Obamacare's cost-sharing subsidies helped him afford brain surgery

If the Affordable Care Act hadn’t made his premium and out-of-pocket costs so cheap, Luis Calle says he would never have bought insurance.
If the Affordable Care Act hadn’t made his premium and out-of-pocket costs so cheap, Luis Calle says he would never have bought insurance.
Rebecca Plevin/KPCC

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Luis Calle knew something was wrong.

"For years, I would look in the mirror, and I would be like, 'why is my head so big?'" recalls the 34-year-old father of two from Rancho Cucamonga. "If I stood next to my wife, it looked like a doll standing next to me."

There was more.

"My feet, they looked like they were webbed," he says. "They were just so wide and so big. And my hands. Everyone would call me gorilla hands at work."

But Calle didn't go to the doctor. He'd been uninsured his whole life. He thought insurance was a luxury for people who could afford it.

Calle's attitude changed when he learned that under the Affordable Care Act, he and his wife qualified for subsidies that would make their premium fit their budget. They also qualified for cost-sharing subsidies, which would significantly lower their out-of-pocket costs.

But the fate of these cost-sharing subsidies is uncertain. The Trump Administration could decide any day whether it will continue to support the subsidy program – or end it.

That would hinder the ability of Calle and nearly 1 million other Californians to afford insurance. He says if the health care law hadn't made his premium and out-of-pocket costs so cheap, he would never have bought coverage.

"I would have just let it go and let it go, and the doctor said I probably would have died when I was 50," Calle says.

Affordable care

Under Obamacare, people qualify for cost-sharing subsidies if they earn below 250 percent of the federal poverty level. (That's $29,700 for an individual and $60,750 for a family of four.)

This year, 980,000 Covered California enrollees are receiving these cost-sharing subsidies, according to a Kaiser Family Foundation analysis.

Because this support reduces the amount people pay in deductibles, copays and other out-of-pocket expenses, "it really makes the actual getting of care affordable," says Nadereh Pourat, research director at the UCLA Center for Health Policy Research.

That has certainly been the case for Calle. At a time when a lot of families have annual deductibles of several thousand dollars a year, his is $150.

The cost-sharing subsidies also helped when Calle finally saw a doctor. He says the physician took one look at him and suspected he had a condition called Acromegaly, but she wanted to order more tests.

With the cost-sharing subsidy, the office visit cost Calle $8.

Then he got an MRI. Because of the subsidy, he paid just $50.

The MRI confirmed the doctor's hunch: Calle had a three-centimeter tumor on his pituitary gland. The doctor explained that the benign tumor was causing his body to release too much growth hormone.

She sent him to a neurosurgeon. In January, Calle had surgery to remove the tumor.

Again, due to the cost-sharing subsidies, he only paid about $1,000 of a nearly $10,000 bill.

He says the surgery was a success.

"My shoes are starting to fit again," Calle says, as he cooks dinner for his family on a recent evening. "I'm back down to a size 10 right now. My wedding ring can at least fit to my first knuckle. My face is starting to look a lot more normal."

'Please save the subsidy program'

The U.S. Department of Health and Human Services directly pays insurers for these cost-sharing reductions.

And that's the sticking point: House Republicans say these payments are unconstitutional, because Congress never approved a specific appropriation for them. In 2014, they sued the Obama administration to block the subsidies.

In May 2016, a federal district court judge sided with the House. But the judge left the subsidies in place while the Obama Administration appealed the decision.

The case is still on appeal; the Trump Administration has not indicated whether it will continue the appeal or drop the case, which would in effect end the program.

The Affordable Care Act requires insurers to offer certain plans with cost-sharing discounts, explains UCLA's Pourat, so "if the federal government is not paying those subsidies, somebody else has to."

She says insurers would most likely increase premiums if Washington stops providing the subsidies, which amount to $7 billion a year nationwide.

The uncertainty is making insurers skittish, as they decide whether to stay in state health insurance exchanges for 2018.

"It's obviously a concern for the health plans who are planning for 2018 right now," says Charles Bacchi, president and CEO of the California Association of Health Plans.

Trump added to the uncertainty when he told the Wall Street Journal last week that he might withhold the payments as a way to pressure congressional Democrats to negotiate changes to the Affordable Care Act. Senate Minority Leader Chuck Schumer (D-NY) slammed the president, accusing him of threatening to hold millions of American's health care "hostage" as part of "a cynical strategy."

In an apparent effort to calm the insurance markets, the U.S. Department of Health and Human Services issued a statement on Monday saying, "while the lawsuit is being litigated, the cost-sharing subsidies will be funded."

Meanwhile, Luis Calle has a message for Trump as the president considers what to do: "Can we please save the subsidy program somehow?"

A lot of people's lives might depend on it, he says.