Beth Weddle found the policies and options on too overwhelming when she first tried to sign up for health coverage under the Affordable Care Act (ACA) marketplace in 2015.

But frustrated with her employer-provided health plan and it’s $5,000 deductible, and needing surgeries related to her neck and bladder, the 62-year-old North Charleston property manager knew she had to get a new policy.

“It had come to be $2,700 a quarter to have the insurance, and my deductible was so high that I was paying for insurance and I wasn’t able to use it,” Weddle said. She quickly sought help from a navigator and found a plan that worked for her needs.

Weddle’s ACA marketplace plan with BlueCross BlueShield of South Carolina includes add-ons for dental, vision, and extended hospital stays. It has a deductible of only $250, but a monthly premium of $974.

If that seems high, it won’t get better any time soon. The South Carolina Department of Insurance approved an average rate increase for ACA marketplace policies of 31.33 percent for 2018. BlueCross BlueShield, the only insurer left in the marketplace for the state, justified the increase with a number of reasons. One was the Trump administration’s war against the ACA, evidenced by the White House’s announcement in October that it would end the $7 billion cost-sharing reductions that helped low-income consumers purchase insurance. Another reason was speculation that the individual mandate — the part of the Affordable Care Act that forces Americans to either buy insurance or face a penalty if their income allows it — might soon be repealed.

Weddle, for one, got word that her current monthly premium would jump to about $1,100. Despite the burdensome price tag, she’s “absolutely” happy with the plan.

“No, I’m not happy with the premium at all, but whenever you compare it to what [I] had before, it’s better,” she says.

The uncertainty surrounding President Obama’s most contentious achievement does not seem to deter residents of the Palmetto State from signing up for what’s commonly referred to as Obamacare. The number of people who signed up for marketplace policies in the state went up by 17 percent in the period between Nov. 1 and Dec. 9 as compared to the same period in 2016, according to data from the Palmetto Project, a nonprofit that helps people sign up for plans in the federal marketplace.

“It feels fast and furious to us,” said Palmetto Project director of programs Shelli Quenga in an interview with CP two days before open enrollment ended on Dec. 15. “Our schedules are packed, and our folks are out in the community doing enrollments and providing as much assistance as they can.”

Non-profits, activists, and individual consumers are left with the task of promoting and maintaining a functioning market amidst curveballs from federal and state governments.

“We will not expand Medicaid on President Obama’s watch,” said former Gov. Nikki Haley at the 2013 Conservative Political Action Conference. “We will not expand Medicaid ever.”

Actions that stifle the law have made South Carolina the 45th state in terms of overall access to health care based on six metrics, according to a study released last week by The Commonwealth Fund. The Fund’s senior scientist, David Radley, cites the lack of a Medicaid expansion as the number one cause for the state’s low ranking.

“We see that states that expanded Medicaid had a much greater reduction in the number of uninsured people than states that didn’t,” Radley said in a phone interview with CP.

Ultimately, a combination of a strong state Medicaid program and ACA-enacted protections seem to help consumers the most. That’s exactly what Janene Smith learned when her daughter was born prematurely in January 2011.

Smith was covered through her husband’s small business group plan. When the business switched insurance companies to save money midway through Smith’s pregnancy, ACA provisions meant that the new insurer could not deny Smith coverage based on her pregnancy — considered a pre-existing condition under the old rules.

Insurance helped Smith cover her five-and-a-half week stay in the hospital before an emergency C-section, a value that she estimates to be between $150,000 to $200,000. After her daughter Violet was born, weighing in at one pound, the baby’s 10-month hospital stay was partly covered by Medicaid’s Katie Beckett waiver, a provision created for children with disabilities that kicks in after 30 days of care.

Violet could have easily been denied coverage if it were not for ACA protections against annual dollar limits, leaving a gap of 30 days of hospital costs (which could average in the “hundreds of thousands of dollars,” according to a MUSC spokesperson) before Medicaid stepped in.

“I’m so glad the ACA made it so we could rely on our private insurance,” Smith says. “I would have never expected to have such a terrible experience with health care. You cannot be prepared, without insurance, to face these things.”

Now, more South Carolinians are better equipped to handle emergencies than ever before. Data from The Commonwealth Fund study reveals that South Carolina’s rate of uninsured adults ages 19-64 dropped from 23 percent in 2013 to 15 percent in 2016. At the same time, panic shakes up the market and creates a sort of self-fulfilling prophecy, with insurers expecting a collapse and raising premiums or pulling out of state marketplaces, and healthier, younger consumers opting out of signing up due to fear of rising costs.

“It’s a brand new market, it’s only three years old,” Radley says. “I don’t think people gave the market enough time to mature before they started critiquing it.”

The latest example of federally influenced instability comes from Republicans’ plan to lower the penalty to $0 in the new tax bill, all but repealing the individual mandate. If it passes, the average unsubsidized marketplace premium for a 40-year-old in the state would rise to $923 a month by the year 2027.

Marketplace navigators say consumers are still surprised by how low their premiums are.

“The prices did go up a lot, but the [Advance Premium] tax credit also went up by the same amount, so the consumers are really shielded by that increase,” says Quenga.

In the meantime, 123,000 people in South Carolina remain in the coverage gap — “too rich” for Medicaid and too poor to afford health plans in the ACA marketplace.

“Try telling someone they’re not eligible for care,” Quenga says. “Because Governor Haley decided you didn’t need it.”

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