Iowa hospitals are urging the state’s congressional delegation to vote against the American Health Care Act (AHCA), the bill designed to “repeal and replace” the Affordable Care Act (ACA) and which is expected to be voted on in the House today.
It’s estimated that this legislation would cause 24 million Americans to lose insurance coverage. In Iowa, it is estimated that 200,000 individuals who gained coverage under the ACA would lose their health care coverage. Because of this loss of coverage, Iowa’s hospitals would be called upon to care for more uninsured individuals through more expensive means, often in the emergency room.
Uncompensated and charity care will drastically rise again, causing concern for the viability of health care services in rural communities in Iowa and throughout the nation. Despite this loss of coverage and expectation for hospitals to shoulder the increased burden, the AHCA fails to restore billions of dollars in cuts to hospital payments that were part of the ACA.
Additionally, 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.
The AHCA will not improve the health and well-being of Iowans. In fact, it will do the opposite. This legislation would return the nation to the dark days when the uninsured rate reached double digits and millions of families didn’t have access to primary and preventive care. That means a less healthy population and higher health care costs. It also means that health care providers will once again carry the burden of providing safety-net care. The impact will be borne by all health care consumers and taxpayers who will experience cost shifts to pay for that care.
AHCA will leave more Iowans without health insurance coverage and harm Iowa’s hospitals and communities.
IHA is asking hospital advocates to reach out to their US House members to vote “no” on AHCA. If you stand with Iowa’s hospitals, click here to send a message to Congress.
(This article was provided by Kaiser Health News.)
Some conservative Republicans have derided the new proposal — the American Health Care Act — calling it “Obamacare Lite.” It keeps intact some of the more popular features of the ACA, such as allowing adult children to stay on their parents’ health plans to age 26 and, at least in theory, ensuring that people with preexisting conditions will still have access to insurance.
In some cases the elements of the law that remain are due to political popularity. In others, it’s because the special budget rules Congress is using — so Republicans can avoid a Senate filibuster — do not allow them to repeal the entire law.
But there are some major changes in how people would choose and pay for health care and insurance. Here are some of the biggest:
Tax Credits To Help Buy Insurance
Both the GOP bill and the ACA provide tax credits to help some people pay their premiums if they don’t get insurance through work or government programs. And in both, the credits are refundable (meaning people who owe no taxes still get the money) and advanceable (so people don’t have to wait until they file their taxes to get them). But the GOP’s tax credits would work very differently from those already in place.
Under current law, the amount of the credit is tied to a person’s income (the less you earn the more you get) and the cost of insurance where you live.
The GOP tax credits would be tied largely to age, with older people getting twice as much ($4,000 per year) as younger people ($2,000). But the Republican plan would also let insurers charge those older adults five times as much as younger adults, so even a credit twice as big might not make up the difference in the new, higher premiums.
The GOP credits also do not vary by location, so they would be worth more in places where health care and health insurance is less expensive.
The GOP credits do phase out gradually, starting with incomes above $75,000 for an individual and $150,000 for families.
The biggest changes the Republican bill would make are to the Medicaid program. Starting in 2020, it would roll back federal funding for the ACA’s expansion that allowed states — if they so chose — to provide Medicaid coverage to all low-income individuals under 138 percent of the poverty level, rather than just the specific categories of poor people (children, pregnant women, elderly, disabled) who were previously eligible. Thirty-one states opted to pursue this ACA provision. People who are covered under the expansion would continue to be funded by the federal government after that, but states would no longer be allowed to enroll anyone under those expanded criteria. And an enrollee who loses eligibility for the expansion program could not re-enroll.
But the bill would go further as well, making changes to the underlying Medicaid program that House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) described as “the biggest entitlement reform in the last 20 years.”
Currently, Medicaid costs are shared between states and the federal government, but the funding is open-ended, so the federal government pays its percentage of whatever states spend. Under the proposed bill, the amount of federal funding would be capped on a per-person basis, so funding would go up as more people qualify. But that per-capita amount might not grow as fast as Medicaid costs, which could leave states on the hook for an ever-increasing share of the costs of the program.
“Capping federal contributions to the Medicaid program will likely force states with already tight budgets to limit eligibility and cut benefits to at-risk Americans,” said the American Public Health Association in a statement.
Help For Wealthier People
If you earn a lot of money, or even just enough to put aside something extra for health expenses, the GOP bill will provide a lot to like.
First, it would repeal almost all of the taxes that were increased by the ACA to pay for the expansion of health coverage. Those include higher Medicare taxes for high-income earners, a tax on investment income, and various taxes on health care providers, including insurance companies, makers of medical devices and even tanning salons.
The bill would also provide new tax advantages for those who can afford to save — including allowing more money to be deposited into health savings accounts, and lower penalties for those who use those accounts to pay for non-medical needs.
In addition, the plan would lower the threshold for deducting medical expenses on income taxes and allow people with job-based tax-preferred “flexible spending accounts” to put away more pretax money. It would also restore over-the-counter drugs as eligible for reimbursement from those accounts.
Mandates To Buy Or Provide Coverage
The GOP plan doesn’t actually repeal either the requirement for individuals to have coverage or for employers to provide it. That’s because it can’t under budget rules. Instead, the bill would reduce the penalties in both cases to zero, rendering the requirements moot.
The individual requirement was used by the health law to force healthy people into buying coverage to help improve insurers’ risk pools since they could no longer bar customers with preexisting conditions. Instead of the requirement that most people obtain health insurance or pay a penalty, the Republican plan would provide a penalty for those who do not maintain “continuous coverage.” Those with a break in insurance coverage of more than 63 days could still purchase insurance without regard to preexisting health conditions, but they would be required to pay premiums that are 30 percent higher for 12 months.
The employer “mandate,” which requires firms with 50 or more workers to offer coverage or pay a fine, has actually had relatively little impact on insurance coverage, analysts have concluded, and probably is not necessary to prevent employers from dropping coverage. In both the ACA and the GOP bill, however, workers whose employers offer coverage could not decline that coverage and get a tax credit instead.
How To Pay For It
With all the taxes and fees stripped from the ACA, how will Republicans pay for their tax credits? The answer is not clear yet.
“We are still discussing details, but we are committed to repealing Obamacare and replacing it with fiscally responsible policies that restore the free market and protect taxpayers,” said the Republican fact sheet that accompanied the release of the bill.
Also still missing is an estimate from the Congressional Budget Office that will detail not only how much the proposal will cost, but also how many people would gain or lose health insurance. Republicans insist that estimate will be available before the full House votes on the bill.
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.
Iowa’s community hospitals generate more than 127,000 jobs that add nearly $6.8 billion to the state’s economy, according to the Iowa Hospital Association’s latest Iowa hospital economic impact report. In addition, Iowa hospital employees by themselves spend more than $1.8 billion on retail sales and contribute more than $111 million in state sales tax revenue.
The IHA study examined the jobs, income, retail sales and sales tax produced by hospitals and the rest of the state’s health care sector. The study was compiled from hospital-submitted data on the American Hospital Association’s Annual Survey of Hospitals and with software that other industries have used to determine their economic impact.
The study found that Iowa hospitals directly employ 72,008 people and create another 55,492 jobs outside the hospital sector. As an income source, hospitals provide $4.5 billion in salaries and benefits and generate another $2.3 billion through other jobs that depend on hospitals.
In all, Iowa’s health care sector, which includes offices of physicians, dentists and other health practitioners, nursing home and residential care, other medical and health services and pharmacies, contributes $16.6 billion to the state economy while directly and indirectly providing 324,977 jobs, or about one-fifth of the state’s total non-farm employment.
“Through the many changes in health care, there is one certainty: That hospitals and health care are vital to Iowa’s economy,” said IHA president and CEO Kirk Norris. “With nearly 325,000 jobs, health care is one of Iowa’s largest employers, and hospitals remain, by far, the biggest contributor to that number. In Iowa cities and counties, hospitals are uniformly among the largest employers.
“As our political leaders in Washington, DC and Des Moines consider legislation and regulations that impact hospitals and health care, they need to keep these facts in mind. As providers of high-quality, low-cost health care, good jobs and economic stability, there is no replacement for community hospitals.”
Complete information from the study, including economic impact data for each of Iowa’s hospitals, is available on the IHA website.
Iowa’s Certificate of Need (CON) regulations were first enacted in 1977 for the express purpose of providing for the orderly and economical development of health care services, thereby avoiding unnecessary duplication of services, controlling the growth of overall health care costs and ensuring the stability of community hospitals. Since that time, these regulations have been re-examined multiple times and each time the same conclusion was reached: Iowa needs Certificate of Need.
Now the Iowa Legislature is considering a bill that, if enacted, would repeal significant portions of the CON program, putting community-based health care at risk. Here are some of the reasons why Iowa hospitals are supporting CON:
CON ensures access to health care services
- CON repeal will reduce access by destabilizing local health care systems.
- Without CON, services that keep hospitals financially healthy will be stripped away by for-profit, out-of-state, investor-owned organizations that selectively perform services simply because those services are likely to create the most income.
- These niche providers would leave the financial burden on hospitals to provide 24/7/365 emergency care, to provide care for patients with complicated conditions and patients with Medicaid or no insurance.
CON supports rural communities
- States without CON have seen hospitals close, especially in rural areas.
- Rural Iowa is uniquely susceptible to losing essential health care services. CON criteria and safeguards ensure health care systems are financially stable and that health care options exist throughout all of Iowa.
- In many counties, rural hospitals are among the largest employers, bolstering Iowa’s rural economy, attracting and retaining young professionals and families and bringing high-quality jobs where they are most needed.
CON promotes quality health care services
- CON criteria ensure new facilities operate with patient volumes that are sufficient to provide high quality services.
- CON criteria ensure excess capacity does not lower volumes in a manner that compromises patient safety.
- CON criteria result in consideration of the quality services available in the community.