SOUTHERN INDIANA — Kyle Megraw's job is tough these days.
A health care insurance agent, Megraw just sent about 300 letters to clients, warning them they will lose coverage under Anthem next year as the company is pulling out of the individual market in Indiana.
"So what does that mean for the people in Southern Indiana?" said Megraw, vice president of marketplace exchanges for Health Insurance By Design in New Albany. " ...That means we really don't have, of the five largest carriers in the country, we don't have an option for health insurance. What is that doing? That's putting a huge strain and a huge stress on these individuals that are going to lose coverage 1-1-2018."
For those who don't qualify for Medicaid or Healthy Indiana Plan 2.0, it appears just two carriers will remain. Neither, Megraw said, offer sustainable plans.
"For quality insurance, we just don't have any option right now, and that is a direct correlation of health care reform not working," he said.
Shrinking marketplace options is just one of the reasons Republican lawmakers have set their sights on repealing and replacing the Affordable Care Act that was enacted in 2014.
Despite the GOP controlling both houses of Congress and the White House, lawmakers can't agree on how the deed should be done.
The House narrowly voted to repeal and replace parts of the ACA in May. The Senate must pass its own version and then the two branches must reconcile both versions before a bill ready for a signature can go to President Donald Trump's desk.
But the bill has been stuck in the Senate for a month now, several iterations failing to garner enough support from a majority of Republicans to even take it to the Senate floor.
Watching the situation from the sidelines has caused frustration, confusion and anxiety for Hoosiers — some who wish Republicans could come to a consensus and others who fear they will.
"It's been rough, especially for those of us who work in the [social services] system, we know that if changes are made, it's going to create an immediate vacuum for our families who are getting healthy now ... that they are going to return to the unhealthy state they were in a couple of years ago," said Missy Smith, a New Albany resident and social worker.
Greg Kordsmeier, assistant professor of sociology for Indiana University Southeast who teaches a course on the social aspects of health and medicine, believes the ACA is the best option on the table to insure the most Americans.
"It's not a perfect bill, and there are certainly issues with it that need to be addressed in order to make it be successful going forward, but the ACA with maybe some minor reforms I think is probably the best way forward right now.
Most people agree that policyholders shouldn't be turned away because of pre-existing conditions, he said.
One fundamental component of the ACA that divides people is the mandate, the law that requires people to buy health insurance. If young, healthy people buy insurance, it increases revenue for insurance companies who pay high claims for unhealthy people who need expensive care.
"The problem is, we knew that all these young 20-year-olds weren't going to buy an insurance plan because they're invincible," said Dr. Dan Eichenberger, president of Baptist Health Floyd Hospital. "They don't think they're going to need it, and they're not going to pay two, three, four-hundred dollars for a plan that they have absolutely no plan on using."
Eichenberger believes the ACA should be repealed and replaced with something completely different. Restrictions or requirements placed on insurance companies cost them money, paid for by policyholders through premiums, he said.
"If you would get rid of some of the mandates and actually let the carriers create plans that people want and coverage that they want to pay for, you would decrease the cost of the premiums tremendously," he said. "That's a true fundamental change."
Kordsmeier, on the other hand, thinks the mandate could work if fewer exemptions were granted. Better advertising of the marketplace exchange could also increase enrollment, he said. He would also like people to be able to buy plans through Medicaid, especially in places with few private insurance options, as long as the companies' livelihoods aren't threatened.
"One of the problems that we have and one of the reasons why I'm skeptical of people who say it has to be completely free-market driven, that that would drive down the cost, is that it would make individual plans much cheaper, but many people wouldn't be qualifying for those plans," Kordsmeier said.
Baptist Health Floyd has seen a "slight increase" in revenue from a higher percentage of insured patients. But Eichenberger said it's nothing sustainable enough to offset the costs of uninsured patients who make too much for Medicaid but who are turned off by the individual marketplace costs.
"Any benefit you get from the 100 patients now on Healthy Indiana Plan, one drug abuser with nothing offsets that in a matter of days," he said.
Like Eichenberger, Megraw believes a return to a market-driven system would lower premiums. He would keep some of the ACA's components, such as protecting people with pre-existing conditions and some of the federal government subsidies.
New Albany resident Dana Garmon and her family of five have gone uninsured since the ACA was enacted in 2014.
Around that time, her employer dropped insurance for part-time employees. Not long after, her husband's employee insurance premiums spiked to $750 a month from $350 monthly, and the deductible rose to $12,000 — from zero.
"When we looked at the exchange when it first rolled out, it was $600 a month with a $12,000 deductible for our family," she said. "It was unaffordable. I haven't looked at it since."
Now, Garmon is going back to school so she can get a higher paying job just to afford health insurance.
She thinks a single-payer system, where the state funds health insurance, is the best option. So does Smith.
John Darr, a public relations and marketing consultant, said he lost $25,000 in income from clients who cut costs, fearing they needed the money to hire specialists to help them become compliant with the ACA. He said the health care reform dealt a "huge blow" to small businesses.
"From that standpoint, what I think personally needs to happen is I think the federal government shouldn't be in the health care industry," Darr said. "I think we're better off allowing states to make their own decisions."
The failure for the GOP to pass a health care bill exposes lawmakers as "obstructionists and not collaborators," Darr said.
"I think it's been very revealing of the current political climate," he said.