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Experts at the Congressional Budget Office say the American Health Care Act (AHCA) would result in 23 million people — including children, the disabled and those with pre-existing conditions — losing coverage by 2026. The analysis also shows the bill would disproportionately affect older Americans, ages 50 to 64, and those covered by Medicaid. Obviously, this includes thousands of Iowans.

Iowa hospitals are particularly concerned about the enormously negative impact to Medicaid from AHCA, which includes $834 billion in cuts to the program. Most distressing is the bill’s intent to roll back Medicaid expansion, which has benefited some 150,000 Iowans who now have coverage and much improved access to consistent, coordinated health care.

AHCA “per-capita caps” placed on Medicaid federal funding would shift greater cost and risk to states. In turn, states would likely respond by tightening Medicaid eligibility requirements and reducing enrollee benefits and provider payments. Meanwhile, states would have to fully cover any future unexpected Medicaid costs without federal help, radically changing a 50-year partnership between state and federal government that has responded to unexpected health crises, including hurricanes and floods as well as economic downturns. Again, tightening eligibility and cutting payments are likely responses.

Here is what else we know:

AHCA would be especially harmful to rural Americans. Nearly 1.7 million rural Americans have gained coverage through Medicaid expansion. In Iowa and at least seven other expansion states, more than one-third of expansion enrollees live in rural areas. Rural hospitals depend on Medicaid for 10-20 percent of their revenue and, because of their smaller patient volume, do not have other revenue sources to make up for what would be lost if AHCA is implemented. Most of the 78 rural hospitals that have closed since 2010 are in states that did not expand Medicaid.

AHCA would cost Iowa jobs: A new study estimates the AHCA would cause serious economic damage across the nation, including the loss of some 9,200 jobs in Iowa. The AHCA would raise employment and economic activity at first, but lower them in the long run. It initially raises the federal deficit when taxes are repealed, leading to 864,000 more jobs in 2018. In later years, reductions in support for health insurance would cause negative economic effects. By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower and business output would be $148 billion less.

AHCA threatens special education programs. School districts, including those in Iowa, rely on Medicaid to provide costly services to millions of students with disabilities across the country. AHCA-imposed “per-capita caps” on Medicaid would effectively transfer the burden of health care to state budgets, likely resulting in higher taxes, eligibility cuts or curtailed services for children or others who depend on Medicaid. Many such education services are mandated under federal law but even now struggle from chronic underfunding.

Medicaid is crucial to fighting the opioid crisis. More than two million Americans are fighting a prescription opioid addiction and another 591,000 have a heroin addiction. Opioid overdoses killed 61 Iowans in 2015, more than double the number from 2005. Medicaid and the Children’s Health Insurance Program cover about one in three of these patients, but their coverage could be lost under AHCA. Coverage of expensive medications, such as methadone and naltrexone, is included in most states’ Medicaid programs and has been effective in reversing addiction, especially when combined with counseling. Most states have also increased Medicaid enrollees’ access to naloxone, which can save the life of someone who has overdosed on opioids.

AHCA could also affect people insured through their work. The Affordable Care Act (ACA), which AHCA seeks to replace, protects essential health benefits (EHBs), a baseline of common procedures and items including emergency room visits, prenatal care, mental-health care and some prescriptions. Because of ACA, employer plans cannot place lifetime limits on the amount plans pay out on EHBs and requires plans to limit out-of-pocket costs an employee must pay annually. The AHCA would allow a business to drop these employee protections by choosing regulations by way of a state-granted waiver.

Americans generally agree that AHCA is a bad idea. The most recent Kaiser Health Tracking Poll finds more Americans have an unfavorable view of the AHCA than a favorable one (55 percent vs. 31 percent, respectively). This poll also showed a considerable “enthusiasm gap” with a far larger share saying that they have a “very unfavorable” view (40 percent) than saying they have a “very favorable” view (12 percent). An earlier Quinnipiac poll showed similar results, with 21 percent of voters supporting AHCA while 56 percent opposed it.

Meanwhile, public approval of ACA has increased to a majority since the election, according to Gallup, from 42 percent approving and 53 percent disapproving in November 2016 to 55 percent approving and 41 percent disapproving in early April 2017.

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IHA opposes congressional efforts to replace or repeal the Affordable Care Act (ACA) through the recently passed American Health Care Act (AHCA), which threatens to roll back coverage obtained through ACA and Medicaid expansion, putting thousands of Iowans at risk. This is the story of one such Iowan. (We have changed this person’s name to protect his privacy.)

“Thomas” is a Cedar Rapids resident who jumped at the chance to sign up for health insurance on the Affordable Care Act insurance exchange as soon as it became available. He has Type 2 diabetes – a diagnosis he’s had since he was first diagnosed in 1997.

When ACA came along – it wasn’t totally the tax credit that was as appealing for Thomas so much as it was the pre-existing condition that was waived. Up to that point insurance companies would not cover him on because, quote, “they knew they were going to lose money on me.”

Thomas went through a divorce and lost his health insurance. It was during his years without insurance his diabetes went unmanaged. He now has kidney dialysis three times a week for three hours a day.

“Between paying for health care and all my other responsibilities in life – lights, water, gas, mortgage – there wasn’t a whole lot of money left to pay for health insurance,” said Thomas. “During this time I would squirrel any medicine I had for my diabetes away and take the medications one day here and there and just try to bounce my way through it and survive. It was cost-prohibitive most of the time. Had I been vigilant and kept up with managing my health – I might not be where I am now.”

Today Thomas, who is in his early 40s, is in stage four kidney failure. He hopes to soon get on the transplant list for a new kidney.

“Without affordable health care – I might as well cash out,” said Thomas. “It’s my safety net and without it I would either be dead of financially buried.”

Thomas estimates he would pay $2,800 a month for his diabetic supplies, which is $33,600 a year without his insurance through ACA. Right now he pays about $240 a month for his health insurance with a $5,500 deductible.

“That’s reasonable,” said Thomas. “I can handle that. I am a contract employee and am not able to obtain insurance through my employer – so this allows me to get treatment and stay alive. I probably could go on Medicaid but I want to work. I am able to work but what about the individuals who are unable to work because they are too sick – they didn’t ask for their illnesses. Having a pre-existing condition is the worst because I can’t change myself. I’m able to work and find a way to pay the premium but if that pre-existing condition clause comes back then no one will insure me. I can’t expect any health care provider or hospital to work for free. (His physician) has gone above and beyond in getting me as many samples as she can but I can’t live on samples forever.”

“Maybe the people at the top making these decisions should go without health care for a year and see what that’s like. What would they do? I know for me – without dialysis, I wouldn’t make it.”

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The American Health Care Act (AHCA), the bill recently passed by the US House, is a storm rolling in from Washington, DC. Obscured by foggy notions of improved fiscal flexibility for states and broader insurance choices for individuals, the AHCA will in fact hamstring state budgets and wipe out coverage in ways that endanger the health of thousands of Iowans and the financial viability of the 118 community hospitals they count on.

AHCA would effectively end the Affordable Care Act’s (ACA) Medicaid expansion and radically restructure the entire Medicaid program through a per capita cap. It would replace the ACA’s premium tax credit and cost-sharing protections with tax credits that would make coverage unaffordable for millions of Americans looking to purchase coverage in the individual market. Taken together, these and other provisions would increase the number of uninsured Americans by 23 million by 2026, according to the Congressional Budget Office (CBO).

Because of AHCA’s $834 billion in Medicaid cuts, Iowa will bear much more Medicaid cost (an additional $340 million annually), forcing the state to cut Medicaid – or else raise taxes or make cuts to other programs. The 150,000 Iowans who now benefit from Medicaid expansion will cycle off the program, even though they will likely need coverage again if they lose a job or an employer cuts their hours.

Scrambling to balance its budget with far fewer federal dollars, the state will also likely tighten Medicaid eligibility requirements and reduce benefits and provider payments. Meanwhile, the state will have to fully cover any future unexpected Medicaid costs without federal help, ending a 50-year partnership between state and federal government that has responded to unexpected health crises, including hurricanes and floods as well as economic downturns. Again, tightening eligibility and cutting payments are likely responses.

At the same time, some 50,000 Iowans currently in the Affordable Care Act “marketplace” will face additional, sharp increases in what they must pay to get coverage for deductibles and out-of-pocket costs, as ACA tax credits are replaced with less-generous ones and cost-sharing subsidies are repealed without any substitute. Additionally, with insurers permitted to charge older Iowans as much as five times what they charge younger individuals — instead of three times or more under ACA — older and sicker Iowans will see their premiums soar.

The insurance markets will continue to destabilize, leading the state to seek a federal waiver (which will be immediately granted) allowing insurers to charge people with preexisting conditions more. With that waiver in place, Iowans signing up for coverage in the AHCA marketplace will be asked for their medical history, leading them to pay either higher premiums or to buy coverage through under-funded high-risk pools. Even employer-based insurance could be impacted as ACA coverage protections are eliminated.

The bottom line is that some 200,000 Iowans lose their health care coverage under AHCA, but not their need for health care services. Instead of a personal physician, they will seek care in hospital emergency rooms – the most expensive place to receive health care – and hospital charity care levels will spike, which will ultimately undermine hospitals’ financial stability and ripple across to privately insured Iowans.

The AHCA steps backwards from what has been achieved since the ACA was enacted and Iowa Medicaid was expanded. And all of it is verified by last week’s CBO report.

Despite the claims of proponents, AHCA does not offer real flexibility for states but instead would force them into a fiscal corner with only one way out: severely cut and/or restrict health care coverage, particularly within the Medicaid program, in ways that will ultimately make Iowans less healthy and their hospitals less viable.

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Iowa Hospital Association (IHA) President and CEO Kirk Norris appeared over the weekend on “Close Up”, an in-depth news program on KCCI in Des Moines. During his segment, Norris provided the Iowa hospital perspective on Affordable Care Act (ACA) repeal/replacement legislation, including the American Health Care Act (AHCA), which passed the US House. However, the Senate is expected to draft a new bill, rather than take up the House version.

Use this link to view the program (the ACA/ACHA segment begins at about 17 minutes).

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John Lawless, son of Evelyn Oppold Lawless, and Pam Westendorf at Hansen Family Hospital in Iowa Falls. Pam received the Lawless family’s scholarship that honored Evelyn’s long nursing career and then unexpectedly met her at the hospital.

Evelyn Oppold Lawless’ life was coming to a close and Pam Westendorf’s was just beginning when the two women met in a chance encounter last fall.

Evelyn, a 99-year-old farm wife who’d raised five children and found her passion in nursing, was admitted to Hansen Family Hospital in Iowa Falls on Nov. 10. She was weak, and was being tended to by nurses, nursing students and an instructor.

Pam, an LPN who’s working toward her RN, was one of those students. And she was looking for a sign. She wanted to know she was in the right place, doing the right thing.

As the nurses spoke with Lawless and her son, John Lawless, they learned she was a nurse.

“In fact,” John told them, “there’s a scholarship in her name to help young nurses.”

Pam looked at the computer screen. Evelyn Oppold Lawless. It was her $500 scholarship that had given Pam a start on her education after graduating from South Hardin High School in 2014. She told Evelyn about their connection.

“Her face lit up,” Pam said. “I will never forget that face, ever.”

The chance meeting was exactly what Pam had been waiting for.

“As a nurse, we always try to find a sign from God telling us that we’re in the right profession,” Pam said. “And that day I totally got a sign that that was where I needed to be. It’s crazy that one scholarship and one lady can tell me I’m in the right area. God gave me a sign.”

Evelyn Oppold Lawless nursing school portrait

Evelyn Oppold Lawless grew up on a farm, one of eight children. In 1938, and the height of the depression, she left home and enrolled at St. Joseph Mercy School of Nursing in Mason City. Inspired by her aunt, Lillian Oppold, who was a member of hospital nursing staff in Iowa Falls for 24 years, Evelyn was the first of her siblings to get an education.

In 1943, Evelyn married Harry Lawless. Shortly thereafter, he was sent overseas to fight in World War II. Evelyn headed to the San Francisco Bay area to work as a nurse in the shipyards where two of her brothers were stationed.

When the war was over, Evelyn came home to Iowa. She and Harry settled on a farm in Hardin County, north of Eldora. They had five children, and Evelyn continued with her nursing career, working as a private duty nurse, and also treating patients at the hospitals in Iowa Falls and Eldora.

She often talked about her love of nursing.

“She was very, very passionate about it,” said John Lawless, who lives in Ankeny after retiring from working the family farm. “Mom was a people person. She loved people. She loved meeting new people and she cared for people very much. That showed through not just in her nursing, but in her personality too.”

She exuded a love of nursing, inspiring both of her daughters to become RNs. A couple of nieces also went into nursing.

When she turned 90 in 2007, her children surprised her with a unique gift: a nursing scholarship in her name.

“Her reaction was tears,” John said.

About five years after the scholarship was established, the siblings’ money ran out. Rather than end the gift, Evelyn continued to fund it herself.

Every year, a $500 scholarship goes to a South Hardin High School student who intends to pursue a career in nursing. Ellsworth Community College attendance isn’t required, but many of the recipients have gone on to school there.

Pam received the scholarship when she graduated in 2014. “I don’t even know what drove me to nursing,” Pam said. “I’d always been a caretaker. So I thought I’d just go into nursing.”

She attended Ellsworth Community College (ECC) and last summer became an LPN. Now she’s enrolled in the ECC RN program. After getting her sign from Evelyn, Pam said she’s focused on figuring out what she’ll do next.

“I still have a lot of praying to do,” Pam said. “God has a plan for me, I just don’t know what it is yet. I’m waiting for another sign.”

In the meantime, Pam is working toward her RN, and spending quite a bit of time at Hansen Family Hospital. The hospital has a close relationship with ECC’s nursing program. Students are able to use the hospital to get experience they can’t get anywhere else.

“We love having students here,” said Christina Peterson, the hospital’s Director of Education. “It’s so much fun to see their growth. They are the future of health care.”

Clinicals at other hospitals aren’t nearly as hands-on, Pam said.

“I love coming here for clinicals,” Pam said of Hansen Family Hospital. “We go to other facilities, but we don’t get the freedom we have here. At other facilities we just go around with a nurse and watch what they do.”

***

About five hours after Pam and Evelyn met, Evelyn passed away. The women’s chance meeting gave Evelyn closure and it gave Pam a path forward. And now the story of their meeting is inspiring others to believe in the power of fate.

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