Don and Debra Clark of Springfield, Mo., are glad they have health insurance. Don is 56 and Debra is 58. The Clarks say they know the risk of an unexpected illness or medical event is rising as they age and they must have coverage.
Don is retired and Debra works part time a couple of days a week. As a result, along with about 20 million other Americans, they buy health insurance in the individual market -- the one significantly altered by the Affordable Care Act (ACA).
But the Clarks are not happy at all with what they pay for their coverage -- $1,400 a month for a plan with a $4,500 deductible. Nor are they looking forward to the ACA's fifth open enrollment period, which runs from Wednesday through Dec. 15 in most states. Many insurers are raising premiums by double digits, in part because of the Trump administration's decision to stop payments to insurers to cover the discounts they are required to give to some low-income customers to cover out-of-pocket costs.
"This has become a nightmare," said Don Clark. "We are now spending about 30 percent of our income on health insurance and health care. We did not plan for that."
Karen Steininger, 62, of Altoona, Iowa, said her ACA coverage not only gave her peace of mind but also helped her and her husband, who is now on Medicare, stay in business the past few years. But they too are concerned about rising costs and the effect of the president's actions.
The Steiningers are self-employed owners of a pottery studio. Their income varies year to year. They now pay $245 a month for Karen's subsidized coverage, which, like the Clarks', has a $4,500 deductible. Without the government subsidy, the premium would be about $700 a month.
"What if we make more money and get less of a subsidy or just if the premiums increase a lot?" Karen Steininger asked. "That would be a burden. We'll have to cut back on something or switch to cheaper coverage."
The experiences of the Clarks and the Steiningers point to an emerging shortfall in the ACA's promise of easier access to affordable health insurance for early retirees and the self-employed. Rising premiums and deductibles, recent actions by the Trump administration, and unceasing political fights over the law threaten those benefits for millions of older Americans.
"These folks are rightly the most worried and confused right now," said Kevin Lucia, a health insurance specialist and research professor at Georgetown University's Health Policy Institute in Washington, D.C. "Decisions about which health plan is best for them is more complicated for 2018, and many people feel more uncertain about the future of the law itself."
At highest risk are couples like the Clarks who get no government subsidy (which comes in the form of an advanced tax credit) when they buy insurance. That subsidy is available to people earning up to 400 percent of the federal poverty level, or just under $65,000 for a couple. Their income is just above the amount that would have qualified them for a subsidy in 2017.