‘A giant mess’: As ACA changes threaten coverage, consequences could be widespread

Sydney Badeau, an advocate and outreach worker for people with disabilities, has been able to afford health insurance thanks to enhanced premium subsidies that will end at the end of 2025. (Photo courtesey of Sydney Badeau)
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Macy Buhler, a DeForest child care provider, has spent the last several years grappling with the challenges to her business. At the top of the list: hiring and keeping qualified teachers.
Adequate pay is important, of course, but Buhler says good health benefits are as well.
She would like to offer health insurance, but the margins make that unsustainable. The majority of her employees either have their health insurance on a spouse’s plan or through their parents if they’re younger than 26 — or they go uninsured.
About one-third of her employees are able to get covered through the Affordable Care Act (ACA) and the ACA’s health care marketplace, HealthCare.gov.
HealthCare.gov was the first-ever national marketplace for people without health insurance to buy coverage for themselves and their families. The law also set standards for what plans sold through the marketplace must cover.
To make insurance more affordable, the ACA included tax credit subsidies tied to the consumer’s income and available for people with household incomes up to 400% of the federal poverty guidelines.
Those subsidies were substantially increased in 2021 under the American Rescue Plan Act (ARPA), then extended in the 2022 Inflation Reduction Act. But without another extension, they’ll disappear at the end of 2025.

Buhler says the enhanced tax-credit subsidies have helped make it possible for her employees who use HealthCare.gov to afford their health insurance.
“I’m thinking I’m very concerned for them next year,” Buhler says of her employees who have been covered under the ACA. “My staff is exposed to everything,” she adds. “Can I keep my staff healthy? … There’s some definite fears going forward.”
For Sydney Badeau, health insurance through the ACA made it possible for her to work two part-time jobs, neither offering health coverage. She does outreach and advocacy working 20 hours a week for The Arc-Wisconsin and 20 hours a week for People First Wisconsin, both of which serve people with disabilities
Badeau has long-term disabilities and was on Supplemental Security Income (SSI), which ended when a review found that she would be able to work.
Being on SSI qualified her for Medicaid. Neither of her jobs provided health benefits for part-timers, but Badeau was able to buy her own through HealthCare.gov, with the enhanced subsidies keeping it affordable for her.
Her premium is expected to increase 30% next year, beyond what she can afford, Badeau says. She has an option — one of her two jobs could take her full time, qualifying her for that employer’s health plan.
But for many people with disabilities who have gotten coverage through the ACA, the options are more difficult. “There’s going to be a lot of people panicking probably in the next six months to a few years, and not insured, because it’s like a giant mess right now,” Badeau says.

Amanda Sherman, a Mequon real estate broker’s assistant, says her current health insurance policy would cost her about $550 a month without the enhanced subsidies, instead of the $300 she’s paying now.

Sherman gets weekly shots for lupus, an autoimmune disorder. Without insurance the injections would cost $4,000 a month. Her plan has brought that down to $500 a month, and the medication’s manufacturer has a program to help cover her copayments and lower that cost further.
Sherman requires monthly bloodwork and sees five different specialists. She’s undergone a bone marrow biopsy, MRI exams and CT scans.
The annual deductible for Sherman’s health insurance is $7,500. She reached that limit in February. Her out-of-pocket expenses are capped at $9,500; she reached that in February as well.
Sherman’s medications reduce the power of her body’s immune system, making her more likely to get infections. Earlier this year she got walking pneumonia and was hospitalized for sepsis. Three days in the hospital would have cost $20,000 without her insurance, she says.
“If I didn’t have the Affordable Care Act I wouldn’t be able to afford health insurance,” Sherman says. “It’s still very hard for me to afford all my medical expenses — even just the copays are a lot.”
Sherman has asked her health insurer how much her premium will increase next year, but the answers have been vague
Pondering her alternatives, “I’m honestly really scared,” Sherman says.
It bothers her when she hears assumptions others make about the people who will be affected as safety-net programs are slashed.
“I just think it’s gotten really ugly the way that people are looking at each other and dehumanizing different groups of people,” Sherman says.
She has heard others assume that people “are just leeching off the system” if they use Medicaid or have relied on the ACA subsidy to afford health insurance.
“Anybody can get a chronic illness. Anybody can end up with a job where they don’t offer insurance, and that doesn’t make them less of a person,” Sherman says.
“Health care should be something that everybody has access to,” she adds. “It shouldn’t be that hard.”
If coverage declines
When Republicans and President Donald Trump enacted the tax-cut and spending cut reconciliation bill in July, the measure placed new limits on who can qualify for the ACA’s premium tax credit subsidies. The bill also included provisions that will cut Medicaid enrollment and put new barriers to enrollment in federal nutrition aid programs.
When drawing up the bill, the authors declined to include a provision that would have extended enhanced subsidies based on a person’s income on health plans purchased through HealthCare.gov.

William Parke-Sutherland, government affairs director of Kids Forward, says that the combination of Medicaid cuts and ACA changes could lead as many as 18 million people to lose health care coverage.
“This will mean America will get sicker,” Parke-Sutherland says. “Individuals and families and everybody will have less regular and affordable access to primary care. Uncompensated care is likely to go up. Taking people off of health care coverage doesn’t make their health care needs go away.”
Those factors are likely to drive up health costs and health insurance costs for the rest of the public, according to health care and insurance experts.
Wisconsin Commissioner of Insurance Nathan Hodek says insurers have filed their rate plans for the marketplace with the Office of the Commissioner of Insurance (OCI), and while the new rates won’t be announced until early this fall, “what we are seeing is a trend of higher rates.”
The changes are also likely to show up in the Wisconsin Health Care Stability Plan, Hodek says.
The stability plan provides reinsurance to help absorb the risk for insurers and has helped keep rates 13 to 19 percentage points lower than they would have been without the stability plan, he explains.
State lawmakers and the state budget have given the plan full support, Hodek says. Federal support, however, is based on a formula that includes the size of ACA marketplace enrollment in the state.
If enrollment goes down because of the ACA changes this year, “we are concerned that we’ll also see decreased federal funding” for the stability plan,” Hodek says. If so, the plan will need more from the state “to make sure that program is fully funded and continuing to keep rates more affordable.”
Dr. Jill McMullen, a Tomah family practitioner, says that as insurance rates are driven up, people will be driven out of the insurance marketplace.
“Anything that makes it more expensive to get insurance on the health insurance marketplace means that higher percentage of healthy people, younger people will opt out of getting insurance,” McMullen says.
One consequence is that the people who do buy insurance are likely to be sicker, with higher health care costs, she adds — driving up the cost of insurance premiums even more.
The impact on people’s health may take longer to show up — in the form of uncontrolled, chronic illness such as high blood pressure or diabetes.
“That may not show up in terms of what we call poor outcomes, complications, or difficulties for a few years,” McMullen says. “But then when they do come into place, then they will be more expensive because it’s much more expensive to fix the problem than to prevent it.”
Part One: After years of growth, advocates fear Affordable Care Act is going backward
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