Repealing the Affordable Care Act

by Bob Schober

“The world is a dangerous place to live; not because of the people who are evil, but because of the people who don’t do anything about it.” — Albert Einstein

Editor’s note: With the dawning of the Age of Trump, this section is devoted to studying the local impacts of specific issues the new administration or Congress will propose. This is the first of a series.

The Affordable Care Act (ACA) has been the whipping post of conservatives since its launch in 2010. The November election gave Republicans control of all three branches of government, and they are wasting no time in moving to repeal and replace the ACA. Its formal name, lost in common usage, is the Patient Protection Affordable Care Act.

As of this writing, Republicans have offered no replacement plan for Congress and the public to debate. The new president insists that the “disaster” be repealed and replaced quickly, and a few hours after his inauguration, Trump issued an executive order instructing federal agencies to “relieve the burden” of the ACA. Trump had previously claimed his plan will get insurance to “everybody” but offered no details.

How this plays out is anyone’s guess. Republican congressional leaders support immediate repeal with replacement to take place over months, two years, even three years, depending on who’s talking. And a growing number of senators have growing jitters about the chaos that could ensue and are urging caution. The GOP has promised an “orderly transition” to “universal access” — not “universal coverage” — of healthcare, but that remains to be defined.

It seems Republicans are like dogs who have chased the bus for six years and finally catch it, only to bite into a very hard reality. And what they’re hinting at could prove to be a very hard reality indeed, for the thousands of our neighbors and 20 million people nationwide who were finally able to get healthcare, and for local caregivers who were able to expand their services — all thanks to the ACA.

There is some hope that both parties will work together to improve healthcare delivery, because many agree the ACA needs some tweaking. It’s a complex law covering one-sixth of the U.S. economy. But the far-right detests the mandates built into the law to pay for it, but without them, the analysts say the numbers required to expand health coverage won’t add up. The GOP remains deeply divided over the fundamental question about government’s role in healthcare and all other aspects of public life.

For Carol Gipson, executive director of Whatcom Alliance for Heath Advancement, providing health care to the most vulnerable should be a national ethic. “There are many protections that are now taken for granted,” she said. “We are not a developing nation, yet a proposed “repeal without a replacement” would have the effect of once again putting millions of people at risk of severe health hardships and even medical bankruptcy. This suffering is needless. We can do better than that as a country.”

Facts Speak
Exactly what the Republicans will propose is still up in the air, but here are the facts on the ground here in Whatcom County:
• In 2016, 20,318 residents were enrolled in Washington state’s Apple Health program, created with the expansion of the Medicaid program, part of the ACA;
• 7,170 residents were covered by qualified health plans through the Washington state healthcare exchange;
• Visits by uninsured residents to various healthcare providers dropped from 15 percent in 2010 to 5 percent in 2016;
• Health care costs rose by double digit percentages every year on average before the ACA, but rose only 2 or 3 percent the last couple of years. Last year’s raise was 7 percent;
• The ACA funded greatly expanded behavioral health care for alcoholism and addiction treatment, and for specialty beharioral healthcare for psychiatric and other treatment services.

And here are the facts for Washington state:
• 601,802 people enrolled in Apple Health under the ACA;
• 166,098 were covered by qualified health plans;
• The uninsured rated dropped from 14 percent to an estimated 5.8 percent in 2015;
• Federal subsidies (tax credits and cost-sharing reductions) in 2016: $20,320,319;
• About 50,000 individuals under age 26 gained health coverage by staying on their parents’ plans.

The GOP Game Plan
Here are some proposals being floated by Republicans:
• Guarantee “universal access,” not “universal coverage”;
• Create high risk pools for those with pre-existing conditions;
• Offer consumer tax credits for health insurance purchases — every person, regardless of income, would receive $1,200 per year, increasing with age; it is highly regressive;
• No one could be denied insurance as long as she maintains coverage — should that lapse, insurance companies could then deny coverage or charge hefty penalties for re-entering the market;
• Create health savings accounts;
• Turn Medicaid into block grants to the states.

A Kaiser Family Foundation poll taken December 18–19, 2016, shows the country sharply divided on repealing the ACA:
• 20 percent want to repeal immediately and work out the replacement details later;
• 28 percent want Congress to wait to vote on repeal until details of a replacement plan are announced;
• 47 percent want no repeal.

Previous Kaiser polls, however, showed that several provisions of the current law are extremely popular, especially the regulations prohibiting insurers from denying coverage or raising costs on people with pre-existing conditions.

Public concern about the stability of its healthcare showed in a December 2016 NBC/Wall Street Journal poll of 1,000 adults nationwide (500 via cell phone). Forty-five percent of respondents said they believe the ACA is a good idea, the highest percentage since a 2009 poll first posed the question. Fifty percent of respondents said they had little to no confidence that Republican proposals to replace the ACA would improve things.
In brief, what does the ACA provide?

• Coverage for people with pre-existing conditions;
• Eliminates the lifetime cap on coverage;
• Reduces the fear of medical bankruptcy, the leading cause of bankruptcy in the United States;
• Guarantees health protections for women, LGBTQ individuals and under-served communities.

Gipson said the ACA helped her with a major health crisis. Before 2010, insurance companies had stopped writing individual plans, but that stopped with the passage of the act.

“In 2014 I had a major spine surgery which saved me from paralysis, and the cost was over $100,000,” she said. “Fortunately, thanks to the PPACA, I was able to buy individual insurance, and without that policy, I would have been bankrupted.”

ACA Expanded Services
Most talk and worry has been about the threat to the 20 million people who were able to get health insurance under the ACA. And that’s a legitimate concern, depending on what the Republicans propose. On January 17, 2017, the Congressional Budget Office issued a report stating that 18 million people would lose insurance in the first year if the ACA is repealed and replacement is delayed.

But according to several local caregivers, the ACA provided far more than individual access to healthcare.

“The act insured the previously uninsured which raised revenue, allowing Unity Care NW’s services to grow significantly,” said Des Skubi, executive director of Unity Care Northwest. “Before the ACA, 15 percent of our visits were uninsured, and now it’s 5 percent,” he said. The rise in subsidies for the insured and decrease in covering care for the uninsured greatly increased the agency’s revenue stream.

Unity Care NW has used that increased revenue to broaden its services. It can now provide adult dental services to help treat the estimated 46,000 low-income county residents with “accumulated” dental problems, Skubi said.

The agency was also able to expand its behavioral care services to more extensively treat alcoholism and drug, including opiate, addiction. It also expanded its specialty behavioral healthcare services, which now include two full-time psychiatrists, a full-time nurse practitioner and counseling staff.

Unity Care also opened a pharmacy with use restricted to its clients and offering a sliding fee scale for drugs sold at discounted prices.

The agency currently has a clinic in Ferndale which caters to people living in the north county, but which is operating at capacity. Unity Care NW received a permit to build a new facility in Ferndale, but may put the project on hold until Republicans reveal their replacement plans.

“The project has been cast into a period of uncertainty as to what will be included,” Skubi said.

Greg Winter, executive director of Opportunity Council, said the ACA’s making health insurance possible to a broader clientele has helped everyone in our community, and saved money.

The ACA “helps the most vulnerable people with the least access to services,” Winter said. “When people have insurance, the whole community is affected. If that is taken away, those people with complex needs will go back to what they were before — using Emergency Medical Services, walking into the emergency room or ending up in the criminal justice system. That ends up costing all of us far more.”

Chris Phillips, director for Community Affairs at PeaceHealth, said much of the ACA has been funded by hospitals, which took reductions in Medicare reimbursements and Medicaid payments. The rise of the insured, however, has reduced by more than 50 percent the number of people requiring charity care.

“It’s a really important point, that when people have insurance, they come to get care and don’t delay care,” he said. “The data are clear. When people have insurance, people are healthier.”

The act also changed the way care is provided — “value instead of volume,” Phillips said. Before the ACA, hospitals were paid on all visits by the services provided, so repeat patients with repeat services were still billed. There was little incentive to do things differently.

That changed, he said. “Now, the question we must answer is, ‘Was that visit necessary? Was that treatment necessary?’ Now payments are made for value, not volume,” he said.

Growing Concern
Des Skubi agrees with critics of the act that some changes to the current law are probably necessary. But he’s aware of rising unease.

“Patients have come to appreciate the benefit they care for and rely on, and the uncertainty is creating a lot of anxiety,” Skubi said. As for upgrades to ACA or replacement, he said, “We’re standing on three principles: Nobody loses coverage. Patients shouldn’t bear the increased cost for premiums or out-of-pocket. And the federal government’s obligation should not be transferred to states that don’t have the financial ability to support.”

U.S. Rep. Rick Larsen, (D-2nd District), held a town hall meeting in the Unity Care NW building on Sunday, Jan. 15, 2017. Scores of people filled to overflowing the meeting area, many older people concerned about their children’s insurance.

Richard Clarke’s two grown children both have health insurance through the ACA.

“I’m here to find out what’s going on,” he said. “I’m wondering what will happen if it goes away.”

Larsen told the group he is fighting repeal of the healthcare law, saying it “would be a disaster for the 530,000 individuals in Washington.”

“Large insurers are not looking forward to going back to square one,” he said. “Destabilization in the insurance market means redoing and repricing all plans and impact all of us consumers.”

He urged the crowd to contact their congressional representatives and senators and those of their friends around the country, to make their voices heard.

“Right now, my Republican friends don’t seem to care,” he said. “But politicians don’t see the light until they feel the heat.”

Call Congress! Speak Your Mind! Make Your Voice Heard!

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