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Americans are getting their first close look at a congressional proposal to replace the federal Affordable Care Act (ACA), also known as “Obamacare.” There’s a lot to pore over, but the first and most overriding concern from the hospital perspective is that access to health care through safety net providers does not equal coverage – and coverage is essential to good health, a strong health care delivery system and reduced health care costs. This proposal threatens to both reduce coverage and access for poor, elderly and disabled Iowans, making it a significant step backward from the current law.

President Trump assured the country that no one would lose coverage under his plan, but this proposal does not uphold that guarantee. Most significantly, the legislation would undermine Medicaid expansion. Iowa took a big step closer to becoming the nation’s healthiest state when Governor Branstad agreed to expand Medicaid. Because of expansion, 150,000 more Iowans have access to a primary care doctor and preventive care. They have a home in the health care system and they are receiving more of the right care, in the right place, at the right time.

It would be a very harmful step backward if those Iowans lose their coverage and the state returns to the days when Iowans were forced to rely on hospital emergency rooms for much if not all of their health care. That’s not good for those Iowans and it’s just not a smart way to deliver health care services. Stripping Iowans of coverage for routine and preventive care will raise health care costs for all. And all of this comes at a time when Iowans and communities are struggling with an epidemic of drug addiction.

The proposal to change Medicaid from a federal-state partnership to a program that simply provides per-capita lump-sum payments to the states raises serious worries about the future coverage of 630,000 Iowa residents who depend on the program. Most notably, this fundamental change in Medicaid could eventually force the state, facing another tight budget year, to reduce care or tighten eligibility requirements, creating more uninsured, unhealthy Iowans.

More Iowans without coverage raises real concerns about the future of Iowa hospitals. As more people gained health insurance coverage through ACA, Iowa hospitals have seen a significant decrease in the need for charity care. That was expected. In fact, when ACA became law in 2010, it required Iowa hospitals to give up millions of dollars in future Medicare and Medicaid payments because more insured people would drive down the need for charity care.

That is precisely what happened. However, while the proposal would bring an eventual end to expanded coverage through Medicaid, it does not fully restore what hospitals gave up for ACA. That paints a very unstable financial picture for hospitals in Iowa, which are already struggling with increased costs, payment delays and denials related to the state’s transition to privately managed Medicaid.

The Affordable Care Act is not perfect, but it has achieved important progress by insuring more Americans, providing greater access to high-quality health care and bringing greater stability to health care finances, among other improvements. As our federal legislators consider the future of the ACA, Iowa hospitals are asking Congress to abide by the adage: “Do no harm.”

Unfortunately, this first attempt fails to uphold that principle.

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