR’s Consumer Voices survey in January 2017, 55 percent of consumers said they lacked confidence that they or their loved ones would be able to afford insurance to secure that care.

Don Shope of Ocean View, Del., said the availability of ACA coverage gave him the confidence to leave a corporate job and start his own consulting business. But now, with the ACA’s future in limbo, he and his wife are watching the action in Washington and worrying that they might have to return to jobs with benefits.

“I’m not a liberal or a conservative, a Democrat or a Republican,” Shope said in a phone interview. “Our biggest concern is that with repeal and replace we’re going to be left high and dry.”

He also believes in expanded health coverage for all. “If any American is sick, we should be willing to take care of them,” Shope says. “It’s the right thing to do. Economics and profit shouldn’t be part of the healthcare equation.”

Hanging On Every Dip and Turn

And then there’s Kristin Couch, who has channeled the uncertainty into her own brand of activism.

“I was kind of anxious,” Couch says about the day in March when Congress was set to vote on a less robust bill that would replace the ACA.

The 31-year-old public relations executive, of Gainesville, Ga., has started to follow health-care politics in the intense, almost obsessive way some people follow sports. The morning after Election Day, she called the offices of her local congressional representatives, urging them to preserve the protections the ACA offers.

Couch began caring about healthcare as a high school senior when she was diagnosed with lupus and since then has become something of a reluctant expert on how to manage not only her treatment but also the insurance that pays for it.

With friends and neighbors she talks about the law in simple but personal terms. “I tell people, ‘I have a pre-existing condition, and this has helped me,’” she says of the ACA. Couch follows the healthcare debate in Washington so closely because she knows firsthand what happens when you don’t have adequate coverage.

Couch remembers the time, before the ACA, when a new immuno-suppressive drug that wasn’t covered by her policy became available. “It was expensive,” she explained in an interview, “but it worked, and I knew I needed it. Every month I’d just put it on a credit card. When your medication is thousands of dollars a month, that’s the start of being in debt.” She considered bankruptcy but ultimately worked her way out from under the pile of medical bills.

As a result of the ACA, her coverage shifted again when her employer no longer offered a traditional plan and she had to switch to one with a high $3,000 deductible. Initially she was stunned by her out-of-pocket costs, but she quickly realized that her total costs would be capped once she’d met that threshold.

“It seemed scary and it seemed different,” she explains. “But it actually saved me money.” And now, she says, “I don’t have to worry about how much a new drug costs.”

So on the March day the House of Representatives was supposed to vote on repealing the ACA, she worried that the insurance she’d come to depend on was about to be yanked away. Only after emerging from a client meeting did she learn the vote had been canceled. “I started crying I was so happy,” Couch recalls. “It’s like a weight has lifted.”

But Couch’s relief was short-lived. Now she’s back to paying close attention to the rhetoric and vote-counting deals in Washington, awaiting another possible vote on the newly revised plan. “I’m still optimistic,” she said this week. “I think enough people will stand up and fight for the coverage.”

Consumer Reports, Inc.