Oba­macare re­peal bills au­gur huge dis­rup­tions

GOP plans could stir tur­moil for pa­tients, in­sur­ance mar­kets and hospi­tals, some warn.

Los Angeles Times - - FRONT PAGE - By Noam N. Levey

WASH­ING­TON — Con­gres­sional Repub­li­cans, who for years de­nounced the Af­ford­able Care Act for dis­rupt­ing Amer­i­cans’ health­care, are now push­ing changes that threaten to not only strip health cov­er­age from mil­lions but also up­end in­sur­ance mar­kets, crip­ple state bud­gets and drive med­i­cal clin­ics and hospi­tals to the break­ing point.

Pres­i­dent Trump and GOP con­gres­sional lead­ers have touted their Oba­macare re­peal bills — one passed by the House last month and a Se­nate ver­sion un­veiled last week — as a nec­es­sary fix to prob­lems cre­ated by the Af­ford­able Care Act, known as Oba­macare. But in physi­cians’ of­fices and med­i­cal cen­ters, in state leg­is­la­tures and cor­po­rate of­fices, there are grow­ing fears that the un­prece­dented cuts pro­posed in the GOP leg­is­la­tion would cre­ate even larger prob­lems in the U.S. health­care sys­tem.

“These re­duc­tions are go­ing to wreak havoc,” warned Tom Priselac, chief ex­ec­u­tive of Cedars-Si­nai Health Sys­tem in Los An­ge­les, one of the coun­try’s lead­ing med­i­cal cen­ters. “It will be a tragic step back­ward not just for the peo­ple most af­fected, but for the coun­try as a whole.”

Trump sounded a very dif­fer­ent note in his weekly ra­dio ad­dress Satur­day, pledg­ing anew to save Amer­i­cans from ris­ing health­care costs he blames on Oba­macare. “The Amer­i­can peo­ple are calling out for re­lief, and my ad­min­is­tra­tion is de­ter­mined to pro­vide it,” he said.

Even sup­port­ers of the Af­ford­able Care Act ac­knowl­edge the cur­rent law needs ad­just­ments, es­pe­cially to in­sur­ance mar­kets in which pre­mi­ums have risen sharply in re­cent years and many in­sur­ers have pulled out.

But there are few in­di­ca­tions the GOP re­peal bills would bring much sta­bil­ity.

The non­par­ti­san Con­gres­sional Bud­get Of­fice es­ti­mated that the House re­peal bill, which Trump cel­e­brated in a Rose Gar­den cer­e­mony last month, would nearly dou­ble the num­ber of Amer­i­cans with­out health cov­er­age over the next decade, push­ing the ranks of the unin­sured to more than 50 mil­lion.

And the Se­nate bill, which in­cludes even deeper cuts over time, is un­likely to be much less dis­rup­tive.

The cas­cad­ing ef­fects of such a re­trench­ment will reach far be­yond those who lose cov­er­age, ac­cord­ing to doc­tors, hos­pi­tal lead­ers, in­sur­ance ex­ec­u­tives, pa­tient ad­vo­cates and state of­fi­cials across the coun­try. To date, not a sin­gle lead­ing pa­tient group or physi­cian or­ga­ni­za­tion has sup­ported the GOP re­peal bills.

Gover­nors and state leg­is­la­tors, fac­ing huge re­duc­tions in fed­eral Med­i­caid fund­ing, may soon have to de­cide whether to re­duce ser­vices, limit who can en­roll in the health­care safety net or make cuts to other state pro­grams, such as ed­u­ca­tion or trans­porta­tion.

On Fri­day, Ne­vada Gov. Brian San­doval, a Repub­li­can who ex­panded his state’s Med­i­caid pro­gram through Oba­macare, warned that the Se­nate bill would cost Ne­vada nearly half a bil­lion dol­lars.

“That’s a cost that the state can­not sus­tain,” he said.

Although the Med­i­caid cuts may be phased in over sev­eral years, many states with two-year bud­gets would have to be­gin con­fronting the cuts sooner.

The House bill slashes more than $800 bil­lion in fed­eral Med­i­caid spend­ing over the next decade, ac­cord­ing to the Con­gres­sional Bud­get Of­fice, cut­ting nearly a quar­ter of fed­eral aid for a pro­gram that now cov­ers more than 70 mil­lion poor Amer­i­cans.

The ex­tent of the cuts in the Se­nate bill is still un­clear, but the Se­nate ver­sion caps fed­eral Med­i­caid spend­ing even more ag­gres­sively over time than the House leg­is­la­tion, fun­da­men­tally chang­ing the pro­gram’s his­tor­i­cal cov­er­age guar­an­tee.

Over the last half a cen­tury, the fed­eral gov­ern­ment has paid a share of all med­i­cal ex­penses in­curred by Med­i­caid pa­tients. But un­der the GOP plans, that fund­ing would be re­placed by fixed pay­ments to states, de­spite pa­tient care costs.

Un­der the Se­nate plan, be­cause that cap would in­crease only at the rate of in­fla­tion, states may bear an in­creas­ingly larger share of med­i­cal costs, which have tra­di­tion­ally in­creased faster than in­fla­tion.

In ad­di­tion to the Med­i­caid re­duc­tions, the House and Se­nate re­peal bills would dra­mat­i­cally scale back fi­nan­cial as­sis­tance to low- and mod­er­ate-in­come Amer­i­cans who buy health plans on Oba­macare in­sur­ance mar­ket­places.

The cuts would make health cov­er­age sub­stan­tially more ex­pen­sive for many con­sumers, forc­ing some to drop their in­sur­ance cov­er­age al­to­gether, in­de­pen­dent analy­ses, in­clud­ing from the Con­gres­sional Bud­get Of­fice, have con­cluded.

Those cov­er­age losses, in turn, will put new pres­sures on doc­tors, clin­ics and hospi­tals as they face grow­ing num­bers of pa­tients with no in­sur­ance who are un­able to pay their med­i­cal bills.

Marsh­field Clinic, a large health sys­tem that serves more than 2 mil­lion pa­tients in cen­tral Wis­con­sin, is an­tic­i­pat­ing that the pas­sage of the GOP plan would lead to a ma­jor in­crease in the amount of care it would have to pro­vide for free, said Dr. Susan Tur­ney, the sys­tem’s chief ex­ec­u­tive.

At Val­ley Health, a net­work of clin­ics serv­ing mostly poor pa­tients in West Vir­ginia, south­ern Ohio and eastern Ken­tucky, fewer pa­tients with in­sur­ance would prob­a­bly force cut­backs in ser­vices, such as ex­tended pe­di­atric hours that al­low work­ing par­ents to bring in sick chil­dren dur­ing evenings and week­ends.

“There will be kids and fam­i­lies that will suf­fer, and the health­care in our com­mu­ni­ties will suf­fer,” said Val­ley Health Chief Ex­ec­u­tive Steve L. Shat­tls.

The strain on hospi­tals and doc­tors will reach be­yond the health­care sys­tem.

Amer­i­can em­ploy­ers, which pro­vide health cov­er­age to more than 150 mil­lion work­ers and their fam­i­lies, could see their costs rise as hospi­tals and physi­cians try to make up for losses they in­cur car­ing for more unin­sured pa­tients.

“Ul­ti­mately, if there is in­ad­e­quate in­sur­ance cov­er­age, med­i­cal providers will try to get the rev­enue they need by in­creas­ing prices,” said David Lan­sky, head of the Pa­cific Busi­ness Group on Health, a con­sor­tium of large West Coast em­ploy­ers, in­clud­ing Boe­ing, Chevron, In­tel and Wells Fargo. “That hits em­ploy­ers.”

It also will prob­a­bly hit em­ploy­ees, who will see in­sur­ance pre­mi­ums in­crease and wages stag­nate as busi­nesses shift health­care costs onto work­ers, as has hap­pened re­peat­edly in the past.

In re­cent years, by con­trast, work­ers’ health­care costs have in­creased at his­tor­i­cally slow rates, data show.

In­sur­ance mar­kets, too, could see in­creas­ing tur­moil as states elim­i­nate na­tional stan­dards in the cur­rent law that re­quire all plans to cover a list of ba­sic ben­e­fits and for­bid higher prices for sick pa­tients, push­ing in­sur­ance com­pa­nies back to designing health plans tai­lored to at­tract cheaper, health­ier con­sumers.

The Con­gres­sional Bud­get Of­fice’s anal­y­sis of the House bill, which is broadly sim­i­lar to the Se­nate leg­is­la­tion, es­ti­mated that in­sur­ance mar­kets serv­ing about a sixth of the coun­try would be­come un­sta­ble in com­ing years.

Adding to the in­sta­bil­ity, the Se­nate bill would elim­i­nate the un­pop­u­lar Oba­macare man­date that all Amer­i­cans buy in­sur­ance, while fail­ing to re­place it with any penalty on con­sumers who don’t get cov­er­age un­til after they get sick.

Such penal­ties, which Medi­care has long re­lied on to keep that sys­tem fi­nan­cially sound, are widely viewed as crit­i­cal to func­tion­ing in­sur­ance mar­kets be­cause they in­duce younger, health­ier peo­ple to get cov­er­age.

Be­fore Oba­macare, sev­eral states, in­clud­ing New York and Wash­ing­ton, saw their in­sur­ance mar­kets col­lapse when state lead­ers tried to guar­an­tee cov­er­age with­out any in­sur­ance re­quire­ment.

“No one in any com­mu­nity in New York wants to see his­tory re­peat it­self,” said Karen Ig­nagni, chief ex­ec­u­tive of Em­blemHealth, one of the state’s lead­ing in­sur­ers.

In Athens, Texas, Dr. Dou­glas Cur­ran, a fam­ily physi­cian, is equally trou­bled by what he sees hap­pen­ing in Wash­ing­ton.

“When it comes to the pol­i­tics, I don’t have a dog in the fight,” said Cur­ran, who has been tend­ing to pa­tients in the small city south­east of Dal­las for nearly 40 years. “There is plenty that I’d like to see fixed, but it sure would be nice if we just fo­cused on mak­ing sure ev­ery­one could get care. I just don’t see a lot of that right now.”

Ro­nen Tivony Sipa USA

A MAN ral­lies for the Af­ford­able Care Act at a march in L.A. The health­care cuts sought by Repub­li­cans “will be a tragic step back­ward,” an ex­pert says.

Evan Vucci As­so­ci­ated Press

THE CON­GRES­SIONAL Bud­get Of­fice es­ti­mated that the House health­care bill, whose pas­sage Pres­i­dent Trump cel­e­brated in a Rose Gar­den cer­e­mony, would push the num­ber of unin­sured to more than 50 mil­lion.

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