Christopher Roby is a community health worker who works tirelessly to help people access the health care and support services that they need. It involves a lot of paperwork and on-the ground liaisons with hospitals, clinics and insurers. Clients who have often lived their entire lives without any health insurance are also involved. His parents were one of those clients. They had been avoiding expensive health insurance for years, and the primary and preventive care that it provides. Recently they enrolled in the Affordable Care Act’s federal market. Although they were reluctant to give their personal information to enroll, Roby, a trusted son, connected the dots and got them coverage. Roby’s stepfather, Stanley McCray, and Angie McCray, 58, have never had employer-based coverage for their different jobs in the Mississippi Delta. Stanley McCray now lives in Indianola and Angie McCray works as a homemaker cleaning houses. Private health insurance was too expensive for them and they are not eligible for federal Medicare or state-sponsored Medicaid. Roby, like many public health professionals, is watching as the U.S. Supreme Court considers the fate of ACA. Although the law will remain in effect for some time, some advocates are concerned about the long-term implications of its repeal, which would result in the loss of coverage for hundreds of thousands of Mississippians. This week, 20 Republican governors and lawyers general will present arguments in California v. Texas to the high court. Phil Bryant. Texas collectively challenged the constitutionality and accessibility of the ACA. The ACA provides tax credits and avenues to purchase health insurance, as well as broad protections for affordability, access, and affordability. Nearly all Mississippians would be affected if the law is repealed. Roby’s parents’ health care access is at risk. The law’s broad reach affects nearly all Americans, including those who receive medical reimbursement. But they are front and center in Roby’s mind. Roby convinced them three years ago to enroll in the federal marketplace. Their income could qualify for premium tax credits that would go towards their monthly insurance payments. They were accepted and have been enrolled since then. Both were diagnosed with preexisting hypertension, which puts them at high risk for COVID-19 and other complications. They have managed to lower their blood pressure and been able to access meds and regular treatment. My biggest concern is that they won’t have the ability to continue to receive coverage for any issues that may arise as they age. “We have to be concerned about cancer, deteriorating bone, and limited mobility,” he stated. He also expressed concern that their improved health, along with greater access to preventive care, could reverse. Roby and his parents remain optimistic. Last week, the McCrays voted for the first time in almost two decades. They stated that affordable health care was their main focus when they voted. The law is more than a means for low- and moderate-income families to purchase health insurance. It also provides a wide range of ramifications for patients, insurers, and hospitals. 600,000 Mississippians are currently protected from being denied or charged more insurance because of previous medical diagnoses such as heart disease, cancer, and COVID-19. Nearly 250,000 Mississippians (or 10% of the state) were eligible for tax credits in 2019 to help pay premiums on federal insurance. Due to record unemployment from the COVID-19 epidemic — approximately 130,000 additional unemployed as of July — more families will be eligible for tax credits. If the ACA is repealed, projections show that the state’s uninsured population will rise to almost 450,000. Mississippians also have “essential benefits” that all insurers must provide, including preventive services such as vaccinations and family planning and wellness care like annual cancer screenings. Maria Morris, a Community Health Center Association of Mississippi program consultant, feels the weight of all these benefits for Mississippians. She has coordinated state-wide public health partnerships for 15 years to improve Mississippians’ health care access. She has been helping community health centers prepare to open enrollment in the ACA insurance market for the past ten years. Despite the fact that the fate of the law is looming in her background as she trains this year, open enrollment begins. She says she cannot let the potential losses of an overturned ACA distract from her work and encourages other enrollment counselors not to ignore it. This year’s need to make the switch to virtual enrollment and training is enough pressure. Her message was clear when she trained other health centers to enroll patients in health insurance. She advised them to correct any misinformation they hear and to keep their eyes on the goal of getting them the health care they need. Morris stated that counselors need to enroll people. “We must make sure, especially considering COVID,” Morris said. In 2019, a lower federal court declared the “individual mandate” unconstitutional. This required individuals to either have health insurance or pay an additional fine to increase the country’s insured pool. The penalty fine was set at $0 by Congress two years before, effectively nullifying the tax and opening the door to the Texas lawsuit. Opponents claim that the now-unconstitutional mandate is essential to the ACA, and the entire law would be invalidated without it. Advocates for health care say that while the mandate bonded the ACA together, aiming to broaden coverage — especially for young and healthy people and those who never had insurance before — its exclusion should not mean the law’s other unrelated safeguards are lost. The Healthcare Marketplace, also known as the federal health exchange, was created by the Omnibus ACA. It allows consumers to shop for insurance through a single, policy-guaranteed portal. The marketplace saw 98,000 Mississippians sign up for health insurance last year. 98% of those who enrolled in the ACA’s final year were eligible for tax subsidies. This subsidy helps to pay monthly premiums. Another key feature of ACA is that 98% qualified. Counselor Morris and other counselors can help people meet the eligibility requirements and enroll in insurance. She works with health centers to help staff identify patients who are un- or underinsured and connect them with counselors who can help them sign up for insurance. Patients can get insurance policies to help with their meds and specialty costs. Clinics also benefit from the increased reimbursements. The majority of these centers charge a sliding fee and offer primary and preventive care to those who don’t otherwise have a medical home. Morris states that enrollment assistance has been a core part of the ACA since its inception. It will remain so until patients no longer need it or the access is removed from them. Morris and other advocates for health are concerned about individuals’ health gains. They have gained health through preventive and wellness care. However, they risk losing these gains if their insurance policy is discontinued. “…(New customers who have insurance see the benefits of being able to access the hospital and get your prescription medication. People have also aged in a way that has allowed them to improve their health. They may not be able to access it now. Morris stated that it would be devastating. Morris said, “And then you have stress, depression and anxiety and COVID. It would be terrible to have to go through that. It would be completely catastrophic.” Despite the Trump Administration’s cutbacks in enrollment assistance budgets, counselors such as Morris have steadily increased ACA Marketplace enrollment each year since 2017. This was after enrollment fell due to market instability that was fostered by Donald Trump’s “repeal-and-replace” rhetoric. Many people, if they were to get navigators’ help, might have asked “Do we still have Obamacare?” However, Mississippians continue to use the marketplace to obtain health insurance. The enrollment has increased by almost 20% and is poised to surpass its peak 2016 enrollment of 109,000. Enrollment increased in Mississippi by nearly 20% in 2018, one of five states that saw enrollment growth. The marketplace is a popular part of the ACA in Mississippi. It’s not the only state benefit. On average, 91,000 Mississippians have had health insurance since 2014. This has helped to lower the state’s high unemployment rate and has allowed it to reimburse hospitals and clinics for previously uncompensated care. A third of the state’s population was protected from losing their health insurance due to their medical history. Insurers must cover 600,000 Mississippians who have pre-existing medical conditions under the ACA. Mississippi’s marketplace was not a smooth start. It suffered from low competition and saw many insurers drop out. Ambetter and Molina will be the two new insurers in Mississippi’s market. This is the first time that this has happened since 2017. Average plans have a 6% drop in costs. Despite this, healthcare costs in the U.S. continue to rise — although slower than in previous decades — especially for employer-based plans. The ACA deliberately avoided interfering in employer-based insurance. It only required employers with 50 workers or more to offer it, and provided certain protections for patients. This is the only way that Mississippians receive their healthcare — 40% more than any other state. COVID-19, which saw record numbers of workers lose their jobs and get health insurance, means that more people will be eligible for tax credits and insurance under the ACA. Experts warn it’s a risky time to take the lifeline. Morris, an enrollment counselor, is particularly concerned about new insurance customers — a key target for the ACA’s enrollment — who have purchased health insurance for their first time in recent years. Mississippi’s uninsurance rates have dropped since the ACA was passed, particularly for people of color. Black Mississippians have seen their uninsured rates drop by 35% in 2008, while the state saw a 27% decrease. These gains may all be lost if the state’s broad-reaching health law is not passed. However, advocates insist that little will change in the next year and urge people to enroll. Mississippi has one the highest pre-existing conditions rates in the country, including high blood pressure, heart disease, and COVID-19. You can find more protections under the ACA right here. COVID-19 has caused a pandemic that not only put individuals’ healthcare under greater strain, but also shattered hospitals and clinics’ operating revenues. While public health advocates favor expanding access to healthcare and insurance, they fear that overturning the ACA will reverse years of progress in expanding insurance rolls and funding safety-net trauma hospitals like Jackson’s University of Mississippi Medical Center. “If the ACA is removed without any replacement, it could be devastating. This is because it would mean the end of protections and pre-existing conditions. So it is back in place. The enrollment counselor Morris said that we discussed expanding coverage to 26-year-olds. She recalls helping a man in his thirties to enroll and is worried about what happens if he loses coverage. He is a newcomer to health insurance and he doesn’t want to lose it. Morris stated that these are only a few of the many things that could lead to devastation or tragedy for people who… now need insurance. It could feel like Holy Hell to some people. You’re talking about giving someone access to something they need all the time, and then you come back and take it… that’s where stress, devastation, and hopelessness come in.” The federal marketplace is open for enrollment through December 15, 2020 for coverage for 2021. For more information or to get assistance from community counselors and navigators, visit healthcare.gov.