When the Affordable Care Act became law and implementation was set to begin in 2013, Southwestern Pennsylvania was basically on its own. Federal assistance was virtually nonexistent, says Karen Feinstein, head of the Jewish Healthcare Foundation of Pittsburgh.
Federal officials sent neither canvassers to teach people how to sign up for health insurance through the ACA nor health-care experts to solve problems with the ACA marketplace; other assistance was also not provided to the Pittsburgh area. And Feinstein says that while President Barack Obama’s administration sent “a very nice woman” to Pittsburgh, “she didn’t know McKeesport from McKees Rocks.”
So Pittsburgh and the region had to do what they do best: bring together institutions, nonprofits, religious organizations, businesses and public servants to work on a common goal. Feinstein says nonprofits like JHF, churches, Allegheny County’s Health Department, libraries, hospitals and businesses like Giant Eagle came together to create and implement a comprehensive strategy to get people covered through the ACA marketplace, which offers insurance to individuals under 65 years old.
It worked. Allegheny County and the surrounding counties have some of the lowest rates of uninsured individuals in the entire country. According to a Kaiser Family Foundation analysis, Pennsylvania as a whole is the most insured state in the U.S., despite relatively high uninsured rates in Philadelphia and some other rural counties. Even with the lack of federal assistance that the Pittsburgh region had during the ACA rollout, the region quickly lowered its non-elderly uninsured rate.
According to U.S. Census figures, the Pittsburgh metro area’s 2016 non-elderly uninsured rate is 4.5 percent. In 2012, before the ACA, the rate was 9.5 percent. By comparison, Philadelphia metro area’s 2016 non-elderly uninsured rate is 6.6 percent; it was 10.8 percent in 2012.
Unfortunately, the job of getting people health coverage is not over. President Donald Trump’s administration and many in the Republican-led U.S. Congress are trying to undermine the ACA, by stripping ACA-sign-up advertising funds or attempting to remove the ACA mandate that requires adults to get health insurance (because having more insured individuals reduces the cost of insurance plans). Democratic politicians are worried the whole system could be taken down, even as the program is working. But health-care experts believe Pittsburgh can be used as a model of a region that navigated rough waters on its own and succeeded despite the lack of help from the federal government.
After the ACA was signed into law, Feinstein and other leaders from the Pittsburgh region were invited to have a meeting with Obama and his staff in Washington, D.C. She says Obama met with her group for two hours and that he was straight with them. Pittsburgh would not be receiving much help from the feds, since those resources would be allocated to the Philadelphia area and its significantly higher population.
Regardless, Feinstein says she left inspired. “[Obama] made it sound like he really believed in us, and that he needed us,” says Feinstein. “He needed all of us to pull together to make sure people got insured. We left, and we couldn’t have been more fired up.”
From there, organizations stepped up. Local libraries expanded their computer-log-in times so people could enroll easier. Giant Eagle set up tables at its grocery stores where questions about the ACA could be answered. Pastors, rabbis and others at various churches and temples helped their congregations learn how to get enrolled. Even Steelers owner Dan Rooney held an enrollment event at Heinz Field to help people get health insurance.
It was a coordinated effort, says Nancy Zionts, JHF’s chief operating officer. And all the organizations came together, despite their differences.
“It was Pittsburgh; it was collaborative,” says Zionts. “The faith-based groups weren’t afraid to be in same room as Planned Parenthood. They felt this was so close to what their collective missions were, they institutionalized it.”
Local foundations, like the Pittsburgh Foundation, put their own money in to fund these efforts, says Zionts. Feinstein adds that regional health-care giant Highmark even offered high-quality insurance plans at good rates so that more Pittsburghers could have access to affordable plans.
“We really exceeded expectations. We looked so good,” says Feinstein.
Zionts says she was almost happy the federal government didn’t come in and provide a whole army of navigators to show people how to get health insurance, since Pittsburghers are more likely to listen to their neighbors than to outsiders. And because the Pittsburgh enrollment effort was done by locals helping locals, Zionts is confident the region will continue to see better and better enrollment figures.
She says that in the first two weeks of 2017’s open-enrollment period, Pennsylvania had 2.9 million people submit applications for health-insurance coverage, and that 10 percent of those are new applicants who had no prior ACA coverage. (People receiving health insurance through the ACA can be automatically re-enrolled, but the federal government suggests people shop around each year.) “We are keeping our enrollment numbers high.” says Zionts. “It has just continued. And because it wasn’t someone from out of town doing it for us, it was more successful.”
But in spite of the region’s success in implementing the ACA, the program is still under attack by Republicans. Locally, U.S. Rep. Keith Rothfus (R-Sewickley) and U.S. Rep. Mike Kelley (R-Butler) both voted to repeal the ACA in a bill that cleared the House, but failed in the U.S. Senate.
“Obamacare [ACA] is making insurance unaffordable for those in the individual and small group market, both with and without pre-existing conditions, and the Democrats have no solutions to the problem,” Rothfus said in a May 4 statement.
In August, Trump slashed the ACA’s advertising budget from $100 million to $10 million. And currently, Senate Republicans, as part of their tax bill, are even considering ending the ACA’s requirement that people have health insurance. This means that 13 million individuals could leave the marketplace, which would increase premiums for those who remain.
Pennsylvania U.S. Sen. Bob Casey (D-Scranton) says that could be devastating for Pennsylvanians. “I don’t understand why a political party thinks the country is better off with people losing their coverage,” said Casey in a Nov. 15 conference call with reporters. “That is literally the Republican position in the health-care debate. It is entirely possible that a huge number of Americans will get a tax increase and lose their health care in the same year.”
Critics say ACA marketplace premiums are rising at an uncontrollable rate. In most parts of the country, however, rates actually went down between 2014 and 2016. In Pennsylvania, 2017 rates are 30 percent higher than in 2016, and are likely to be higher still in 2018. But Pennsylvania’s Secretary of Human Services Teresa Miller believes this is mostly because of the uncertainty caused by Republican attempt to repeal the ACA.
“I am here to set the record straight: There is only one party that is making the ACA implode — Republicans — and this provision in the tax bill is just another attempt at that,” Miller said on that Nov. 15 conference call. “The original ACA rate increases were projected at 7 percent, now they are at 30 percent. It is because of uncertainty and sabotage by Republicans and the Trump administration.”
And this behavior by Trump and Republicans is making Allegheny County Executive Rich Fitzgerald a bit nervous. He’s glad to see the region getting a high number of people covered, but can’t say with confidence that things will continue at the same pace.
“We’ll see. We are in new territory. [Republicans] continue to try and repeal it,” says Fitzgerald. “We’ve just got to continue to be vigilant. We need more people enrolled, not less.”
Fitzgerald wishes Congress and Trump would just stay out of the way and let Pittsburgh maintain the positive work it has already accomplished. “I think this is one of the things we do well, and not just on health care; we partner a lot,” says Fitzgerald. “We tend to work together. We know how to do things locally. I think we learned the lesson back in the ’80s when the mills shut down. The feds were not coming in with any bailouts then.”
Regardless of Republicans’ intentions, JHF’s Feinstein says the tasks originally given to her by Obama are still priorities for her group and Pittsburgh as a whole. She says she could have used JHF resources differently, such as writing a health-care policy study, but Feinstein believes that “would be a lot less important than getting people covered, so they actually have access to health care.”
“It’s not only a good role for us to have,” says Feinstein, “I think it is an obligation.”