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Missourians, along with the rest of the nation, are anxiously watching to see what becomes of President Barack Obama’s signature health care law, the Affordable Care Act.

The House and Senate have already passed measures that would allow them to begin peeling back parts of the law through a budget process. The 2010 law brought the country’s uninsured rate to historic lows, and those who gained coverage and are protected by the law’s ban on denying coverage because of pre-existing conditions are waiting to see the Republicans’ plan for a replacement.

People are still signing up for coverage this year. The deadline is Tuesday.

The Affordable Care Act required insurance companies to offer more robust plans with basic consumer protections. At the same time, most Americans were required to buy health insurance or pay a penalty, which was among the least popular provisions.

The idea was that requiring most Americans to obtain coverage would drive young healthy individuals to the online marketplaces to offset the costs of the older and sicker enrollees.

Some individuals were able to afford coverage by qualifying for financial help based on their household income. Some states decided to expand Medicaid so more of their poorest residents had the ability to access care through the state-run insurance program.

Insurance companies complained that those who ended up enrolling in the online marketplaces were older and sicker and caused financial losses for the insurance companies.

Near the end of Obama’s term, many insurers, particularly in Missouri, decided to quit selling plans on the marketplace, leaving consumers with fewer options. However, some reports suggested some insurers bailed on the marketplace when the Obama administration legally challenged two insurance mergers that would reduce the nation’s insurance giants from five to three.

Now, there are signs that the marketplaces have stabilized. But consumers who don’t qualify for financial help have experienced significant increases in premiums in some regions.

Most Americans receive health insurance through their employers, and the law required employer coverage to meet a minimum threshold of benefits, such as no lifetime limits on coverage and providing access to preventive service without copays.

The law required smaller employees with 50 full-time employees or more to offer insurance, which caused some to struggle with the increased costs.

Although the law has remained controversial, uninsured rates have fallen dramatically in a five-year period.

In Missouri, the uninsured rate fell to 9.8 percent in 2015 from 13.2 percent in 2010. Across America, the uninsured rate dropped to 9.4 percent from 15.5 percent over the same period.

In the last figures released during Obama’s time in office, 248,897 Missourians had picked a health insurance plan as of Dec. 24 via HealthCare.gov, a 3.2 percent decline from the same period the previous year.

A majority of them — 59 percent — had incomes between 100 percent and 200 percent of the federal poverty level.

Of the Missourians who enrolled in a plan for 2017, 48 percent picked a different plan. That is the highest percentage of any state, suggesting the insurance carrier dropouts were more acute in Missouri.

A previous Post-Dispatch analysis found that 96 of Missouri’s 114 counties will have only one insurance carrier to choose from when shopping on HealthCare.gov for 2017 coverage.

Meanwhile, in Illinois, 351,270 individuals picked a plan for 2017 coverage by Dec. 24, a nearly 1.3 percent increase from the previous year.

About 41 percent of Illinois enrollees earn between 100 percent and 200 percent of the federal poverty level.

Forty-three percent of Illinois shoppers chose a different plan for 2017 than they had in 2016.

Following are personal stories of people waiting to see what happens with the Affordable Care Act.

Kathy Bingheim, 62, Belleville

Fischer’s Restaurant, which has been operating in its current location on Main Street in Belleville since 1941, will close its doors Feb. 15. Bingheim, a co-owner, points to several reasons why, including the ACA’s mandate that businesses with 50 full-time employees provide health insurance for those employees and their dependents or pay a fine.

Bingheim said when the mandate went into effect in 2015, the restaurant used layoffs and reductions in employees’ hours to avoid the mandate. “I told our insurance carrier that we need to do whatever we need to do to not get involved,” Bingheim said. “It was going to be an extreme amount of money.”

Though the restaurant avoided the costs, she feels the reduction added to a feeling of demise at the restaurant and banquet facility. Five years ago, Lindenwood University bought the adjacent hotel to turn into student housing, Bingheim said, and rumors were the restaurant would be bought and closing, too. People stopped booking the seven banquet rooms.

“I feel that everyone should have health care, but I don’t know if it should the employers’ responsibility all the time, especially if their employees are part time,” said Bingheim, who did not want to say who she voted for. “We need to find some other way.”

Valeria Souza, 36, St. Louis

At age 27, Valeria Souza woke up to find her body completely numb from the waist down on her left side. She was diagnosed with multiple sclerosis, a disease in which the body’s immune system attacks the protective lining in the brain and spinal cord, causing permanent damage to the central nervous system. Some eventually lose the ability to walk, write or swallow, but nearly 10 years later, Souza is in relatively good health and works full time.

Insurance through her employer, Washington University, gives her access to pricey drugs to keep her condition stable. But she fears for the future. She’s the only Portuguese lecturer at WU and her one-year contract is up for renewal each year. What options would she have without the ACA? she wonders. The cost of her medication is nearly twice her annual salary.

She fears she’ll be forced to leave the city she has come to call home. “I’ve really grown to love it here ... and it would really break my heart, but I don’t see how I’d be able to stay here (if the ACA is repealed).”

Toni Deluca, 57, Bunceton, Mo.

Toni Deluca lives in rural Missouri and works part time at a casino, earning $8 an hour. She went almost a decade without seeing a doctor because she didn’t have insurance. She enrolled in a plan on HealthCare.gov for coverage beginning in 2016 after she started experiencing health issues. She qualified for financial assistance and pays about $20 a month on premiums.

She found out one of her kidneys failed and caused a major systemic infection. The kidney was removed, and she has mostly healed. “Once I get over the financial shock, I will be much better.”

She’s worried about the repeal of the Affordable Care Act and again losing access to care. “It’s a direct war on the people of this country who are too poor to afford health care,” Deluca said. “I work very hard, and I’ve basically been told I’m not worth any help with health care.”

Mahina Nightsage, 57, St. Louis

After losing her job in July, Mahina Nightsage, a lifelong St. Louisan, turned to the online marketplace because she couldn’t afford the COBRA plan her employer offered at the end of her employment. She doesn’t have any serious health conditions, but at age 57, she said, “I’m at an age where it’s risky to be without health insurance. If something serious happens to me, I’ll be able to get care.” She qualifies for financial help with her plan and pays about $25 a month in premiums. Now, she doesn’t live with the burden of worrying about getting sick.

Nightsage has a master’s degree in public administration and policy and is working to get back in the nonprofit sector. “Those messages about who is more deserving of help colors our view of what is good public policy,” she said.

Kirsten Pahde, O’Fallon, Mo.

Kirsten Pahde runs her own business, Right at Home, providing at-home assistance to disabled adults and seniors. Under the ACA, Pahde was required to provide health insurance because she employed 50 full-time equivalent employees. Pahde employs 150 caregivers, most part time. The law considers two employees who each work an average of 30 hours per week one full-time employee. She thinks full time should be based on an average of 40 hours a week.

She says the law has put small businesses at a disadvantage. “I don’t have an HR department that can deal with this, so it’s up to me.” It’s costing her more money each year, but she’s reluctant to pass along those added costs to her clients. Pahde said she wishes there was more competition for her health insurance business like she sees when shopping for workers’ compensation and liability insurance. This year she thought about incurring the financial penalty for not offering insurance. It would have been less costly to pay the penalty, she said. “But that’s just not who we want to be.”

Steve Taylor, 63, Neosho, Mo.

The Affordable Care Act allowed Taylor to retire early as a custodian for Neosho High School in Newton County, near the Oklahoma border. Taylor was a few years away from qualifying for Medicare, but the work was getting too painful.

Taylor has worked since he was 13, but he has developed degenerative bone disease, scoliosis, spinal stenosis and severe arthritis, he said. “I couldn’t have done it for much longer.”

He retired last March and got insurance the following month through the health care exchange. Earning only disability, he qualified for assistance to help cover the cost. He paid $125 a month for the insurance, and this year he will pay only $67 a month, he said.

Taylor said he is prone to extremely painful intestinal obstructions that require expensive emergency care. An episode could occur at any time. He fears that he will not be able to afford insurance, and he could get hit with an emergency. When he suffered an obstruction last fall, the bill to insurance for a one-day hospital stay was $15,000, he said. “That would’ve wiped me out.”

He also worries about keeping his diabetes and blood pressure under control, which he does with medication and regular doctor visits.

Taylor says he is conservative and has mostly voted Republican in the past but couldn’t vote for either candidate in November. He said he thinks the Republicans’ effort to scrap Obamacare without a replacement is reckless.

“You don’t know how much it is going to be or what they are going to replace it with,” he said. “They are so out of touch with people on the cost of things.”

Kris Kleindienst, 63, St. Louis

Kleindienst and her husband, Jarek Steele, own Left Bank Books, an independent book store with about a dozen full-time employees in the city’s Central West End. They’ve owned the store for 42 years and have always provided health insurance to their employees.

In the years preceding Obamacare, however, it was becoming more difficult, Kleindienst said. They could only afford to purchase a policy with a high deductible, which made accessing care very difficult for their workers.

“It was getting so expensive, it was a constant source of financial stress for us,” she said. “We had hours of gut-wrenching number-crunching to figure out what we could do.”

The legislation created a special insurance marketplace — called the Small Business Health Options Program — open only to businesses of this size. It provides small employers increased purchasing power to obtain better choices for coverage. Businesses purchasing coverage through the marketplace can also qualify for tax credits worth up to 50 percent.

“When we were able to access the Affordable Care Act, we were able to purchase insurance that could support our needs and is usable by our staff,” said Kleindienst, a Hillary Clinton supporter. “We were able to afford a deductible that made more sense.”

Kleindienst fears her business will return to the prospect of increasingly expensive policies that cover fewer things for fewer people.

“There’s more emphasis on wellness and preventive care, and that’s just common sense,” Kleindienst said. “I don’t understand why a government would be hostile to the health of its citizens, and it’s going to be more costly in the long run for our country.”

Tami Heaton, 44, St. Louis

“I’m freaking out. I own a small business,” Heaton said. “Without an employer to put me on a plan, I’m completely terrified.”

Three years ago, Heaton started her own marketing agency, called Undeniable. She fears her health coverage will be denied, however, without the ACA protecting her from being denied coverage or charged more because of her health status.

She has been able to get affordable insurance on the marketplace despite being self-employed, and despite treatment of depression, Hashimoto’s disease, polycystic ovarian syndrome and fibroid tumors.

“It’s not even about affording insurance, it’s about being able to get insurance at all,” said Heaton, who voted for Hillary Clinton.

If replacement legislation doesn’t offer the same cost protections, she will have to try to find a job at a big agency. She had dreamed of owning her own business, though. “I don’t want to give up.”

Tina Friederich, 63, Fairview Heights

Friederich watched her premiums rise and her coverage get worse under the ACA. She said she thinks it did nothing to control costs and improve access to care for middle-class workers.

Friederich, who works as an insurance agent in a small office, has been getting health insurance on her own for nearly nine years, since her husband became eligible for Medicare. She signed up through the marketplace, but her income was too high to qualify for a subsidy. Last year she paid $789 a month, and this year she pays over $1,000 a month.

“Obamacare is wonderful for the people always getting everything for free, but it’s not good for the blue-collar middle-class worker that is slapped with a monthly premium they struggle to have to pay,” she said. “But you have to pay it, or they will penalize you on taxes, so now you’re frustrated and your anxiety is so high because you are being pushed against a wall.”

Last fall, Friederich fell and fractured her leg. Then after the start of the new year, she discovered her nearby hospital and primary care doctor were no longer considered in-network under her plan. She must travel to St. Louis for physical therapy and treatment for blood cots.

“Losing Obamacare in my estimation is not a big problem,” she said. “It’s put me in worse shape.”

Friederich, who did not want to say who she voted for, is anxious to learn details of a replacement plan, she said. “This is a terrible situation we are in; and we need to get it corrected, because for the middle class, it is just killing them.”


EDITOR'S NOTE: This story has been updated. The last names of Valeria Souza and Tina Friederich were misspelled in an earlier version.

Samantha Liss • 314-340-8017

@samanthann on Twitter

sliss@post-dispatch.com