Seven months after being diagnosed with breast cancer and later undergoing a double mastectomy, LaDonna Appelbaum of St. Louis recently finished her 16thand final chemotherapy treatment.
Without the $600 monthly tax credit that pays the bulk of her insurance premium under the federal health care law, Appelbaum isn’t sure how she and her husband, Tom, would have paid for her medical care.
She still faces 33 radiation treatments, several reconstructive surgeries and a host of medical challenges.
And while she’s optimistic about the complex care that lies ahead, Appelbaum worries that the U.S. Supreme Court could declare illegal the tax credits that help make it possible.
The high court is expected to decide in June whether to continue the tax credits for Appelbaum and others who live in the 34 states where the federal government operates the health insurance marketplace.
The stakes are not only high for Appelbaum but for all women who make up a majority of marketplace plan enrollees.
Plaintiffs in the King v. Burwell case argue that a section of the Affordable Care Act says the tax credits can only go toward coverage purchased “through an exchange established by the State.”
If the plaintiffs prevail and tax credits are disallowed in Missouri and 33 other states, millions of Americans could immediately find their insurance unaffordable and subsequently drop coverage.
The majority of those coverage losses would likely fall on women. Females probably account for 54 percent of the 8.6 million marketplace plan members in the 34 states that rely on the federal exchange at HealthCare.gov.
And national trends suggest that roughly 87 percent of these women – nearly 4.2 million – receive tax credits that could be lost if the Supreme Court decides that the subsidy is illegal.
Losing their coverage means they no longer would benefit from consumer protections in the health law that outlawed discrimination against women in the individual insurance market.
Although her husband is an attorney in private practice, Appelbaum said business is slow and they can’t afford their $900-per-month insurance premiums without the subsidy.
“It’s scary because I could lose the insurance,” she said, if the court strikes down the tax credits before she completes her radiation treatments.
“I could be halfway through. I could be almost done. I just don’t know,” Appelbaum said. “. . . My family and friends say, ‘Don’t think about it. Just concentrate on getting better and healing.’ But it does stress me out.”
Individuals and families with annual incomes from 100 percent to 400 percent of the federal poverty level are eligible for the tax credits. They average $263 per person per month on the federal exchange and cover, on average, about 72 percent of the total monthly premium.
Losing the subsidies would hurt all low- and middle-income Americans who receive them.
But because women, on average, earn less and have higher poverty rates than men, the loss of tax credits would be harder for them to overcome.
Research has shown women are more likely than men to bypass medical care and preventative services because of cost. But they’re also more likely to face more health care problems over the course of their lives.
Researchers from the Commonwealth Fund and the National Women’s Law Center found that nearly 40 percent of women have a chronic condition that requires regular treatment, compared with just 30 percent of men. And 60 percent of women are on prescription drug regimens compared with just 44 percent of men.
Women are also more likely than men to face certain mental health problems, such as depression. The disparities are even greater for women of color.
Before the Affordable Care Act, women seeking health insurance outside the workplace often faced higher rates than men based solely on their gender. Others could be denied coverage if they were pregnant, had a previous caesarian child birth or had health problems stemming from domestic abuse or sexual assault.
When Appelbaum became pregnant in 2010, her individual policy wouldn’t cover her medical costs. They said her pregnancy was a “pre-existing condition.”
Other insurers wanted $1,000 per month more to cover maternity costs – and they told her she had to wait a year for coverage to begin.
Angry and frustrated, she dropped her coverage altogether.
“That was the kicker for me,” Appelbaum said. “I was so furious. I mean, why are we giving our money to the insurance companies if we can’t get the health care we need? We’re just throwing money away.”
She later had a miscarriage.
“That’s how the insurance companies could dictate” to patients, she said. “That was pre-Affordable Care Act. They can’t do that now.”
The health law made it illegal to charge higher rates based on gender, occupation or an individual’s medical claims history. It also required individual policies to cover maternity and newborn care.
But if the high court bans tax credits in 34 states, “those kinds of historic improvements are at risk,” said Karen Davenport, health policy director at the National Women’s Law Center.
“If you’re a health plan and you have to offer coverage to anybody who looks for it and the only people looking for it are the people who are sick . . . you get a lot of pressure on the market and on the policymakers to change the provisions that create those protections,” Davenport said.
In North Carolina, another state that relies on the federal exchange, Nancy O’Dell of Murphy said her marketplace insurance helps keep her autoimmune disorder, arthritis and fibromyalgia in check.
A 56-year-old self-employed psychotherapist, O’Dell went nearly 10 years without health insurance because her ailments made coverage too costly. While uninsured, she said it was hard getting doctors to see her. That changed when she got coverage through HealthCare.gov.
“Suddenly, the doctors were available to me,” O’Dell said. “It was like I got this magic card that got me through the door. Without the insurance, they didn’t want to have anything to do with me.”
O’Dell pays $83 per month for coverage and her $600 tax credit pays the rest.
But without the subsidy, “I’m toast. I’m done. I’m history,” she said. “The plan I have now would cost about $700 per month. That’s impossible for me. That would be it. I wouldn’t have insurance again.”
The Obama administration has said it can’t undo the damage that would occur should the Supreme Court rule against the health care law, and it has not offered a contingency plan.
Congressional Republicans who support the plaintiffs are mindful, however, of the political backlash that the lost subsidies could cause.
Sen. Ben Sasse, R-Neb, has introduced legislation that would extend the tax credits for up to 18 months if the plaintiffs prevail.
If the tax credits are scrapped, Appelbaum and others will have to find a way to pay for the care they need. She feels pretty good about her chances.
“I feel lucky,” Appelbaum said, fighting back tears. “What the (Affordable Care Act) has done for me is save my life.”
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