An Uncertain Future: The Fate of the ACA, and Those Who Depend On It, Is In Limbo

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An Uncertain Future: The Fate of the ACA, and Those Who Depend On It, Is In Limbo

Uncertainty surrounding the future of the Affordable Care Act, also known as Obamacare, is steeped in policy-related what-ifs that are nearly as dizzying as the voluminous 2010 law that changed the way health insurance was delivered and paved the way for millions more Americans to gain health coverage.

But for Columbians Scott Fines and Brianna Lennon — and more specifically, their son, Ryan — the uncertainty is deep and personal.

Ryan was born in 2014 with a rare congenital defect, esophageal atresia — his mouth did not connect to his stomach — that required extensive surgeries, nursing and care.

That health history would be considered a pre-existing condition under pre-Obamacare insurance requirements, most likely meaning Ryan would not be able to find health coverage as he grows older — at least not for an affordable price.

Fines pleaded in an open letter to Congress, “Please do not steal my son’s health from him.”

REPEAL AND REPLACE?

Both the Senate and the House have passed budget reconciliation measures that aim to remove the penalty for not having health insurance — which would basically nullify the so-called individual mandate for everyone to purchase coverage — and the mechanics of providing subsidies to qualified families and individuals to help offset the cost of a health plan. Committees now are working on ways to achieve those objectives while other legislators are floating proposals that would replace Obamacare.

Rather than repeal-and-replace, opponents of the efforts to dismantle the Affordable Care Act have called for “replace-then-repeal.”

“You don’t tear down your house before you find a new place to live,” said Jen Bersdale, executive director of Missouri Health Care for All, an advocacy group that staged statewide rallies this week to bring attention to the call for Congress to first work on a replacement for Obamacare that protects the estimated 30 million Americans — including 900,000 Missourians — who have health insurance as a result of the law.

“We see this train just kind of moving down the tracks,” Bersdale said, adding that there shouldn’t be a sense of urgency, especially considering Republicans in Congress have said for several years now that they were working on a replacement plan.

Bersdale said there’s consensus even among Obamacare advocates that the health care law needs changes. For instance, even though the uninsured rate is lower than ever, health care really hasn’t become more affordable for everyone. Premiums continue to increase, though less than before the Affordable Care Act took effect, she said.

“The ACA has started behind that cost curve,” she said. “Don’t roll back the progress we’ve made. It’s helping a lot of people that really had no options before.”

Dave Dillon, vice president of public and media relations for the Missouri Hospital Association, said changes to the law could have “far-reaching implications” to hospitals and health providers, which in turn could affect jobs and the economy.

Bersdale added, “It’s really kind of playing Russian roulette with something that’s important to peoples’ lives.”

Fines and Lennon are a family that dispels the myth that Obamacare primarily was a law to help low-income people obtain health insurance. Fines succinctly pointed out in his letter that Ryan was “lucky.”

“He was born … to successful parents with good employer-provided insurance; there were no coverage gaps, no denials of coverage, and no limits on how much insurance would pay,” he wrote, detailing provisions of the law.

Fines is a software engineer. Lennon, who recently joined a local law firm and previously worked in the attorney general and secretary of state offices, unsuccessfully ran for the Boone County Commission last fall.

Repealing the Affordable Care Act could allow insurance companies to deny coverage to Ryan “for the rest of his life.”

“Please do not make his future impossible before he even has a chance to live it. Please do not repeal the Affordable Care Act,” Fines wrote.

Fines continued: “We rely on our representatives to protect us from forces which are beyond our control. I cannot stop a gigantic national corporation from preventing my son from getting life-saving treatments, but you can. I cannot stop a hospital from denying him care because he can’t afford it, but you can.”

‘A LITTLE BIT NERVOUS’

Even before the Affordable Care Act was signed into law nearly seven years ago, it already was a divisive issue.

Supporters said the law would deliver on its promise to provide affordable insurance and consumer protections for millions of uninsured Americans. Opponents warned of unknown, unintended consequences, including crushing costs to taxpayers.

Even though the Republican-controlled House voted more than 40 times to kill the law, the Senate did not agree. Now that Republicans control the presidency, the House and the Senate, there are clear indications that at least portions of the law are doomed.

“It’s too early to know what direction they’re going to go,” Dillon said. “We don’t know exactly what policy solutions are going to be put into place. We’re certainly paying very close attention.” But the lack of a replacement plan “makes many portions of the provider community — not just hospitals — a little bit nervous.”

Boone Hospital Center spokeswoman Madison Burke said hospital officials were not commenting on the topic yet “as it is currently all speculative.”

University of Missouri Health Care officials referred questions to Dillon at the Missouri Hospital Association.

“It would be difficult to project potential policy implications of ACA repeal when there is no proposed plan to replace it,” said MU Health spokeswoman Mary Jenkins.

Meanwhile, the hospital association on Tuesday released its annual community investment report that showed for the first time in a decade a reduction in “uncompensated care” — charity or free care and bad debt of unpaid medical bills — for 2015.

Dillon said the figures reflected, in part, the additional number of people with health insurance as a result of the online health insurance marketplace that the federal government began for Missouri in 2014.

“What it says fairly clearly is when individuals have health insurance, they have the ability to pay for their care,” Dillon said. “The folks who were able to access insurance through the new marketplace, probably subsidized in many cases, were able to pay for their care.”

Any effort to roll back provisions that helped reduce the number of uninsured Missourians from some 900,000 to 700,000 could push the uninsured numbers right back up, Dillon said, which would increase the costs for health systems.

“When those individuals don’t have insurance, there’s a significant cost shift to pay for uncompensated care,” Dillon said.

Boone Hospital provided $6.8 million in charity care in 2015, down from $7.2 million the previous year but more than the $5.7 million in 2013. MU Health provided $19.6 million in charity care in 2015, down almost $1.1 million from 2014 but up almost $1 million from the 2013 total.

When it comes to unpaid medical bills, Boone’s total for 2015 was $8 million, compared to $10.2 million in 2014 — the year Obamacare health insurance marketplace plans first went into effect. MU Health’s bad debt total in 2015 was $27.8 million, up from $27.1 million in 2014.

Although the numbers fluctuate, there is indication statewide that an overall decrease in charity costs and bad debt was related to the advent of the health insurance marketplace that offers federal subsidies to qualified individuals and families to help offset the cost of commercial health insurance.

 

The community investment report detailed that Missouri hospitals delivered $2.7 billion in “community benefit” — including $1.2 billion in uncompensated care — to communities throughout the state in 2015.

“Although a decrease in Missourians needing charity care is good news, hospitals continue to bear the cost of the state’s high uninsured rate,” said Herb Kuhn, president and CEO of the Missouri Hospital Association.

Kuhn said hospitals provide a significant financial boost to the communities they serve, where they often are the largest employer. In addition, hospital investments in their facilities “underpin the economy of cities, small and large, providing support for families and businesses throughout the state,” he said in a news release.

‘IT’S ALL INTERCONNECTED’

While the mandate that requires everyone purchase insurance and the subsidies for people who qualify often are at the heart of debate over the health care law, there are multiple aspects of Obamacare that have become a part of the new way health insurers do business. Those changes have probably become a common expectation, Dillon said.

For instance, insurance companies are now required to provide cover at no-cost an array of preventative services — mammograms, colonoscopies and others; allow young adults to stay on their parents’ health plans until the age of 26; no cap on lifetime coverage limits; and, among other things, a prohibition on denying coverage because of a pre-existing condition.

“It’s all interconnected,” Dillon said. “If you start taking pieces apart, it has implications for all the other parts of the system.”

And if there’s no mandate to have insurance yet the marketplace remains, the dwindling number of carriers that offer plans — Anthem is the only carrier for Boone County — could shrink even more. Without younger, healthier people in the risk pool, rates would increase for poorer, potentially sicker individuals who receive subsidies.

Another wild card in the Obamacare repeal-and-replace scenarios is Medicaid, the “safety net” that provides health insurance to some 70 million Americans. The health law created a provision to expand Medicaid programs by using less restrictive guidelines, but the Supreme Court in 2013 struck down the federal government’s ability to withhold Medicaid money to states that refused to expand the program.

Missouri was one of 19 states that did not expand Medicaid. Missouri also was among the 30-plus states that declined to establish their own health insurance exchange, or online marketplace, meaning the federal government had to step in to run the exchange.

It’s possible that a new ACA repeal bill could leave Medicaid untouched and instead focus only on the private insurance reforms, the individual mandate and the subsidies. But many in Congress appear to want to use repeal to reform Medicaid as well.

Dillon said changes to Medicaid add to the “pocketbook issues” related to ACA reform. For instance, states were expected to expand the program, which would have meant more patients with the ability to pay for services. As a result, the law called for a reduction in payments known as disproportionate share funds that hospitals received for taking care of people with little or no ability to pay for their care.

So far, those payments have not been reduced, but the timeline for starting those reductions is looming — and hasn’t been changed, Dillon said.

The potential funding loss for Missouri hospitals, particularly those in rural areas, is “extremely concerning,” Dillon said.

Bersdale also pointed out the growing chorus of Congressional voices to transition Medicaid to a block grant program that could make the funding competitive among states with a cap on overall spending. She said formulas currently being floated would lead to a 30 to 40 percent decrease in federal Medicaid spending over the next few years.

“There’s no way for a state to come up with that kind of money,” she said.

The result likely would be massive cuts at the state level leading to fewer low-income families and children being uninsured, she said.

Despite all the hand-wringing and rancor about Obamacare’s future, Bersdale said there have not yet been any changes. Advocates of the law and the online marketplace are getting a lot of questions possibly losing health insurance, she said, especially from people with pre-existing conditions.

“No one is losing their health insurance the minute there’s a vote,” she said, adding that people should continue to pay their premiums. “It’s really what happens a year or two or three from now that we’re worried about.”

Source: Columbia Daily Tribune