SALT LAKE CITY — Several years ago, Stephanie Rosenfeld relied on the health insurance of her then-husband, who owned a small business.

The couple's monthly premium wasn't always easy to pay, but it was manageable, Rosenfeld said. Their health care situation was stable.

Everything changed in 2007 when Rosenfeld's husband had to close his business. He began a job in consulting that didn't come with insurance — and then fell ill.

Around that time, Rosenfeld had her own scare when she was nearly tagged as having a preexisting condition that would have made her lose out on replacement insurance.

"We were just a regular family going through a pretty rough patch," said Rosenfeld, 56, a nonprofit grant writer who doesn't have employer health benefits.

The Sugar House woman credits the Affordable Care Act — nicknamed Obamacare by its opponents — as a financial boon for her beginning in 2014, when she signed up for coverage on the federal insurance exchange.

"I got a sizeable subsidy, and it's really good care because all the preventative stuff is covered," she told the Deseret News recently. "(It's) huge. It keeps people from going under."

While the Affordable Care Act has earned its fair share of converts across the country, it also has been bitterly divisive since becoming law in 2010. Congressional Republicans made it their main target and voted dozens of times to repeal parts of the law while then-President Barack Obama was still in office.

Utah's four House members — all Republicans — voted again Thursday to repeal the law, and this time also voted for its proposed replacement, the American Health Care Act.

The bill, which stalled six weeks earlier and failed to reach a vote, this time narrowly passed the House, 217-213. It next goes to the Senate for consideration.

'The right first step'

Rep. Jason Chaffetz, who wasn't expected to be in Washington this week after foot surgery, made a surprise visit to vote. Chaffetz and Utah's other House members called it a first step toward health care reform.

"No doubt there is still work to do," he said. "But I believe the Republicans’ health care plan is the right first step toward fixing a complex and crumbling system."

Chaffetz, who rolled into the House chamber on a scooter, said Obamacare has driven up premiums for people in his district, and several counties have just one insurer available to them.

"This situation is simply not acceptable. States need the ability to manage health care locally," he said.

Chaffetz, who recently announced he would not seek re-election in 2018 and might step down early, took considerable flak on social media for showing up to vote.

"Jason Chaffetz, fresh from surgery FOR A PREEXISTING CONDITION, en route to sign death warrant for disabled children," said one post on Twitter over a photo of the congressman on the scooter.

Another tweet said: "May his political career end unremarked and he be nothing more than a footnote in history."

Rep. Mia Love said the status quo is unacceptable. The American Health Care Act puts patients in charge of their health decisions and doesn’t require people to buy insurance, she said.

"Utahns, not the federal government, should decide what is best for them and their health care," Love said.

The legislation provides many levels of protection for those with preexisting conditions, while giving states greater flexibility to lower premiums and stabilize the insurance market, she said. Women’s access to health services will be expanded with money going to community health centers, Love said.

The Democratic Congressional Campaign Committee blasted Love for her vote on the bill.

“Make no mistake about it: Love must face the music, look her constituents in the eye, and answer for the mess she created,” committee Chairman Ben Ray Lujan said in a statement.

Lujan said the bill raises premiums and deductibles, tosses 24 million Americans off their insurance, and lets insurers charge more for preexisting conditions.

“That means if you, your kids or your parents are sick with cancer, diabetes or any other illness, insurance will not be affordable,” he said.

Salt Lake City Mayor Jackie Biskupski said the House vote leaves a “grave gap” in health care coverage, especially for senior citizens, low-income families and those most in need.

“This comes at a time when the city, county and state are engaged in a critical collaboration to address homelessness, including some of its underlying causes — most notably mental health and substance abuse,” the mayor said in a statement.

Biskupski said the vote shows that too many congressional leaders are more concerned with political posturing than thoughtful, well-crafted ways to improve the Affordable Care Act.

Rep. Rob Bishop said in addition to raising premiums, Obamacare caused workers to have their hours slashed or even lose their jobs. Americans, he said, have been forced into either a government program or being fined, and newly insured people were pushed into a plan doomed to fail.

"The passage of today's health care reform bill is the first step to allow people to have choices that meet their needs, not forced into what the government demands," Bishop said.

Rep. Chris Stewart said the House delivered on the promise to repeal and replace Obamacare.

"The American Health Care Act will drive down costs, offer families more choices and importantly protect people with preexisting conditions," Stewart said.

Preexisting conditions

Much of the reaction among state leaders centered around the American Health Care Act's provision allowing states to request a waiver to permit insurers to charge higher premiums based on a person's health status, including preexisting conditions.

Under the Affordable Care Act, insurers cannot increase premiums because of preexisting conditions.

People who have a major preexisting condition and do not have proof of continuous coverage would then be classified under a high-risk pool. The American Health Care Act would provide high-risk pool funding for the next several years, though not indefinitely.

That would make up the difference so "they can have premiums like normal-risk (people) and still get coverage," said Rep. Jim Dunnigan, R-Taylorsville, chairman of the Utah Legislature's Health Reform Task Force.

Dunnigan said he is confident the proposed monetary provisions for the high-risk pool will be sufficient to keep costs manageable for those people. Others who are not in high-risk pools will subsequently benefit with improved premiums because of the lightened load on their insurers, he said.

Dunnigan said he believes Utah will ultimately apply for the waiver, which he called "a good step."

Matt Slonaker, executive director of the Utah Health Policy Project, said Utah likely will apply for the waiver at some point, but cautioned that its effects would be crushing for the roughly 1 in 4 Utahns who have a preexisting condition.

"This bill puts them out there as a vulnerable population. With the Affordable Care Act, you had a ban on preexisting condition discrimination,” he said.

Slonaker said he's doubtful that a high-risk pool would be meaningfully useful to most Utahns who could be grouped into it, citing previous high-risk pools in the state prior to the launch of the Affordable Care Act.

”It was unaffordable. It didn’t serve our population," he said. "We have the experience. We know what the old way was like. Why go back?”

Rosenfeld said she's not convinced that people with preexisting conditions would be helped by the American Health Care Act. The term is used to exclude more potential insurance customers from good coverage than Utahns tend to realize, she said.

Rosenfeld narrowly avoided being stamped as having a "preexisting condition," she said, because of a "benign" finding during a gynecological exam.

"It was a complete shock," she said. "You don't have to be very sick or sick at all to be excluded for preexisting conditions. So that's a huge concern of mine."

Before the passage of the Affordable Care Act, Rosenfeld's former husband was moved into a high-risk pool, she said, because of his ongoing health problems.

His experience was a bad one.

"He struggled to pay his premiums, and he couldn't use his health care," Rosenfeld said.

That criticism echoes what some conservatives have been saying about plans offered under the Affordable Care Act — particularly on the individual market.

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Boyd Matheson, president of conservative-leaning Sutherland Institute, told the Deseret News that a reworking of the American health care system is needed because of what he called unacceptably expensive premiums, high deductibles and few health care provider choices, particularly in rural areas.

"What you've seen with Obamacare was particularly people who were supposed to be helped the most haven't really had access to health care because the deductibles are so high," he said.

Matheson said he is encouraged by the waiver option and the funds being set aside under the American Health Care Act to help keep subsidy costs down for people in the high-risk pool. But he said he wants to know more about the high-risk pool generally and would like to see precisely how much those funds could keep subsidies and other costs down.

"Whether those dollars are the right amounts or the right framing, I'm less convinced of that," Matheson said.

There generally isn't enough accessible information about the bill, he said, because it wasn't negotiated nearly enough on the House floor. He said he hopes the debate in the Senate will be more transparent.

"Congress has got to get comfortable having these conversations in front of the American people," Matheson said.

High-risk pool

Greg Bell, Utah Hospital Association CEO and former Republican lieutenant governor of Utah, gave a mixed reaction to the bill but was supportive of the preexisting condition waiver and the idea of states using a high-risk pool.

Bell's characterization of previous such pools are at odds with Slonaker's description. He believes they "worked very well."

"We really believe in a high-risk pool," Bell said.

Under the Affordable Care Act, a person's ability to add or drop insurance, depending only on precisely when they need it, is "really a ridiculous financial arrangement" that naturally drives up premiums to unacceptable levels, he said.

But Bell is also profoundly worried over a Congressional Budget Office report that predicts 24 million fewer Americans would have have health care coverage by 2026 under the American Health Care Act than the Affordable Care Act.

Such a loss of coverage would mean people would go to the emergency room for non-emergency care, costing themselves and hospitals more, he said.

A new Congressional Budge Office report on the amended American Health Care Act was not completed prior to the House vote.

State Senate Minority Leader Gene Davis, D-Salt Lake City, said he's skeptical that the federal money to help states create high-risk pools will make health insurance as affordable as Republicans believe it will. It's likely that the monthly subsidy for someone in a high-risk pool would become unsustainably high, he said.

"These pools are limited in time and scope, and they are not funded on an ongoing basis," Davis said. "It's a temporary funding that then drops on the states to either do or walk away from."

Davis also went after the lifetime and per-year coverage limits that would be allowed under the American Health Care Act but are outlawed under the Affordable Care Act. Such an allowance would be devastating for families facing major health crises, he said.

"How does a family pay for saving the life of their child without declaring bankruptcy?" Davis asked rhetorically.

A rallying cry

Advocates, political candidates and others gathered Thursday night in downtown Salt Lake City for a rally denouncing the bill.

About 70 people at the Wallace Bennett Federal Building took turns calling out and booing Utah's representatives in the U.S. House for approving the measure. Many told personal stories, and others about loved ones fearing impossible fees under the pared down replacement.

"You can be young and healthy one minute, and young and sick the next," said Darlene McDonald, the Democrat challenging Love in Utah's Fourth District. McDonald said she was diagnosed with lupus in her early 30s.

"I'm angry," said Stephanie Gomez, 33.

Before buying health insurance on the federal exchange established by the Affordable Care Act, Gomez was uninsured. She recounted waiting days to go to the doctor for a staff infection in her arm because she was nervous about the medical bill.

"You're lucky to be alive," the doctor told her.

Gomez's job as an adjunct professor does not include benefits, and she makes about $20,000 a year. She now receives mental health treatment for severe anxiety, and fears she will lose that coverage if the new bill passes.

"ACA, while not perfect, gives me insurance," Gomez said.

Contributing: Annie Knox, Ladd Egan

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