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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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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.

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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.

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(This article was provided by Kaiser Health News.)

Elizabeth Cosgrove, left, helps Yolanda Solar, 73, who suffers from depression, organize her medications during a home visit on Nov. 3 in San Antonio. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Elizabeth Cosgrove, left, helps Yolanda Solar, 73, who suffers from depression, organize her medications during a home visit on Nov. 3 in San Antonio. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Yolanda Solar has battled a life-threatening disease for more than three decades. The disease nearly killed her last summer and Solar, a 73-year-old grandmother, was rushed to the hospital by ambulance.

When Solar was discharged one week later, she received bad news: She would have to wait until March to see a doctor.

Waiting seven months for treatment would be unthinkable if Solar had cancer or heart disease. But Solar suffers from severe depression, and waiting that long for help is typical — and potentially dangerous.

Although San Antonio has earned widespread praise for its success in keeping people with mental illness out of jail, patients here routinely wait months to see psychiatrists, who are in short supply across the country. The number of available psychiatrists who specialize in the care of the elderly or children is even smaller.

Without routine medical care, patients like Solar, who tried to kill herself in August with an overdose of pills, can quickly deteriorate. Many return to the emergency room. Some don’t survive.

But Solar was luckier than most.

Emergency room (ER) staff made an appointment for her at a transitional care clinic at the University of Texas Health Science Center at San Antonio, which annually treats up to 1,500 patients with serious mental illness until they can find regular care. The clinic helps the mentally ill avoid winding up in the ER, where round-the-clock activity and confusion is ill-suited to the needs of patients who are already agitated, suicidal or psychotic.

Communities like San Antonio are increasingly focused on reducing emergency room use by people with mental illness. In addition to being chaotic, emergency rooms are among the most expensive places in the health system to get urgent care.

Patients like Solar end up in the ER because they can’t find care in the community, and emergency rooms can’t legally turn anyone away. The mentally ill can be stranded in the ER for hours, days or even weeks with minimal treatment, because doctors deem them too disabled to discharge, but can’t find them an inpatient psychiatric bed, which would allow patients to get more intensive care.

More than half of emergency room physicians said their local mental health system has gotten worse in the past year, according to a survey of 1,716 members of the American College of Emergency Physicians, released in October. Seventy-five percent of ER doctors said on their last shift, they saw at least one psychiatric patient who needed to be hospitalized.

“The emergency department becomes the de facto dumping ground for all mental health patients,” said Gillian Schmitz, a San Antonio emergency physician.

The number of ER patients with a mental illness grew from 4.4 million in 2002 to 6.8 million in 2011, an increase of 55 percent, according to a 2016 study in Health Affairs. About 836,000 Americans a year go to the emergency room after harming themselves, according to the Centers for Disease Control and Prevention. Nearly 43,000 Americans committed suicide in 2014 — more than are killed annually in car accidents.

The American College of Emergency Physicians devoted much of its annual meeting in October to patients with psychiatric crises.

Everyone suffers when people with mental illness are stuck in limbo in the ER, Schmitz said. Other patients face longer waits for care and hospitals lose money. That’s because insurers pay emergency rooms only for their initial encounter with a patient, but not for time spent waiting for an inpatient bed.

“Every hour we are holding a psych patient,” Schmitz said, “is lost revenue that hospitals could be earning on other medical patients.”

Elizabeth Cosgrove, right, helped 73-year-old Yolanda Solar make a reminder to take her medication that Solar put on her dresser. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Elizabeth Cosgrove, right, helped 73-year-old Yolanda Solar make a reminder to take her medication that Solar put on her dresser. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Personalized care

Solar’s story also shows the progress that people with mental illness can make when they receive prompt and comprehensive care. She has not returned to the ER since beginning treatment in August.

Hospital staff scheduled her appointment at the transitional care clinic through a web-based computer system before she left the hospital. Like most patients, Solar was seen within a few days.

Solar now meets regularly with a psychiatrist, who manages her medications, and a counselor to discuss her fears.

A therapist visits her at home to help organize her medications, which include pills for high blood pressure and cholesterol. The visits are paid for through a Medicaid pilot program, which allows staff to provide extra services for up to five patients who are considered “high utilizers” of health care, or patients who are particularly costly to insurers because of repeat trips to the hospital or ER, said Megan Fredrick, the clinic’s program manager.

Patients with serious mental illness, which can cause cognitive changes similar to dementia, often need help with day-to-day tasks, said psychologist Dawn Velligan, project director at the transitional care clinic. Therapists help patients set alarms that remind them when to take their medicines. They work with patients on calendars and organizational skills, so that clients don’t miss appointments.

Through a type of therapy called cognitive adaption training, clinic staff teach basic skills, such as how to shop for groceries or take the bus to a medical appointment, Velligan said.

Only 2.5 percent of psychiatric patients seen at the transitional care clinic return to the ER within three months, compared to 10 percent of patients who aren’t seen at the clinic, Fredrick said.

Without the clinic’s help, Solar said, she would probably have considered suicide again.

“Sometimes, I get pretty, pretty, pretty depressed,” said Solar, who was raised by an alcoholic father. Her depression began, Solar said, during an unhappy marriage.

Yet for years, Solar suffered in silence. The first time she saw a psychiatrist was after her August suicide attempt.

Nationwide, more than half of people with mental illness go without treatment, according to Mental Health America, an advocacy group. The reasons are complex. Many people with mental illness don’t realize they’re sick, or that treatment can help. Some patients lack transportation or money to pay for care. About 17 percent of people with a mental illness in the U.S. are uninsured, according to Mental Health America.

“For many of our elderly Hispanic patients, this is the first time they’ve seen a therapist,” Cynthia Sierra, a clinic counselor. “You’re raised not to talk about your problems with strangers … You can carry years of burdens and trauma.

Unsolved problems

For all its success, the transitional care clinic can’t help everyone.

With an annual budget of $3.5 million — provided by a variety of grants and a fund for Medicaid demonstration projects — the clinic sees just a fraction of those who need help.

“We constantly have to beg for money,” Velligan said.

Although the transitional clinic accepts patients covered by Medicare, Medicaid or private insurance, it can’t accept most uninsured patients.

Psychiatrist Harsh Trivedi describes the program as a “Band-Aid” that fails to address the larger problem of inadequate care for people with mental illness.

“Unfortunately, creating these programs doesn’t actually solve the real access issues,” said Trivedi, chair of the American Psychiatric Association’s council on healthcare systems and financing.

Trivedi notes that the national shortage of psychiatrists means that even well-insured patients often have to wait for care. Although the overall number of physicians increased 14 percent from 2003 to 2013, the number of psychiatrists fell by 10 percent when adjusted for population growth, according to a July study in Health Affairs.

That shortage is projected to worsen over the next decade as large numbers of psychiatrists reach retirement age, said Trivedi, who is also the president and CEO of Sheppard Pratt Health System in Maryland.

Many psychiatrists have stopped taking insurance because health plans pay them too little to sustain a practice, Trivedi said.

To really help more patients, the country needs to rebuild the mental health system, investing both in outpatient care, more hospitals beds and supportive services, Schmitz said. Instead, states have been steadily slashing mental health budgets for years.

“As a society, we’re OK with the fact that someone with depression isn’t able to get care,” Trivedi said. “That double standard allows some of our most vulnerable people to end up in harm’s way.”

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Iowa has one of the highest quality, lowest cost health care systems in the United States. And at the heart of that system are 118 community hospitals that stand ready, day and night, to serve everyone, regardless of their ability to pay. A significant reason for health care excellence in Iowa has been state oversight of institutional health care services through the Certificate of Need law.

Iowa’s Certificate of Need 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.

As the name implies, Certificate of Need ensures that new medical services are truly needed at the community level. This is important because new facilities (including nursing homes, ambulatory surgical centers and hospitals, among others) must have sufficient patient volumes to support proficiency among medical staff and ensure high-quality care. The same applies to existing facilities, yet without Certificate of Need, new, for-profit facilities would spring up all over the state and deplete patient volumes across the board.

Not only would this compromise the quality of care for everyone, but these new facilities would target lucrative lines of medical service while not providing emergency care, charity care and other unprofitable services that are at the core of the community hospital mission. If Iowa’s community hospitals are left with only unprofitable services and only care for complicated patients who are on Medicaid or uninsured, their ability to survive and continue providing high-quality, community-focused care to everyone will be jeopardized.

In fact, repeal of the law in other states has led to hospitals closing. Furthermore, nearly all of these states have instituted a different review process that is highly politicized.

One of Iowa’s greatest strengths is its health care system. Not only do Iowa’s health care providers deliver excellent, accessible and efficient care, but health care employs more than 200,000 people, injecting some $11 billion into the state’s economy. More than 71,000 of these workers are employed by hospitals, which alone have an economic impact of $4.3 billion.

Certificate of Need, which exists in 36 states, not only ensures the stability of these major employers and economic engines, but it also supports the collaborative spirit that fosters communication and cooperation among Iowa health care providers, which, again, leads to better health care for everyone.

Today, with the uncertainties surrounding the future of the Affordable Care Act (Obamacare), Iowa’s Medicaid program and even Medicare, the constancy of Certificate of Need is more important than ever. During this time of significant change in the health care industry, the stability provided by this law allows hospitals to more confidently plan and respond to the needs of the communities they serve.

In all parts of the state, Iowans depend on their community hospitals being there all day, every day. That level of access and preparedness is jeopardized by those who would significantly change or repeal Certificate of Need.

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