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For millions, the health reform decision could take away benefits they're already using

While the Supreme Court deliberates behind closed doors, nearly 8 million Americans who already are benefiting from the Affordable Care Act may be awaiting the court's decision on the fate of the landmark health reform law decision more closely than most.

• More than 5 million people, mostly seniors, have received discounts on prescription drugs once they reached the dreaded Medicare "doughnut hole."

• More than 2.5 million young adults age 19-26 have remained covered by their parents' health insurance plans.

• And nearly 50,000 Americans — including 4,000 Floridians — have enrolled in a health plan for people with pre-existing health conditions who could not get insurance otherwise.

The fate of these three popular programs seems clear if the court upholds the entire law, or declares the whole thing unconstitutional.

"All that has been done would have to be undone," said Len Nichols, the director of the Center for Health Policy Research and Ethics at George Mason University in Virginia.

But things become murky if the court strikes only part of the law, particularly the controversial insurance mandate.

Then what?

Experts say certain provisions stand a better chance of survival than others. The insurance mandate was designed to spread out the costs of health care more broadly, so if that is struck, more expensive provisions likely will be too, said Jay Wolfson, associate vice president for health law, policy and safety at the University of South Florida.

Keeping young adults on their parents' plans, for example, doesn't cost insurers a ton of money because this generally is a healthy group.

"It's a low-risk population for insurance rate calculations," Wolfson said.

Plus, "this is not a new requirement in many states," said Robert Zirkelbach, spokesman for America's Health Insurance Plans, an industry trade association. "Many states had already extended the age of dependent coverage prior to the (Affordable Care Act)."

Nick Mildebrath, 23, has been on his parents' health plan since graduating from the University of Florida last year.

Before the Affordable Care Act, the Tampa Bay-area native who now works in Gainesville said he'd often meet people his age who had medical problems. "Nothing they could do about it because they didn't have insurance," he said.

Actually, he said, they did have the option of going to a hospital emergency room — where taxpayers would foot the bill.

"It makes an immense difference," he said of the law.

• • •

The doughnut-hole provision is more expensive, and therefore more vulnerable to the loss of the insurance mandate, some experts have said.

Wolfson said he sees a way it might survive, though. The health law gives Medicare beneficiaries a 50 percent discount on prescription drugs once they enter the doughnut hole, which occurs after they've spent more than $2,830 but less than $6,440 on prescription drugs. The amount of the discount is scheduled to increase steadily until 2020, when the doughnut hole will be effectively closed.

Wolfson said that as more people reach Medicare age, more will pay premiums for prescription drug coverage. And if current trends hold, only a fraction of them fall into the doughnut hole.

So — at least in theory the people who avoid the doughnut hole could subsidize the discounts for people who fall into it.

The discounts have helped people like John Sheridan, 74, a retired educator from St. Petersburg, who fell into the coverage gap a few years ago, said his wife, Barbara, 63.

"He would stop taking a pill, or skip taking a pill," she said of her husband, who had colon cancer and is dealing with neuropathy and other conditions.

Sheridan hasn't had to do that since, his wife said.

• • •

But if the court strikes the insurance mandate, it would likely make the program to help people with pre-existing health conditions prohibitively expensive, experts say.

History suggests they're correct.

In 1982, Florida offered coverage to people with pre-existing conditions through a high-risk pool, and at its peak it had more than 7,000 members. But in 1991, with the program losing tens of millions of dollars, the state stopped accepting new enrollees.

Other states, including Washington, have tried similar reforms, but couldn't pay for them without an individual mandate.

The Affordable Care Act's pre-existing condition insurance plan got off to a rocky start in 2010, with premiums that were too high for many people to afford. Premiums have been lowered at least twice in an effort to help cover more people.

Among them is Marlys Lenz Cox, 57, of St. Petersburg, who called the plan a "lifeline."

Cox, who has had serious health issues, including cancer and hepatitis C, spoke during a news conference Monday in Washington, D.C., attesting to the health law's benefits.

She's unsure what she'll do if the court strikes down the law.

"What happens to the people like me if this law isn't found valid?" she asked. "Do we just get cut off and never buy insurance again?"

Information from McClatchy Newspapers is included in this report. Richard Martin can be reached at rmartin@tampabay.com or (813) 226-3322.

For millions, the health reform decision could take away benefits they're already using 03/30/12 [Last modified: Friday, March 30, 2012 9:43pm]
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