Talk of repealing the Affordable Care Act scares Lester Conway.

"There are nights I can't sleep," the retired Cape Girardeau man said.

Conway retired from a job at an auto dealership in January 2016 at the age of 62. His wife, Donna, also is retired.

The couple have a health-insurance plan through the Affordable Care Act (ACA).

"It has been good for us," Lester Conway said.

The Conways are not alone.

Health-care coverage

Some 15,700 people in Southeast Missouri received coverage through ACA insurance policies as of February 2016, according to Center for Medicare and Medicaid Services data provided by the office of U.S. Sen. Claire McCaskill, D-Mo.

In the 18-county region, Cape Girardeau topped the list, with more than 2,600 people receiving health insurance from insurance policies obtained through ACA.

No other county in the region cracked the 2,000 mark.

Other counties with more than 1,000 individuals covered by ACA policies included St. Francois, Butler, Scott, Stoddard and Dunklin, according to figures provided by the senator's office.

According to McCaskill's office, nearly 250,000 people statewide were enrolled in ACA insurance plans as of mid-January 2017.

McCaskill said in an emailed statement she is "willing to change and improve the Affordable Care Act" but has yet to see a plan from Republicans.

McCaskill and other Democrats have said the law has benefited Americans in several ways, including requiring insurance companies to cover people with pre-existing conditions and allowing young adults to stay on their parents' insurance plans until the age of 26.

According to McCaskill's office, 30 percent of non-elderly Missourians have a pre-existing condition.

An estimated 44,000 Missourians have stayed on their parents' health-insurance plans as a result of ACA, the senator's office reported.

Republican lawmakers have suggested those two popular provisions will be a part of any replacement plan.

But Cape Girardeau lawyer J.P. Clubb worries repeal and replacement of ACA may do away with coverage for pre-existing conditions.

His daughter Lorelai, now 13, battled acute myeloid leukemia. She endured difficult treatment, including a bone-marrow transplant.

Clubb and his family have private insurance.

Clubb said his daughter is doing well now, but he is concerned she may find it hard to obtain insurance in the future. At some point, he said, Lorelai could be faced with not having insurance coverage if insurers are not required to cover individuals with pre-existing conditions.

He suggested lawmakers should not repeal ACA until a replacement plan is in place.

"The ACA is not perfect," said Clubb, who advocates a single-payer system. But he said the program has helped those who otherwise can't afford insurance.

Republican lawmakers have argued the ACA is not affordable. Premium costs have risen dramatically around the country, they said.

The Associated Press reported premiums for a mid-level benchmark plan were expected to increase an average of 25 percent across the 39 states served by the federally run online market, according to the U.S. government.

Help from subsidies

But Conway said that has not been his experience.

"Our premium has not increased like some that have been reported," he said.

He said in 2016, he and his wife paid just over $193 a month in premium costs, with a federal subsidy referred to as a "tax credit" picking up the remaining $1,448 monthly expense.

The tax credits are designed to help eligible individuals and families with low or moderate income afford health insurance purchased through the Health Insurance Marketplace or Exchange, according to online information from the Internal Revenue Service.

Such credits can be paid directly to insurance providers, lowering the cost to households such as the Conways'.

Conway said their cost dropped this year to $159 a month.

He credits that to the fact the couple's income dropped by $2,000 now that he is fully retired.

The subsidy is calculated on the basis of taxable income, he said. The lower the income level, the greater the subsidy.

This year, the tax credit for the Conways is $1,934 a month.

Conway said he and his wife can't afford health insurance without the subsidy.

"Who can afford $2,000 or $2,400 a month for insurance?" he said.

Conway, who suffers from heart problems, said he and his wife need health insurance.

"We can't afford to be without it," he said. He worries Congress might repeal the law without an adequate replacement plan.

"They are just playing around with people's lives," he said.

In a Dec. 6 letter to U.S. Rep. Jason Smith, Conway urged lawmakers to keep the ACA.

"This insurance helps so many people that are caught in the middle who do not qualify for Medicaid and are too young for Medicare, as is in our case," he wrote. "We are very pleased with the plan and price we pay."

Republicans in Congress have yet to settle on a legislative plan to replace the ACA.

President Donald Trump has directed federal agencies to stop issuing regulations that would expand the law's reach. It also directs them to grant waivers, exemptions and delays of provisions in the Affordable Care Act that would impose costs on states or individuals, potentially including the law's fines on people who remain uninsured, according to The Associated Press.

The executive order may not have much impact for 2017, since government rules for this year already have been incorporated into contracts signed with insurance companies, AP reported.

Smith, a Republican lawmaker from Missouri's 8th District, said during a recent visit to Jackson any replacement bill will include a transition period.

"They (ACA-covered individuals and families) are not going to be thrown off," he said.

Any replacement law will allow for better coverage, Smith said. Conway and all Americans would have "more choices, more options" for health insurance under yet-to-be-drafted Republican legislation, the congressman said.

Lack of insurance competition

Smith said many insurance companies have pulled out of the ACA Exchange, leaving fewer health-care coverage options.

In the 8th District, Smith said 26 of 30 counties have only one provider, including Cape Girardeau County.

Conway said he and his wife initially had coverage through United Healthcare, but that company has since left the market.

The Conways now are insured through Anthem Blue Cross Blue Shield. Conway said the insurance company provides several insurance plans.

U.S. Sen. Roy Blunt, R-Mo., said in an emailed statement many Missourians are "struggling" under the health-care law, "which has left them with higher costs and fewer options than they had even a year ago."

"This year, 97 Missouri counties will have only one insurer participating in the Obamacare exchanges. Last year, every Missouri county had at least two insurance options," Blunt said.

Blunt added most Missourians "will see an increase in their premiums, with some facing an increase upward of 40 percent. Those who can't afford the few options available to them will face a penalty of more than $2,000."

Under the law, Americans face fines if they are not insured.

Blunt said Missouri families "shouldn't be punished for a law that just isn't working."

More insured

But Dave Dillon, spokesman for the Missouri Hospital Association, said the ACA has resulted in more Americans having health-insurance coverage.

Uncompensated care at Missouri hospitals declined by nearly $100 million in 2015, the first decline in a decade, Dillon said.

Uncompensated care consists of charity care and bad debt involving patients who were unable to pay their bills, he said.

In 2015, uncompensated care at 119 hospitals, including the two in Cape Girardeau, totaled $1.2 billion. But that still was better than the previous year and reflects the fact more Missourians had insurance coverage, Dillon said.

"It is good news that more people are insured," he said.

Southeast Hospital and Saint Francis Medical Center each reported more than $15 million worth of uncompensated care in 2015, according to online information from the Missouri Hospital Association.

Those numbers reflected a decrease from 2014, when Saint Francis Medical Center had $22.9 million and Southeast Hospital had $16.3 million in uncompensated care, according to the association.

Those who don't have insurance are more likely to rely on hospital emergency rooms as their primary medical provider, Dillon said.

"It is the most expensive place to get care," he added.

While the ACA took effect in 2010, the insurance exchange did not open until 2014, Dillon said.

"Most of the provisions that affected care did not take effect until 2014," he said.

"The problem is the Affordable Care Act is an interwoven web of parts that are dependent upon one another," Dillon said.

He said the "risk pool has to have both well and sick people" for the insurance system to work properly.

"So it matters if you eliminate the mandate (requiring people to have insurance)," Dillon said.

Red tape for business

Cape Girardeau businessman David Knight objects to the ACA.

He said the law burdened businesses with more red tape and discouraged small businesses from expanding. Knight said the law requires businesses with 50 or more employees to provide health insurance to their employees.

Knight, whose company manufactures and sells wood-burning smoker ovens, said the ACA has resulted in more government regulations that add to the cost of health insurance.

"Part of the problem is nobody read the bill before it passed," he said.

Knight favors allowing insurance companies to compete across state lines.

He said the added competition would reduce the cost of insurance for businesses and individuals.

He said he learned recently he cannot receive Medicare benefits because he and his employees are covered by a private health-insurance plan.

Knight said he could receive Medicare if he dropped it, eliminating coverage for all his employees.

"It is crazy," he said.

Knight said he hopes Congress will repeal the ACA and get government off the backs of businesses.

mbliss@semissourian.com

(573) 388-3641

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Health coverage by the numbers

Number of people in Southeast Missouri by county receiving health coverage through Affordable Care Act insurance plans in February 2016:

• Cape Girardeau -- 2,615
• St. Francois -- 1,963
• Butler -- 1,486
• Scott -- 1,243
• Stoddard -- 1,174
• Dunklin -- 1,057
• Pemiscot -- 747
• New Madrid -- 693
• Ste. Genevieve -- 674
• Perry -- 619
• Bollinger -- 536
• Wayne -- 520
• Madison -- 513
• Ripley -- 475
• Mississippi -- 435
• Iron -- 356
• Carter -- 324
• Reynolds -- 273

Source: Center for Medicare and Medicaid Services, provided by U.S. Sen. Claire McCaskill's office