One year after federal health care reform was signed into law by President Barack Obama, it's still so controversial people can't even agree on what to call it.

Supporters tout it as the Affordable Care Act, while opponents demanding its repeal refer to it as "Obamacare."

The legislation, formally named the Patient Protection and Affordable Care Act, faces more than 20 challenges pending in federal court, including one filed by Missouri Lt. Gov. Peter Kinder, a Cape Girardeau Republican.

About 20 provisions of the law took effect during the past year, including extending insurance coverage for dependents up to age 26, preventing insurance companies from denying coverage based on pre-existing conditions, expanding prescription drug coverage for seniors, and creating state insurance pools for high-risk patients. More reforms will roll out over the next three years. The most contentious: a requirement that all Americans who are able to afford it purchase health insurance coverage by 2014.

The act calls for the creation of health insurance exchanges, where people who aren't offered insurance by their employer may purchase coverage. It leaves the responsibility of establishing the exchanges up to the states. Missouri House Bill 609, sponsored by Rep. Chris Molendorp, R-Belton, would establish the Show-Me Health Insurance Exchange. A hearing on the bill is scheduled for Monday.

Kinder, whose lawsuit challenges the constitutionality of the new health care law, said implementing the mandates of the law in Missouri will cost the state $2 billion.

Budget concerns

"It will wreck Missouri's budget, beginning in under three years," Kinder said. "If you think we have a budget shortfall now, this will crowd out everything else in the state budget. Education, roads, bridges. It is designed to force higher taxes."

Kinder's suit, filed July 7, awaits a ruling by U.S. District Court Judge Rodney W. Sippel. The U.S. Justice Department filed to dismiss the suit in January.

Either way Judge Sipple rules, the losing party will appeal the case in the U.S. Court of Appeals' 8th Circuit, Kinder said.

A recent Missouri Foundation for Health poll of 800 Missouri voters showed half the respondents opposed the Affordable Care Act, while 30 percent supported it and 20 percent were undecided. Missourians voted in August to adopt the Health Care Freedom Act, known as Proposition C, by 71 percent. It passed in all 114 counties.

While respondents opposed the law in general, the survey showed there was majority support for many of its individual components.

But more than 80 percent, regardless of gender, age, region or political affiliation, said they supported tax credits for small business providing health insurance, requiring insurance plans to cover preventive health and making it illegal for insurance companies to cut off coverage when patients get sick. Those are all provisions of the Affordable Care Act.

Only 22 percent of those surveyed knew that all the provisions discussed in the survey were actually part of the law, the study showed.

"Missourians and Americans generally just don't understand this law," said Thomas McAuliffe, health policy analyst for the Missouri Foundation for Health. "Twenty-two percent of people in a recent Kaiser Family Foundation poll thought it had already been repealed. There is a general lack of information."

Dr. John Mackel of Continental Wound Center in Cape Girardeau, who teaches health care administration in Southeast Missouri State University's MBA program, said his students are puzzled by the law.

"This is a 2,400-page bill which nobody understands, and the reason nobody understands is because the bricks and mortar of it hasn't been written yet," Mackel said.

Many provisions of the law, including the health insurance exchanges, are left up to states to implement, and many haven't formed plans for several portions.

Businesses are anxious as they await the implementation of remaining reform measures.

"The largest concern for small-business owners is the uncertainty of what's going to happen when all the pieces of this are implemented," said Kathy Swan, owner of JCS Wireless in Cape Girardeau. Swan appeared in a video opposing the health care reform law released Wednesday on Sen. Roy Blunt's website. Several other small-business owners around the state appear in the video, including Glenn Reeves, owner of Horizon Screen Printing and Promotional Products in Cape Girardeau.

Swan is concerned the mandates for companies to offer insurance will keep businesses from expanding their workforce in the future.

'A disincentive'

"Business people will try not to hire if they can do the job without adding another employee, or they'll hire part-time workers instead of full-time workers so they won't be required to provide insurance," Swan said. "Instead of growing the economy this is a disincentive to create more jobs."

Health care is one of the largest line-item expenses on Swan's profit-and-loss statement in her business. Two years ago she switched insurance companies facing a 30 percent increase in premiums. Last year, her business switched to a higher deductible plan.

A native of Northern Ireland, Mackel practiced in Canada when that country's universal health care system was created in the late 1960s.

"It was fabulous," he said. "There were no more copays, no more deductibles, patients could see any doctor they wanted to, go to any hospital."

Americans, however, don't want a system like Canada's in which the government pays for all health care costs, and Mackel said they're right not to want that.

"The design of any health care system has to incorporate deeply held values and cultural norms in that country," Mackel said. "But there is no reason America could not have universal health care."

Most people agree that health care reform was needed, McAuliffe said, but the disagreement comes when asking if this particular legislation gives the country what was needed.

"Missourians understand we need to do something and in lieu of nothing they'll take what we have. Is this a perfect solution? No," he said.

mmiller@semissourian.com

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