“Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

In a Facebook post, Oct. 20, 2020

A viral post claims that former President Barack Obama’s health insurance law penalized a family a large amount of money for not buying health insurance and that President Donald Trump was responsible for stopping the practice.

The post features writing on the back of a car windshield that says, “Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about .) We found a similar post on Instagram.

The post appears to refer to the penalty, a tax under the Affordable Care Act placed on those who chose not to get health insurance. At the end of 2017, Republican-backed tax legislation, also supported by Trump, zeroed out the fine. Beginning in 2019, people could no longer be penalized for not having health insurance. Thus, the mandate hasn’t been in effect for about two years.

But $10,000 — the hefty amount this family was supposedly penalized for not having health insurance — raised questions for us. And was that money really used to pay for other people’s health insurance? We decided to look into it.

The History of the Individual Mandate

The ACA was implemented in 2010 during the Obama administration. The aim of the health care law — often referred to as Obamacare — was to ensure everyone had health insurance.

To that end, the law used what health policy experts call a approach. For low-income and middle-income individuals who had difficulty affording health insurance, the government would provide tax subsidies to reduce the cost of insurance — that was the carrot. And to make sure everyone enrolled in a health insurance plan, those who didn’t sign up were fined, under what was known as the individual mandate provision. That was the stick.

The individual mandate, which didn’t kick in until 2014, was unpopular with the American public, according to polling at the time. A showed that 55% of Americans supported the idea of eliminating the requirement that everyone must have health insurance or pay a fine. (KHN is an editorially independent program of KFF.)

Although one of was to repeal and replace the ACA, efforts to do so failed in 2017 when the Republican-held Senate failed to get the votes it needed.

Instead, in their , Republicans set the penalty for the individual mandate to $0. Starting in 2019, Americans no longer had to pay a fine for not having health insurance. Trump signed the 2017 tax bill into law. So, it is true that Trump and congressional Republicans were responsible for neutralizing the penalty.

However, experts pointed out that the individual mandate is still in place, it’s just that the penalty is set to $0. In fact, the end of the penalty is behind the justification for a attempting to overturn the ACA, brought by Republican attorneys general and supported by the Trump administration. The plaintiffs argue that the health care law is no longer constitutional because the penalty no longer for the federal government. The Supreme Court will hear oral arguments on the case Nov. 10.

The Math

The viral social media posts claim that the family “couldn’t afford health insurance” and was penalized $10,000.

Health policy experts told us that while the social media post doesn’t give all the specifics needed to know if this was absolutely true, it seems unlikely a penalty would be this high.

One issue is the post doesn’t specify whether the $10,000 penalty was incurred in one year or over multiple years. It also doesn’t say how many individuals were part of the family.

Assuming the $10,000 penalty was incurred in one year, multiple experts told us that the family would have had an annual income above $400,000 and at least one person would have had to be uninsured for the entire year. That math is based on the penalty structure , the last year the mandate was enforced.

In 2018, the penalty was calculated one of two ways. The fine was the greater of the two results:

• $695 for an adult and $347.50 for a child, up to a max of $2,085 per family annually, or
• 2.5% of family income above a certain tax filing threshold ( the tax filing threshold was $10,650 for a single individual or $21,300 for joint filers in 2018).

The first way to calculate the penalty obviously doesn’t apply since the max was $2,085 per year. So, the second would be the only way to get a $10,000-a-year penalty. To arrive at such a number, you would have to take 2.5% of the family’s income. In this case, 2.5% of a $400,000 income gets you close to $10,000.

And experts said it is highly unlikely that a family with a $400,000 income would have had difficulty affording health insurance.

“So I would highly doubt the veracity of what is written on that car windshield,”, a senior fellow in health reform and private insurance at KFF wrote in an email. “People with that much income almost always have job-based health benefits and, if not, generally are inclined to insure themselves very well in order to protect assets — otherwise, if hospitalized and uninsured, they could owe many multiples of the penalty amount in medical bills.”

, a health policy professor at the University of North Carolina-Chapel Hill, also pointed out that a $10,000 penalty would have been rare.

“Very few American families would have paid anything close to that amount in penalty for not having insurance — the average penalty per person in 2017 was around $700,” Oberlander wrote in an email. “Moreover, only a small percentage of Americans ever paid the penalty for not having health insurance — in 2017, 4.6 million persons,” or about 1% of the population. (In 2017, 325 million people lived in the U.S., according to the .)

It’s also unclear whether it would have just been cheaper for the family to pay for health insurance rather than incur a $10,000 penalty, said , a health policy scholar at the Brookings Institution.

“It depends on the ages of the members of the family, where they live, what year (or years) we are talking about, and the family’s income,” Fiedler wrote in an email. “There are conceivable scenarios where the family could have found a bronze plan for $10k or less. But there are also plenty of plausible scenarios where they could not have. Without knowing more about the family’s circumstances, it’s just hard to say with any confidence.”

Where Did the Penalty Money Go?

Experts also told us that the post’s assertion that the penalties paid for not having health insurance were directly applied to fund other people’s health insurance was off the mark.

The individual mandate penalties were assessed during each annual tax filing, and then payments were made the year after there was a lapse in insurance coverage.

Those penalties were collected just like any other tax payment.

“As a strict accounting, keep in mind, everything gets dumped into the Treasury regardless of the source, and then it is appropriated out of the Treasury by Congress,” said , a senior research fellow in health care policy at the Heritage Foundation. “It’s not like money goes into one account and then another.”

So, while it’s certainly possible that the penalty money could have been used to help pay for some of the ACA subsidies for other people, the money also could have gone to any other number of things the government pays for, like the military, disaster relief or education.

“You don’t know exactly where your taxes or penalties go,” said , an assistant professor in economics at Emory University. “Maybe a small share went to Obamacare, but that’s a stretch. You can’t track where every dollar you spent on your taxes is going.”

It’s also misleading to say that other individuals received “free Obamacare” from the penalty payment. The experts said that while Medicaid expansion, which was a part of the ACA, does provide health care coverage for low-income people who are eligible, those who bought insurance on the marketplace would still likely have paid for some part of their coverage after subsidies were applied.

Our Ruling

A viral social media post claims that a family was penalized $10,000 for not being able to afford health insurance. It also claimed the penalty money was taken to pay for others’ “free ObamaCare” and Trump stopped that practice.

It is true that Trump and Congress did zero out the individual mandate requirement, so people could no longer be penalized for not having health insurance. But after that, skepticism abounds.

For instance, it’s very unlikely that a family would face a $10,000 penalty in one year. Moreover, if such a family did face this penalty for not having health insurance, they would likely be in a high-income bracket for which health insurance tends to come from an employer or be affordable. And the charge that the penalty was used to provide “free coverage” for others doesn’t fit with federal accounting processes.

Experts said, though, that the lack of specifics about this family’s situation makes it difficult to be completely definitive.

We rate this claim Mostly False.

SOURCES

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At least it seemed that two of the three appeals court judges were during oral arguments in the case, , in July.

Trump administration health officials have said they will continue to enforce the health law pending a final ruling from the Supreme Court. But that is not a guarantee that President Donald Trump won’t change his mind. That’s what in canceling some payments to health insurers.

There’s no doubt that invalidating the ACA in whole or in large part would have a dramatic effect on the nation’s health system ― and not just for those 20 million or so Americans whose coverage directly flows from the law.

“Billions of dollars of private and public investment ― impacting every corner of the American health system ― have been made based on the existence of the ACA,” said a . Declaring the law null and void “would upend all of those settled expectations and throw healthcare markets, and 1/5 of the economy, into chaos,” they wrote.

And with health care continuing to be a top issue in the presidential campaign, both Democrats and Republicans could find themselves scrambling for a fast stopgap solution if the law were to suddenly go away.

First, Some Background

At issue in the ACA case is whether the language in the 2017 GOP tax bill reducing to zero the tax penalty imposed for failing to have health insurance should render the rest of the law invalid.

A group of Republican state attorneys general and governors say it should. They argued that without the tax, the Supreme Court’s justification for upholding the law in 2012 no longer exists and so the law is now unconstitutional. U.S. District Judge Reed O’Connor last December.

Supporters of the law ― including not just Democratic attorneys general, but also the Democratic-led U.S. House ― and bipartisan groups of legal and health policy scholars say that’s just nonsense, that the law not only can function without the individual mandate penalty but is functioning now.

What would go away ― meaning which provisions consumers have become accustomed to ― if the law is eventually struck down? Let’s take a look.

Insurance Protections

Most people think the health law directly affects only those Americans who purchase their own insurance through the exchanges the law created (and who get subsidies if their incomes are between 100% and 400% of the poverty level). That’s about 10 million to 12 million households.

But many of the insurance protections in the law also protect those who have insurance through their jobs. These provisions include allowing adult children to stay on their parents’ health plans and requiring that insurers cover people who have preexisting health conditions at no additional charge to those patients. The law also requires that ACA-compliant policies provide preventive care with no out-of-pocket cost, and bans annual and lifetime insurance coverage limits.

It also . That makes for a lot of chaos right there should the entire law disappear. But there is more.

Medicare And Medicaid

Most people with a passing familiarity with the health law know it expanded the Medicaid program for those with incomes up to 138% of the poverty level (at least in states that opted into the program).

The law also made big changes to the Medicare program, including closing the notorious “doughnut hole” that left some seniors with big drug bills despite having insurance. The ACA also extended coverage of more preventive benefits for people with Medicare coverage.

Generic Biologics

An important, though frequently overlooked, portion of the health law created the first legal framework and regulatory pathway for copies of expensive, already FDA-approved biologic drugs, called biosimilars, to reach the market. Biologic drugs are among the most expensive medications and treat life-threatening ailments such as cancer, rheumatoid arthritis and macular degeneration. It is unclear what would happen to the stream of biosimilars already approved if the law is struck down ― will their approvals be revoked? What about medications currently in the approval pipeline?

Funding For The Indian Health Service And Training More Health Professionals

Among other little-known features of the ACA is a provision that permanently authorized the U.S. Indian Health Service, which provides health coverage for more than . An overturn of the law could leave in doubt the legality of some of the program’s operations.

Here’s one more provision you may not have thought about. On the theory that if more people have health insurance more people will seek medical care, the ACA has an entire section devoted to increasing the supply of not just physicians, but nurses, therapists, dentists and community health centers. Many of these training programs could founder if the ACA is overturned.

And those now-ubiquitous on restaurant menus? Those are there because of the ACA. Some people may not be sad to see those go away. But if the ACA is invalidated, the health system will likely change in ways that no one can predict.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

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Can’t see the audio player?Ìý.

The Affordable Care Act was back in court again this week — this time before a three-judge panel at the 5th Circuit Court of Appeals in New Orleans.

A lower court ruled last December that the entire ACA is now unconstitutional because Congress in its 2017 tax bill eliminated the tax penalty for failing to maintain health insurance. It appeared that two of the three judges — both appointed by Republicans — seemed sympathetic to the arguments made by the plaintiffs, mostly attorneys general from Republican-led states.

Meanwhile, President Donald Trump on Wednesday signed an executive order calling for major changes in how the government pays for care for people with kidney disease, including making it financially easier for people to donate kidneys.

This week’s panelists are Julie Rovner from Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of the Washington Examiner and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

• Many people who have employer-based insurance and don’t get coverage from the ACA don’t realize that key protections they now enjoy come from that law. These include provisions such as allowing adult children to stay on their parents’ plan until age 26 and barring insurers from using annual coverage caps or lifetime limits.
• The legal challenge to the ACA by conservative states is a real threat to the law, but the case could still be resolved in a wide variety of ways. It is likely, however, to be appealed to the Supreme Court at some point.
• The Trump administration’s plan to revamp how kidney patients get care appears to have satisfied many different stakeholders and is being widely hailed — except by the two giant firms that profit from clinic-based kidney dialysis and the status quo.
• The administration this week had two setbacks on its efforts to slow the rise in prescription drug costs. A court, ruling on procedural grounds, set aside the government’s plan to require drugmakers to add prices to television ads. Also, the administration announced it is shelving its rule that consumers get some of the rebates from drugmakers that pharmacy benefit managers negotiate for insurers.
• The legal challenge to the administration’s rule that would restrict doctors and other health professionals who receive Title X federal family planning grants from referring women for an abortion has created chaos among those health care providers because the rules have been on and off again. But for groups supporting the right to an abortion, time is the name of the game. They hope to run out the clock and elect a different president in 2020.

Also this week, Rovner interviews University of Michigan law professor Nicholas Bagley about the latest legal threat to the ACA.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Washington Post’s “” by Christopher Rowland

Joanne Kenen: The Los Angeles Times’ “,” by Noam Levey

Alice Miranda Ollstein: CNN’s “ by Eric Bradner

Kimberly Leonard: Vox’s “” by Dylan Matthews

And

Fox News’ “” by Ed Henry

To hear all our podcasts,Ìýclick here.

And subscribe to What the Health? onÌý,Ìý,Ìý,Ìý, or .

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The fate of the Affordable Care Act is again on the line Tuesday, as a federal appeals court in New Orleans takes up a case in which a lower court judge has already ruled the massive health law unconstitutional.

If the lower court ruling is ultimately upheld, the case, , has the potential to shake the nation’s entire health care system to its core. Not only would such a decision immediately affect the estimated 20 million people who get their health coverage through programs created under the law, ending the ACA would also create chaos in other parts of the health care system that were directly or indirectly changed under the law’s multitude of provisions, such as calorie counts on menus, a pathway for approval of generic copies of expensive biologic drugs and, perhaps most important politically, protections for people with preexisting conditions.

“Billions of dollars of private and public investment — impacting every corner of the American health system — have been made based on the existence of the ACA,” said a filed by a bipartisan group of economists and other health policy experts to the 5th Circuit Court of Appeals. Upholding the lower court’s ruling, the scholars added, “would upend all of those settled expectations and throw healthcare markets, and 1/5 of the economy, into chaos.”

Here are five important things to know about the case:

It was prompted by the tax bill Republicans passed in 2017.

The big tax cut bill passed by the GOP Congress in December 2017 included in the ACA for failure to maintain health insurance coverage. The lawsuit was filed in February 2018 by a group of Republican attorneys general and two governors. They argued that since the Supreme Court had upheld the ACA in 2012 specifically because it was a valid exercise of Congress’ taxing power, taking the tax away makes the entire rest of the law unconstitutional.

Last December, Judge Reed C. O’Connor agreed with the Republicans. “In some ways the question before the court involves the intent of both the 2010 and 2017 Congresses,” O’Connor wrote in his decision. “The former enacted the ACA. The latter sawed off the last leg it stood on.”

State and federal Democrats are defending the law.

Arguing that the rest of the law remains valid is a group of Democratic attorneys general, led by California’s Xavier Becerra.

“Our argument is simple,” said Becerra . “The health and wellbeing of nearly every American is at risk. Healthcare can mean the difference between life and death, financial stability and bankruptcy. Our families’ wellbeing should not be treated as a political football.”

The Democratic-led has also been granted “intervenor” status in the case.

The Trump administration has taken several positions on the lawsuit.

The defendant in the case is technically the Trump administration. Traditionally, an administration, even one that did not work to pass the law in question, defends existing law in court.

Not this time. And it is still unclear exactly what the administration’s position is on the lawsuit. “They have changed their position several times,” Sen. Chris Murphy (D-Conn.) told reporters on a conference call Monday.

When the administration first weighed in on the case, in June 2018, it said it believed that without the tax penalty only the provisions most closely connected to that penalty — including requiring insurers to sell policies to people with preexisting conditions — should be struck down. The rest of the law should stay, the Justice Department argued.

After O’Connor’s ruling, however, the administration changed its mind. In March, a spokeswoman for the Justice Department said it had “determined that the district court’s comprehensive opinion came to the correct conclusion and will support it on appeal.”

Now it appears the administration is shifting its opinion again. In a late last week, Justice Department attorneys argued that perhaps the health law should be invalidated only in the GOP states that are suing, rather than all states. It is unclear how that would work.

Legal scholars — including those who oppose the ACA — consider the case dubious.

In a brief filed with the appeals court, from both sides of the fight over the ACA agreed that the lawsuit’s underlying claim makes no sense.

In passing the tax bill that eliminated the ACA’s tax penalty but nothing else, Congress “made the judgment that it wanted the insurance reforms and the rest of the ACA to remain even in the absence of an enforceable insurance mandate,” wrote law professors Jonathan Adler, Nicholas Bagley, Abbe Gluck and Ilya Somin. Bagley and Gluck are supporters of the ACA; Adler and Somin have argued against it in earlier suits. “Congress itself — not a court — eliminated enforcement of the provision in question and left the rest of the statute standing. So congressional intent is clear.”

It could end up in front of the Supreme Court right in the middle of the 2020 election.

Depending on what happens at the appeals court level, the health law could be back in front of the Supreme Court — which has upheld the health law on other grounds in 2012 and 2015 — and land there in the middle of next year’s presidential campaign.

Democrats are already sharpening their rhetoric for that possibility.

“President Trump and Republicans are playing a very dangerous game with people’s lives,” Senate Minority Leader Chuck Schumer told reporters on a conference call Monday.

Murphy said he is most concerned that if the lower court ruling is upheld and the health law struck down, Republicans “won’t be able to come up with a plan” to put the health care system back together.

“Republicans tried to come up with a replacement plan for 10 years, and they couldn’t do it,” he said.

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The number of new enrollees in Covered California health plans plunged by nearly a quarter this year, largely because of the elimination of the federal tax penalty for people without insurance, officials announced Wednesday.

The decrease was steeper than expected — and larger than the drop in new enrollment in the federal marketplace, healthcare.gov. It occurred even as Covered California, the state health insurance exchange, spent to entice people to sign up for coverage during the open-enrollment period that ended Jan. 15.

Overall, about 1.5 million Californians selected a health plan for 2019 coverage, a figure similar to last year’s, the agency said. But new enrollment fell by 23.7 percent, with 295,980 sign-ups, compared with 388,344 last year. Meanwhile, plan renewals remained strong, posting a 7.5 percent increase.

“Recent actions at the federal level appear to be causing large drops in enrollment that will lead to more uninsured and higher premiums for all Californians,” said Covered California Executive Director Peter Lee.

“The federal removal of the individual mandate penalty appears to have had a substantial impact on the number of new consumers signing up for coverage,” he said.

New enrollment in the federal health insurance exchange, healthcare.gov, which serves 39 states, fell to 2.1 million, down 15.8 percent from the previous year, from the Centers for Medicare & Medicaid Services.

Total enrollment dropped to 8.4 million from roughly 8.7 million in 2018.Ìý

The drop in enrollment, especially if fewer healthy people are signing up, could lead to higher premiums, explained David Panush, president of California Health Policy Strategies, a Sacramento-based consulting firm, and former external affairs director for Covered California.

“When you have fewer healthy people enrolling, that has an effect on the risk pool. And when you have a sicker pool that means premiums go up, although so do subsidies,” Panush said. “But for people on the non-subsidized side, that’s a big deal.”

In fact, premium rates have already increased because of the elimination of the penalty for not having health coverage, which took effect this year. Covered California said the average rate increase for 2019 would have been — instead of 8.7 percent — if the individual mandate penalty hadn’t been axed as part of the 2017 Republican tax bill.

, California Democratic Gov. Gavin Newsom called for a state-based mandate, which would require all Californians to have health coverage. The legislature would have to approve it, which isn’t guaranteed even with a Democratic majority because the mandate was one of the least popular provisions of the Affordable Care Act.

Penalizing uninsured Californians in this way could raise roughly $500 million a year, Newsom said when he earlier this month. That money, he suggested, could be used to create state subsidies for Californians who struggle to afford health insurance.

New enrollment fell even though Covered California spent $40 million on ads during the latest open-enrollment period, out of a monster $107 million marketing budget. By comparison, the federal government spent $10 million on advertising.

While advertising is important, it alone doesn’t do the trick, experts say. “You need all three — affordability, a mandate and advertising,” Panush said.

Kevin Knauss, an insurance agent in Granite Bay, Calif., said he believes affordability played the biggest role in the drop in new enrollment. He added that a strong economy means that more people have job-based health insurance, and so they don’t need to buy plans on the open market.

“In my experience, high rates are the primary driver for people not signing up,” not the end of the penalty, Knauss said. “They say ‘I can’t do it, I can’t afford it.’”

At the same time, Knauss said the drop in new enrollment is almost expected, given the evolution of the market.

“We have to remember the market is saturated — Covered California has been around for a while, and people that want to buy have probably already made that decision,” he said.

Doreena Wong, a project director for Asian Americans Advancing Justice, a civil rights organization, said it was harder this year to persuade people to enroll and renew their coverage.

The group, part of a statewide collaborative, receives grant money from Covered California for outreach and enrollment, particularly in immigrant and low-income communities.

“It’s hard to know exactly why, but we have seen at least a 10 percent drop ourselves,” she said.

Wong blames the elimination of the penalty coupled with fear among immigrant communities as reasons for the decline in new enrollment.

She pointed to the proposed “public charge” rule change, which is awaiting final action by the U.S. Department of Homeland Security. The change would allow the federal government to consider legal immigrants’ use of an expanded list of public benefit programs, including Medicaid, food stamps and Section 8 housing, as a reason to deny lawful permanent residency — also known as having a . Medicaid is the state-federal health insurance program for low-income people.

Although federal tax credits for plans bought through Covered California are not included in the list of public programs that would be considered, there’s so much confusion among immigrants that some chose to skip enrolling in coverage, Wong said.

“There are fears that communities are experiencing,” she said. “The proposed public charge rule, for example — we’ve gotten a lot of calls about that.”

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The embraces a state health insurance mandate, beefed-up insurance subsidies, coverage for undocumented immigrants and six months of paid parental leave — not unexpected from a Democrat who campaigned on expanding health care and criticized President Donald Trump and congressional Republicans for eroding the Affordable Care Act.

The new governor declared his $209 billion state budget proposal, of which health care accounts for nearly 30 percent, “a reflection of our values.”

Newsom’s 2019-20 budget plan is just the starting point. He must negotiate with the legislature on a final budget by June 15 — so some of these proposals are certain to change or be eliminated.

“These are first-in-the-nation, new steps to provide new help for people to afford access and coverage,” said Anthony Wright, executive director of Health Access California. “That’s a good thing.”

Lee Ohanian, a senior fellow at the conservative Hoover Institution and an economics professor at the University of California-Los Angeles, countered that California would need to cut costs if it wants pay for Newsom’s initiatives.

“Newsom has a long list of very expensive things he would like to do,” Ohanian said. “He’s going to have to take money from something else.”

While the Democratic legislature is generally supportive of expanding health care coverage, there are both political and financial obstacles to the sweeping proposals that Newsom has laid out.

The governor’s plan to create subsidies for middle-class Californians, for example, relies on lawmakers approving a financial penalty on the uninsured, which was an unpopular provision in the Affordable Care Act. Newsom estimated the penalty would raise roughly $500 million a year.

The estimated subsidies would be modest. For an individual who earns between 250 and 400 percent of the federal poverty level — or between about $30,350 and $48,560 — the subsidies would average about $10 a month, said Newsom cabinet secretary Ana Matosantos. Although these Californians already qualify for a federal tax credit under the Affordable Care Act, many still can’t afford their insurance.

For individuals who make between 400 and 600 percent of the federal poverty level — or between about $48,560 and $72,840 — and therefore don’t qualify for federal tax credits, the state subsidy would come to about $70 a month on average, depending on location and premium costs, Matosantos said.

“It will certainly be a help to some people,” but doesn’t do a lot to address overall affordability, said Larry Levitt, a senior vice president at the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Congress eliminated the for uninsured people, effective this year, as part of its 2017 tax bill. In response, New Jersey, Vermont and the District of Columbia have passed their own mandates in an effort to keep healthy enrollees from dumping coverage. A third state, Massachusetts, already had a state mandate.

Newsom argued during his budget briefing that, unlike the federal tax penalty, the California penalty would not be considered a tax and would only need a simple majority to win legislative approval.

“California does not need to go in the direction of the rest of the country,” he said.

Whether lawmakers will embrace the penalty is unclear, even though Democrats have supermajorities in both houses. California voters last year a Democratic state senator who voted for a gas tax increase.

Assembly Health Committee Chair Jim Wood acknowledged the vote could be “a difficult one.” ÌýThe Healdsburg Democrat, who is carrying a bill to create state-based subsidies, said he is hopeful his colleagues will consider all the governor’s health care proposals as a revenue-neutral package.

For example, that Newsom signed earlier this week that directs state agencies to work together to negotiate prescription drug prices could save the state hundreds of millions of dollars, Wood said. Those savings, along with the revenue from the health insurance penalty, could help pay for subsidies, or for coverage under Medi-Cal for unauthorized immigrant young adults, he said.

“It’s kind of a three-dimensional chess game right now in trying to put all these things together,” Wood said.

Lawmakers last year considered extending full Medi-Cal benefits to both young adults and seniors who are in the country illegally. But the proposals were dropped during budget negotiations, in part because former Gov. Jerry Brown balked at the cost.

Medi-Cal is California’s version of the federal Medicaid program.

Newsom’s budget includes $260 million to pay for Medi-Cal for undocumented immigrant adults ages 19 to 25. California already coversÌýall kids up to age 19, regardless of their immigration status. Newsom described the expansion as the right thing to do from both a moral and a financial standpoint.

U.S. Sen. Bill Cassidy (R-La.) on Tuesday announced he would introduce legislation in Congress prohibiting California from using federal dollars to provide Medi-Cal to undocumented immigrants. However, Newsom’s budget would use state dollars to pay for the expansion, just as state funds pay for undocumented children’s coverage. Cassidy’s spokesman did not return an email seeking comment.

Among the health-related proposals that still need more vetting is Newsom’s plan to expand the state’s program from six weeks to six months.

Details were scarce, and the governor said a task force is studying how to pay for it — whether through increased taxes on employers or using general fund dollars. That too could be a sticking point among lawmakers.

“I am a big proponent of parents spending time with newborn children,” said Assemblyman Jay Obernolte, the ranking Republican on the Assembly Budget Committee. “However, I am absolutely opposed to forcing employers to do that.”

Newsom’s budget also includes several other health-related initiatives, including:

• $25 million to improve the detection and treatment of early psychosis, which includes symptoms such as hallucinations and disorganized thoughts and behaviors.
• $10 million to provide clean water, including bottled or hauled water, to communities during emergencies.
• $100 million for programs that coordinate health and social services and help provide housing for people with mental illness.
• $60 million to increase developmental screenings for children at 9, 18 and 30 months of age.
• $342.3 million to restore recent cuts in the In-Home Supportive Services program, which provides in-home care and transportation to low-income older people or those with disabilities.

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Reaction is still coming in about last week’s federal court ruling that declared the Affordable Care Act unconstitutional. And nearly final numbers for insurance sign-ups at healthcare.gov were surprisingly brisk despite the elimination of the health law’s tax penalty for not having insurance and a dramatically shrunken budget for outreach and enrollment assistance.

The panelists for this year-end edition of KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Kimberly Leonard of the Washington Examiner. Listen in to hear their choices for most important health policy story of the year, most overhyped and nerdiest, among others.

Also, Rovner interviews Frank Luntz, the Republican pollster and strategist, about the future of the health care issue for the GOP.

Among the takeaways:

• As a response to the court decision invalidating the ACA, Senate Democrats tried to force a vote that would have Congress intervene in the lawsuit in support of the law. Republicans rebuffed that effort.
• But for Republicans, the court ruling could be a minefield because Republican state officials brought the case and it could impact many popular provisions of the law. A number of GOP lawmakers are seeking to keep some distance from the case — at least now.
• Enrollment in insurance plans offered on the ACA’s marketplaces surprised many people this week. The sign-up period for most states closed last week and the overall numbers appear to be about 4 percent lower than last year. That is a smaller difference than many people expected since the penalty for not having insurance is disappearing in 2019 and other, less comprehensive plans have been championed by the Trump administration.

Plus, for extra credit, the panelists recommend their favorite health policy stories or books of 2018 they think you should read, too:

Julie Rovner: The Arkansas Times’ “,” by Benjamin Hardy

Joanne Kenen: “,” by John Carreyrou

Anna Edney: The New Yorker’s “,” by Atul Gawande

Kimberly Leonard: BuzzFeed News’ “,” by Stephanie M. Lee

To hear all our podcasts,Ìýclick here.

And subscribe to What the Health? onÌý,ÌýÌýorÌý.

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It’s also time to re-up her health coverage. But that’s where Farrell, a 54-year-old former social worker, is drawing the line.

“I’ve been retired two years and my savings is gone. I’m at my wit’s end,” says the Murrieta, Calif., resident.

So Farrell plans — reluctantly — to drop her health coverage next year because the for not having insurance is going away.

That — which can reach thousands of dollars annually — was a key reason that Farrell, who considers herself healthy, kept her coverage.

Now, “why do it?” she wonders. “I don’t have any major health issues and I’ve got a lot of bills that just popped up. I can’t afford to pay it anymore.”

Farrell is among millions of people likely to dump their health insurance because of a provision in last year’s Republican tax bill that , starting in 2019, by zeroing out the fines.

The Congressional Budget Office that the repeal of the penalty would move 4 million people to drop their health insurance next year — or not buy it in the first place — and 13 million in 2027.

Some people who hated Obamacare from the start will drop their coverage as a political statement. For people like Farrell, it’s simply an issue of affordability.

Since Farrell started buying her own insurance through the open market in 2016, her monthly premium has swelled by about $200, she says, and she bears the entire cost of her premium because she doesn’t qualify for federal ACA tax credits. Next year, she says, her premium would have jumped to about $600 a month.

Instead, she plans to pay cash for her doctor visits at about $80 a pop, and for any medications she might use — all the while praying that she doesn’t get into a car accident or have a medical emergency.

“It’s a situation that a lot of people find themselves in,” says Miranda Dietz, lead author of a that projects how ending the penalty will affect California.

People like Farrell whose incomes are too high to qualify for tax credits are especially vulnerable, says Dietz, a research and policy associate at the University of California-Berkeley Center for Labor Research and Education. They must pay the entire premium themselves.

Premiums, even for a bronze plan with a deductible of , are enormous in some cases, she says. “The state’s done a great job of implementing the ACA,” she says, “but there are still Californians who just find insurance out of reach.”

Up to 450,000 more Californians may be uninsured in 2020 as a result of the penalty ending, and up to 790,000 more by 2023, boosting the state’s uninsurance rate for residents under 65 to 12.9 percent, according to the study. The individual market would suffer the biggest losses.

Covered California, the state health insurance exchange, predicts that enrollment in the individual market — both on and off the exchange — could drop by 12 percent next year, says agency spokesman James Scullary.

Exchange officials also blame the end of the penalty for a average increase in premiums, because the departure of some healthy people from the market will lead to a sicker and costlier insurance pool.

Health insurance can be difficult to afford, but going without it is a “bad gamble,” Scullary says. Keep in mind: More than 22,000 Covered California enrollees broke, dislocated or sprained arms or shoulders in 2017, and 50,000 enrollees were either diagnosed with — or treated for — cancer, he explains.

“We know that none of those people began the year thinking, ‘This is when I’m going to break my arm,’ or ‘This is the year I get cancer,’” he says.

If you’re considering dropping your plan and risking the devastating financial consequences of an unexpected medical expense, check first to see if you can lower your premium.

“A big mistake for people is to look at the notice they get for their current health insurance and see it’s going up a lot and then throw up their hands and decide they’re going to go without,” says Donna Rosato, a New York-based editor at Consumer Reports who covers health care cost issues.

“Before you do that, look at other options.”

The most important thing to do is seek free help from a certified insurance agent or enrollment “navigator.” You can by clicking on the “Find Help” tab on Covered California’s website, .

Next, see if you can qualify for more financial aid. For instance, if is close to the threshold to qualify for tax credits through Covered California or another Obamacare insurance exchange — about $48,500 for an individual or $100,000 for a family of four this year — check with a financial professional about adjusting it, Rosato suggests. You might be able to contribute to an IRA, 401(k) or health savings account to lower the total, she says.

Beyond that, be flexible and willing to switch plans, she advises. Consider different coverage levels, both on and off health insurance exchanges. If you’re in a silver-level plan (the second-lowest tier), you might save money by purchasing a less expensive bronze-level plan that has higher out-of-pocket costs but would protect you in case of a medical emergency.

This year, Farrell got a clean bill of health from her doctor after a round of tests. She’s nervous about being without coverage next year, but feels she doesn’t have a choice.

“It’s going to be the first time in my life I’m not going to have insurance,” she says.

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And not only is the ACA, which mostly protects people who buy their own coverage, at risk. Also potentially in the crosshairs are preexisting conditions protections that predate the federal health law.

Democrats charge that Republicans’ opposition to the ACA puts those protections in peril, both by their (unsuccessful) votes in Congress in 2017 to “repeal and replace” the law, and via a federal lawsuit underway in Texas.

“800,000 West Virginians with preexisting conditions in jeopardy of losing their health care,” claimed Sen. Joe Manchin (D-W.Va.).

Republicans disagree. “Preexisting conditions are safe,” President Donald Trump declared at a for Manchin’s GOP opponent, Patrick Morrisey. Morrisey, West Virginia’s attorney general, is one of a group of state officials suing to overturn the ACA.

Who is right? Like everything else in health care, it’s complicated.

What is clear, however, is that voters want protections. Even majorities of Republicans that it is “very important” that guarantees of coverage for preexisting conditions remain law.

Here are some key details that can help put the current political arguments in perspective.

Preexisting conditions are common.

Preexisting conditions are previous or ongoing medical issues that predate health insurance enrollment. The problem is that the term is a grab bag whose limits have never been defined. It certainly applies to serious ongoing conditions such as cancer, heart disease and asthma. But insurers also have used it to apply to conditions like pregnancy or far more trivial medical issues such as acne or a distant history of depression.

The Kaiser Family Foundation that more than a quarter of adults younger than 65 — about 52 million people — have a preexisting health condition that likely would have prevented them from purchasing individual health insurance under the pre-ACA rules. (Kaiser Health News is an editorially independent program of the foundation.)

Protections vary by what kind of insurance you have.

But what protections people with preexisting conditions have depends on how they get their coverage. For that reason, it’s not right to say everyone with health problems is potentially at risk, as Democrats frequently suggest.

For example, Medicare, the federal health program for seniors, and Medicaid, the federal-state health plan for low-income people, do not discriminate in either coverage or price on the basis of preexisting conditions. The two programs together cover roughly 130 million Americans — nearly a third of the population.

The majority of Americans get their coverage through work. In 1996, Congress protected people with preexisting conditions in employer-based coverage with the passage of the Health Insurance Portability and Accountability Act, known as HIPAA.

HIPAA was intended to eliminate “job lock,” or the inability of a person with a preexisting condition (or a family member with a preexisting condition) to change jobs because coverage at the new job would likely come with a waiting period during which the condition would not be covered.

HIPAA banned those waiting periods for people who had maintained “continuous” coverage, meaning a break of no more than 63 days, and the law limited waiting periods to one year for those who were previously uninsured. In addition, it prohibited insurers from denying coverage to or raising premiums for workers based on their own or a family member’s health status or medical history.

HIPAA was less successful in protecting people without job-based insurance. It sought to guarantee that people with preexisting conditions leaving the group market could buy individual coverage if they had remained continuously covered. But the law did not put limits on what individual insurers could charge for those policies. In many cases, insurers charged so much for these “HIPAA conversion” policies that almost no one could afford them.

The Affordable Care Act, passed in 2010, built on those 1996 protections, and specifically sought to help people buying their own coverage. It barred all health insurers from excluding people due to preexisting conditions, from charging them higher premiums and from imposing waiting periods for coverage of that condition.

While the protections were mostly aimed at the individual insurance market, where only a small portion of Americans get coverage, the ACA also made some changes to the employer market for people with preexisting conditions, by banning annual and lifetime coverage limits.

Will protections on preexisting conditions become collateral damage?

In 2017, the GOP-controlled House and Senate voted on several versions of a bill that would have dramatically overhauled the ACA, including its protections on preexisting conditions. Under that narrowly failed in the Senate, states would have been given authority to allow insurers to waive some of those protections, including the one requiring the same premiums be charged regardless of health status.

In February, 18 GOP attorneys general and two GOP governors filed suit in federal court in Texas. They charge that because Congress in its 2017 tax bill eliminated the ACA’s penalty for not having insurance, the entire federal health law is unconstitutional. Their argument is that the Supreme Court upheld the ACA in 2012 based only on Congress’ taxing power, and that without the tax, the rest of the law should fall.

The Trump administration, technically the defendant in that case, said in June that it disagreed that the entire law should fall. But it is arguing that the parts of the law addressing preexisting conditions are so tightly connected to the tax penalty that they should be struck down.

Clearly, if the lawsuit prevails in either its original form or the form preferred by the Trump administration, preexisting protections are not “safe,” as the president claimed.

Even more complicated, the protections written into HIPAA were rewritten and incorporated into the ACA, so if the ACA in whole or part were to be struck down, HIPAA’s preexisting conditions protections might go away, too.

Republicans in Congress have introduced of they say would replicate the existing protections. But critics contend none of them covers as many situations as the ACA does. For example, a bill unveiled by several Republican senators in August would require insurers to offer coverage to people with preexisting health conditions, but not require coverage of the conditions themselves.

That hasn’t stopped Republicans from claiming that they support protections for preexisting conditions.

“Make no mistake about it: Patients with preexisting conditions should be covered,” said Wisconsin GOP Senate candidate Leah Vukmir, who is running to unseat Democratic Sen. Tammy Baldwin. Health care has been in that race, as well as many others. Yet Vukmir was recently hailed by Vice President Mike Pence as someone who will vote to “fully repeal and replace Obamacare.”

Meanwhile, Democrats who are chastising their Republican opponents over the issue are sometimes going a bit over the top, too.

An example is Manchin’s claim about the threat to coverage for . West Virginia’s population is only 1.8 million and more than a million of those people are on Medicare or Medicaid. That would mean every other person in the state has a preexisting condition. A found West Virginia has a relatively high level of preexisting conditions among adults, but it is still less than 40 percent.

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President Donald Trump’s proposed rule that would make it more difficult for immigrants to gain permanent status if they use government aid programs could have a major impact in Texas, with its large immigrant population.

Texas is also ground zero for the health debate in this year’s midterm elections. Texas Attorney General Ken Paxton is the lead plaintiff in a case filed by 20 GOP state officials arguing that the entire Affordable Care Act is now unconstitutional in light of last year’s tax bill, which canceled the penalties for people who fail to obtain health insurance. The Trump administration does not agree that the whole law should fall, but says the parts protecting people with preexisting health conditions should be struck down. A federal district court judge in Fort Worth is expected to issue a decision in the case soon.

This week’s panelists for KHN’s “What the Health?,” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Alice Ollstein of Politico. Technical difficulties prevented us from bringing you the discussion taped Sept. 27 before a live audience in Austin as part of the 2018 Texas Tribune Festival. So, the panelists, back in D.C., joined Rovner, still in Austin, for a redo Sept. 28.

Among the takeaways from this week’s podcast:

• The latest version of the new “public charge” regulations proposed by the Trump administration could penalize immigrants who use food stamps, Medicaid, housing assistance or Medicare prescription drug subsidies. But unlike an earlier version of the proposal, it would not take into account immigrants’ use of subsidies under the Affordable Care Act.
• With less than six weeks to go before the critical midterm elections, federal protections for people with preexisting health conditions has become the top campaign health issue in many states, in many races eclipsing concerns about prescription drug pricing and other out-of-pocket health costs.
• As hearings continued on the nomination of federal Judge Brett Kavanaugh to serve on the Supreme Court, a three-judge appeals court panel heard arguments on a case he decided earlier this year concerning the right of minor immigrants to obtain an abortion.
• Increases in premiums for insurance under the Affordable Care Act appear to moderating, and some states are reporting decreases for plans that start Jan. 1, 2019. The Trump administration is now trying to take credit for “fixing” the ACA’s marketplaces. However, state insurance officials have noted that premiums are moderating in spite of, rather than because of, the administration’s actions.

To hear all our podcasts,Ìýclick here.

And subscribe to What the Health? onÌý,ÌýÌýorÌý.

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