Luz Rivera (Clinic Coordinator) and operations manager Olivia Knewstub, outside the Ithaca Free Clinic.

When Donald Trump was first elected President, Beverly Chin’s office got a flood of phone calls.

“Many consumers were very concerned about the potential ACA repeal,” said Chin, who is the Program Director of the Tompkins County Human Services Coalition’s Health Planning Council. “We didn’t have more information than what was on the news.”

Retired Nurse Practitioner Anne Dalton responded to the election of Trump, who campaigned with the promise that he would “very, very quickly” repeal the ACA, by tripling the hours she spends each week volunteering at the Ithaca Free Health Clinic.

“It’s the only thing I can do personally,” Dalton said.

And when Senate Republicans began making attempts to repeal the ACA earlier this year, Octavia Solá feared that her health insurance was in jeopardy.

“I was nervous about [ACA coverage] not being available anymore,” Solá said. “I feel like there was some purposeful confusion. I didn’t even know how it would affect my plan.” ?

Indeed, every time a new bill has been proposed this year that would threaten the ACA, Chin said the Health Planning Council health insurance navigators would receive another surge of calls.

“Our advice was certainly to enroll in the plans,” said Chin. “Today, as it still stands, the Affordable Care Act is still the law of the land.”

Recently, however, Senate Republicans made some headway toward its demise. In the early hours of Saturday morning, the Senate passed a tax bill that would remove the individual mandate in the Affordable Care Act. The Senate’s bill will first need to be merged with the House’s version of the tax bill, which might happen by the end of the month: “Looking forward to signing a final bill before Christmas!” Trump tweeted.

The Senate bill takes away the tax penalties for individuals who do not enroll in health insurance under the Affordable Care Act, which will be yet another attempt from the Republican Party to undermine the legislation.

The tax penalty is thought to keep healthy people within the marketplace, and if these healthy individuals choose to forego buying health insurance without the mandate, premiums on ACA plans will increase dramatically. According to a November report by the Congressional Budget Office, 13 million Americans would lose their insurance by 2027.

The removal of the individual mandate could potentially save the government $338 billion according to the CBO report and the money that would be spent paying for ACA enrollees’ health coverage would instead be used to pay for tax cuts for businesses and individuals.

However, this savings estimate could be off. According to a study by the Kaiser Family Foundation, the vast majority — over 90 percent — of those enrolled in plans under the ACA would continue buying health insurance, even if there were no tax penalty.

“Everyone needs health insurance,” said Solá, who is enrolled in the Essential Plan of the New York State of Health marketplace, created in 2013 under the ACA.

Solá, who has a chronic condition, requires regular lab testing and daily medication which is paid for by her plan. If she didn’t have health insurance, “it would cost hundreds and hundreds of dollars just to get routine stuff that I have to get done,” she said. “Not being insured is very expensive.”

Individuals who earn too much to qualify for Medicaid or the Essential Plan can purchase the Qualified Health Plan. For an individual earning over 200 percent and 400 percent above the federal poverty level (or between $24,120 and $48,240), the lowest cost QHP plan was $368 last year; this year the premium for the same plan has gone up to $480. But according to Chin, the value of the tax credits might also be increasing for some.

“All the plans did increase a little bit,” Chin said. “For some people, that might net a fairly even monthly premium for them. Maybe the premium changed, but you receive a higher tax credit. It depends on the individual situation.”

Despite the tax credits, health insurance plans under the ACA have become too expensive for some families and individuals, according to Luz Rivera, the Clinic Coordinator for the Ithaca Free Health Clinic. When the ACA was first put into place, Rivera remembers more affordable coverage.

“The premiums were a lot lower, and the deductibles were not sky high as they are now,” Rivera said. “Prescriptions were on a set price. Now, it depends on the plan.”

The vast majority of the clinic’s patients are uninsured, and turn to the clinic to receive free medical services.??

“[Some of our patients] would rather not have health insurance,” Rivera said. “They’d rather come here, see a doctor, get a prescription, pay out of pocket [for their medicine] and not have health insurance that is ridiculously expensive and is half the time not going to cover things. A lot of people would rather pay the penalties because it ends up being cheaper.”

According to the Kaiser Family Foundation, almost half of those who are insured say that their premiums, deductible and copay expenses have gone up lately, and nearly 75 percent say that an increase in their premiums in the future would be a financial burden. Sixty percent of those enrolled in plans through the marketplace fear that the rising costs will result in them not being able to afford to keep their plans.

If the individual mandate is repealed, premiums are only going to get higher.

The individual mandate was put into place in the ACA to maintain a balanced number of healthy and sick individuals within the insurance pool, to even out the costs to insure marketplace enrollees. Without the mandate in place, a domino effect would ensue that would raise premiums while diminishing the quality of care for enrollees.

The Congressional Budget Office estimates that healthy individuals will leave the marketplace if they are not required to purchase coverage, and the insurance pool would then be composed of a higher percentage of sick individuals, who are more expensive to cover. This would cause insurance to become more expensive, which would lead to even more enrollees leaving the marketplace. The CBO anticipates premiums to rise by at least 10 percent every year if the individual mandate is lifted.

Dalton is afraid of what these threats mean for the future of healthcare in America. In addition to tripling her time volunteering at the free clinic, she also found a winter apartment in Ithaca so that she could more easily commute to the clinic, rather than drive in rain or snow from her home in King Ferry, 20 miles north of Ithaca.

If the ACA is compromised, Dalton said, “the quality of healthcare will diminish significantly.”

“There’s a very large number of people who have chronic diseases and need continuous follow-up, otherwise they would become extremely ill,” Dalton said. “The illness and death rate would rise if they didn’t receive care, and they can’t afford the Emergency Room.”

The free clinic continues to see an increase in new patients according to Rivera. Most of the clinic’s patients are low-income but still don’t qualify for Medicaid, or can’t afford the premiums and deductibles of other plans, so have chosen to go without.

The clinic, sometimes only operating on one volunteer provider, can see as many as a dozen brand new patients during the 3- to 4-hour time frame that the walk-in clinic is open.

“It’s a full house every time I work,” said Dalton, who has to ask the front desk to start turning patients away as the clinic is closing. “I just say, ‘Oh my God, look what time it is, and how many people are still here.’ If I saw their faces, I probably wouldn’t turn them away.”

With the threats made to the ACA, and as more individuals are being pushed out of the marketplace and unable to afford health insurance, Rivera fears that the Ithaca Free Health Clinic is where many will turn.

“Many people are also afraid of the changes that are going on, so they don’t want to reapply [for coverage],” Rivera said. “My fear is that it’s going to make more individuals not have access to health care. We’re not going to have the capacity to cover the need, because there’s only so many volunteers I can have.”

Since the New York State of Health marketplace was put into place in 2013, more than 4 million New Yorkers have enrolled in ACA coverage, and the number of uninsured New Yorkers has reached an all-time low at 4.7 percent, down from 10 percent in 2013. According to the Center for Disease Control, there are 20.5 million fewer uninsured people in the U.S. than there were in 2010, when the ACA was passed.

“[The ACA] is a wonderful first step in covering the American citizen,” Dalton said. “But it’s a long way from being able to cover everyone who needs health insurance.”

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