How Will An Obamacare Repeal Affect The Nation's Freelancers? We Decided To Ask Them.

"I think that repealing ACA would be devastating. It's kind of hard to overstate it."

UPDATED: This article has been updated to reflect that on Thursday, May 4, the American Health Care Act narrowly passed the House of Representatives and will now be considered by the U.S. Senate. 

Today, the House of Representatives voted on the third iteration of a bill to repeal the Affordable Care Act and replace it with the Republican alternative, the American Health Care Act. After two failed attempts to pass the AHCA bill, its contents remain largely controversial, ever-changing, and often unknown, especially as they impact patients with pre-existing conditions. Now that the House has passed the bill 217–213, it still faces what The Washington Post describes as a "steeper climb" in the Senate, with millions of Americans' health care hanging in the balance.

On Wednesday, May 3, Republican legislators scrambled to secure enough votes to pass the bill before a recess on Friday. In an effort to secure more votes from moderates, including influential representatives Fred Upton of Michigan and Billy Long of Missouri, they added an amendment to the AHCA that would provide $8 billion in additional funds over five years to supplement the insurance of people with pre-existing health issues. Now it is clear that these overtures worked, though the actual protections these added funds would provide for patients remain heavily disputed.  

According to The New York Times, Families USA, a liberal health advocacy group, said that $8 billion would "do little to improve so-called high risk pools that would be set up by state governments to help insure people unable to afford insurance on the open market." Overall, House Democrats and several patient organizations, including the American Diabetes Association and the American Heart Association, have united in criticizing the bill, even with the added amendments. On Thursday, all 193 House Democrats unanimously voted "no" on the bill. Twenty House Republicans joined them. 

In many ways, it is still unknown how the proposed bill will affect the average American even after it has passed the House. However, self-employed citizens working in the "freelance gig economy" without the ability to opt into workplace-provided insurance are one of the most crucial economic subsets with the most at stake.

"I think that repealing ACA would be devastating," Brent Messenger, Global Head of Community at Fiverr, an online freelance marketplace, told A Plus. "It's kind of hard to overstate it." Since Donald Trump became president on January 20, 2017, the issue of government health care "has been sort of looming in the background," especially for those, like Messenger, with some role in the skilled gig economy. 

He and his colleagues at Fiverr have been trying to prepare themselves, and the freelancers their platform facilitates, ever since. They've asked themselves, "Okay, how do we respond if the ACA is repealed? What can we do to help our community?" However, not knowing what the latest iteration of the AHCA bill will contain, their answers, if they can even be called that, are "totally unsettled."

Though Messenger doesn't work in the skilled gig economy like the average Fiverr user, he can still imagine being "very worried" about losing his health care under the new bill. Recently, Fiverr polled its community and "found out that there's a significant number of people that have gotten their coverage through ACA [30 percent through an exchange, an additional 22 percent through Medicaid or similar programs]," according to Messenger. He views the Affordable Care Act's economic role as one of providing a sense of security for individuals daring to work for themselves — often in precarious industries. "Generally speaking, ACA has spawned entrepreneurialism," he explained. "It's allowed people to take risks and pursue passions and do things they might not otherwise do. It's taken people away from that notion of job lock."  

Often, those industries are creative ones, ranging from computer animation to voiceover recording to costume design. Jez Insalaco is one such individual who, immediately after graduating from college, has struck out on her own in an highly specialized yet unconventional industry. Because the 23-year-old freelance costume designer works with various theaters in Boston, she is ineligible for employer-provided health insurance. Currently enrolled in Tufts Health Direct, she pays a premium of $43 per month, though it will soon be raised to $49 a month. "Before that, it'd actually been free because I think I was young enough that I didn't have to pay for it," Insalaco told A Plus. "But the thing with government health care is that it's not easy. You have to stay on top of it because some bureaucratic thing can happen in your paperwork, and it can get cancelled." 

She experienced this firsthand after changing addresses in college, which caused her insurance to lapse because she didn't receive letters from her insurance company telling her to renew her paperwork at her new address. It took 60 to 90 days for her new paperwork to process. "That's three months when you're uninsured... Luckily I'm very healthy, so I was fine and I got insurance," she said. As a Boston resident, Insalaco has access to many hospitals through the ACA and opts for Boston Medical Center "just because they have such a big facility" so she knows that "whatever issue [she has], there'll be a department for it."  

Because Insalaco’s parents moved from the United States to Japan when she was in college and still reside there, she is one of the few millennials ineligible to stay on her parents’ health care plan until she is 26. The Affordable Care Act has been, in many ways, a lifesaver for the recent grad.

Photo Credit: Carina Allen
Photo Credit: Carina Allen Jez Insalaco 

"It's been really helpful for me because, as an individual living away from home, I don't have the luxury to hop on to my parents' insurance plan," she explained. "So to be able to have insurance has been really great. And to have it at a relatively affordable cost is really great." 

After polling the Fiverr community of freelancers and small business owners, Messenger and his colleagues found that at a rate of "about two to one," their members favor keeping the Affordable Care Act, even as they acknowledge its imperfections. "We've always sort of suspected that was the case, and I think we know from a business perspective that ACA makes a lot of sense," Messenger added. "But we were happy to know that the freelancers who participate in our marketplace feel the same way, and that they would like to see ACA defended." What form that defense takes and what role the freelancer community plays is yet to be determined, but it's safe to say calling their political representatives has been and will continue to be a key element.    

"I'm sure there could be improvements to the system, but I'm perfectly happy with the way it is," Insalaco concurred. But even as she recognized ACA's benefits, she wasn't afraid to acknowledge its shortcomings. "The system works, but it's work. You have to make sure you're on top of it," she explained. "That's been a part of this year, learning what it means to be a freelancer. It means you have to be really on top of everything." 

And though neither Messenger, the Fiverr community, or Insalaco would call Obamacare perfect, they do believe it is better than any alternatives the GOP has put forth in the past few months.

"I don't think the implications were fully understood, so it's hard to say what the impact would be." Messenger said of the first two attempts to pass AHCA. Despite the bill being passed in the House of Representatives, this lack of foresight remains as it has yet to receive a score from the Congressional Budget Office. "At least if they waited for the estimate, they could make further changes to the bill that might respond to concerns," Douglas Elmendorf, the former director of the nonpartisan CBO, told Politco. "To go ahead with a vote before you know the effects of what you're voting for is a terrible mistake."

"Sometimes, you see representatives working against the interests of their constituencies, and it's painful to watch," he added, referencing the threat to Medicaid coverage in certain states, particularly rural, Southern ones that need it the most. According to a Consumers Union fact sheet from March 2017, "repeal of presumptive and retroactive eligibility" Medicaid applicants will likely force hospitals, especially those in rural areas, to close due to steep decreases in revenues. On the national level, the nonpartisan Congressional Budget Office (CBO) estimated that the AHCA's proposed changes to Medicaid would cause 14 million Americans to lose Medicaid coverage by 2026.

"Our community is spread out all over the country, but we have… large groups of people in sort of more urban areas and, frankly, in states where states will work harder to provide protections for people who are the most vulnerable," Messenger added. "But I do worry from a personal perspective about the most vulnerable — the people that aren't participating in the gig economy — that would be lost in all of this."

One common misconception Insalaco acknowledges that she had herself "up until recently" is that government-funded health care is a handout. Now, however, she said, "I don't think it is a handout because a certain amount of relatively healthy people have to join the program so that people who aren't as healthy, who have more life-threatening conditions, can receive the same health care at the same price." 

While Insalaco is "relatively healthy," she said she joined Obamacare and pays her monthly premium, despite only needing to use her insurance once every two or three month, because she wants to help the system work. "I provide health care for everyone, even though I also am just like above that poverty line when it comes to income," she added. "I feel like I'm also doing my part to help the system exist to help other people." 

Her worries about not only losing her own insurance, but millions of others losing theirs, has contributed to her negative opinion of the AHCA. "I was pretty biased against it, and a lot of it was based off of fear because I have an insurance that does the things I need it to do," Insalaco said of the AHCA bill. "And I don't want to lose it because I know how long it takes to make my insurance work when something goes wrong when there's already a system in place." 

From what she had read and seen about the new plan, she didn't have much faith in Congress's ability to come up with a more comprehensive alternative that benefitted more people at a lower cost.  "There's a lot of fear with people who are in a similar situation [to me]," Insalaco added. Worrying about what will happen to her if Obamacare were repealed and "they don't have a good plan to replace it" has given Insalaco a new source of "anxiety." She imagined a world under the AHCA where "it's not only me trying to figure out the system," but also Congress "trying to figure out what systems work." The result? She said, "It'd just be double the amount of headaches." Potentially without an aspirin in sight — or at an affordable price. 

Nonetheless, it is the nature of these independent, trailblazing, daring entrepreneurs to have what one man once called "the audacity of hope."

The majority of freelancers in the Fiverr community can be categorized as "solo entrepreneurs" fueled by what Messenger called a "rugged independence." He added, "They're not expecting the government to come save them. They're not looking for a handout. They're not looking for anyone to give them anything, except an opportunity to thrive."

The other side of the freelance marketplace, the buyers, are small businesses — oft hailed as the backbone of the American economy and a subset politicians on both side of the aisle, and currently residing in the White House, routinely vow to protect. It would make sense that a president who ran on a neo-populist platform of reviving the American economy would want to support and implement policies that protect that backbone, but the latest iteration of the AHCA does not, even with its newest amendment. "The ability to get insurance with a pre-existing condition is a huge deal," Messenger said. "If you have a pre-existing condition, you're not gonna go out and start your small business. You can't go pursue a risky opportunity, and that's bad for individuals, and that's bad for the economy." 

According to Messenger, the skilled gig economy "is growing by leaps and bounds," while other segments of the economy that might have been "great" in the 1950s continue to struggle. "You'd think he'd [President Trump] want to do things that would prop it up, that would help sustain the growth and expand the growth of the gig economy…" Messenger said. "And not tampering with ACA and improving it — instead of just repealing it for something else — would do that." 

"And it's funny," he added. "You would think that Donald Trump, in particular, would understand that notion, having been the host of, essentially, a game show that was about entrepreneurialism. Yet, somehow there's a disconnect." 

Though Messenger readily admitted how unbelievably complicated health care can be (a frustratingly comparable experience to selecting a cellphone plan), he believed implementing "policies that allow people to make choices" would benefit consumers far more than "policies that force people back into traditional jobs where they can't take risks and pursue entrepreneurialism."

Granted, that's far easier said than done. And far easier said than passed through the legislative branch. "I would hope that whatever comes next, if the ACA is replaced, it [the AHCA] allows a similar type of coverage at a similar type of cost, if not less," he said. "And obviously the reason I say that is because, again, the more people who can feel secure in pursuing something that's not a stable job... where they have health insurance, the better off the gig economy is gonna be."

Case in point: a 23-year-old freelance costume designer empowered to pursue her dream job(s) simply because she was given the opportunity to take care of her most basic need — her health.. "I'm so thankful... I have a career that allows me to live, and I mean, it's living just above the poverty level but still, I'm a millennial and I'm not living at home," Insalaco said. "I'm working in the field that I got my degree in, and I have health insurance. That is a really blessed thing." 

In light of recent events, whether or not Insalaco — and the tens of millions of other self-employed Americans like her — can continue to afford their health insurance is now in the hands of the U.S. Senate. 

Cover image via Shutterstock / Evan El-Amin.

Cover image via Shutterstock