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Montanans’ Coverage, Hospital Revenue At Stake As Supreme Court Considers Affordable Care Act

Chelsia Rice wears a face mask and hands a magazine to a customer underneath a plexiglass shield.
Kevin Trevellyan
Yellowstone Public Radio
Montana Book Company co-owner Chelsia Rice rings up a customer on Nov. 12, 2020.

As demand for federally subsidized health care significantly rises in Montana for the first time in several years, the U.S. Supreme Court is considering whether to strike down the law that enabled expanded coverage. Health insurance experts liken a complete overturn of the Affordable Care Act (ACA) to a “perfect storm” that would cause “complete chaos.”

Chelsia Rice co owns Montana Book Company in downtown Helena.

She says she doesn’t run the store to get rich, though. Diagnosed with bladder cancer in 2012, and denied health insurance coverage for having a pre existing condition, Rice initially had to crowdsource treatment funding and seek reimbursement through whatever means possible.

“So on top of fearing for my life, literally, I had to spend all of my time during my acute care through chemo and surgery appealing for care to insurance companies,” Rice said.

Now, Rice is one of the roughly 44,000 Montanans covered by insurance through the ACA marketplace, which went online in 2014.

“And I jumped right on,” Rice said.

But the law is now under review for the third time by the Supreme Court, which last week heard arguments for a challenge brought forth by GOP led states and President Donald Trump’s administration.

At stake is the possibility of the court striking the entire ACA down, which industry watchers say could lead to increased numbers of uninsured Montanans, fewer federal dollars coming into the state and a health care system without enough revenue to support itself.

While Montana did not sign onto the lawsuit before the nation's high court, the ACA has remained contentious among many Republican elected officials who've advocated for repealing the law, saying it doesn't do enough to lower the costs of health care.

With her ACA subsidies and protections for preexisting conditions on the line, Rice says watching the legal wrangling feels like being trapped in an endless game of bumper cars.

“We're just patients in the middle of this really divisive issue. And we're exhausted,” Rice said.

Rice says some of her employees are among the 88,000 people covered through Medicaid expansion, which the Montana Legislature first passed in 2015 using the ACA.

Expanded Medicaidenrollment has been rising during the pandemic for the first time since early 2019. University of Montana economist Bryce Ward says that’s likely tied to higher than average unemployment during the pandemic and lapsed federal coronavirus relief.

“Particularly without the continuation of enhanced unemployment insurance,” Ward said.

Montanan’s reliance on Medicaid expansion is why the state would see one of the largest increases in uninsured residents if the ACA is struck down: 155 percent, according to an October study by the Robert Wood Johnson Foundation.

Ward says the Supreme Court could issue a narrower ruling to only get rid of the ACA’s requirement that most citizens have health insurance, leaving the rest of the law intact. He says that wouldn’t have much of an effect in the Treasure State because Congress already zeroed out the penalty in 2017.

In contrast, he says striking the entire ACA down would amount to severing key sections of a much needed safety net.

“When people don't have insurance they end up sicker and they're more likely to end up dead,” Ward said.

Cynthia Cox, vice president of the Kaiser Family Foundation’s ACA program, says overturning the law would be particularly bad news for self employed farmers and small business owners outside major cities.

“On average people who live in rural areas tend to be older. They also tend to have more pre-existing conditions. So that means they're going to be more reliant on hospital care, especially during the pandemic,” Cox said.

Health insurance premiums were steadily rising in the U.S. before the ACA was enacted, and the law didn’t stem the tide. But economist Ward says the tradeoff with striking down the ACA, and its protections for preexisting conditions, is having fewer healthy people subsidizing health care for everyone else.

“If you're old and sick, you're going to pay more. And if you're young and healthy, you'll probably pay less,” Ward said.

Hospitals also stand to lose if the ACA is overturned, says Montana Healthcare Foundation CEO Aaron Wernham.

Without federal funding tied to Medicaid expansion, the Robert Wood Johnson Foundation study says Montana would see one of the steepest drops in hospital revenue among all states in 2022: more than $500 million. Hospitals in Medicaid expansion states like Montana are about 6 times less likely to close than hospitals in non expansion states, according to a 2018 study published in the journal Health Affairs.

“If the ACA were just simply ended right in the middle of a pandemic, it's really hard to imagine how the hospitals and clinics, particularly in rural Montana, would stay afloat,” Wernham said

Bryce Ward, the UM economist, says federal dollars tied to the ACA and Medicaid expansion power a sizable chunk of the state economy. The Robert Wood Johnson Foundation study says about half of the Treasure State’s projected federal funding in 2022, at $1.2 billion, will come from the programs.

“That works exactly like if a factory came here and opened up. It brings a bunch of money into the state that wouldn't otherwise be here. That money then ripples through the economy creating jobs and income for lots of other people,” Ward said.

NPR reports Supreme Court justices appeared skeptical of ACA challengers’ arguments during last week’s hearing. But Cox with the Kaiser Family Foundation says that doesn’t necessarily guarantee a positive ruling for the law’s supporters.

“There have been many curveballs in the past, including specifically with the ACA, where the justices have ruled in a way that people did not expect,” Cox said.

The Supreme Court is expected to rule on the ACA by summer.