Thursday, March 23, 2017

In 38 years advocating for doctors, patients I've never seen a bill that will do more harm to health

When I tweeted this on Monday morning about the House GOP bill to “repeal and replace” the Affordable Care Act, I had no idea that it would result in me appearing on MSNBC’s Last Word with Lawrence O’Donnell or that it and my other tweets would be referenced by NBC News, a New York Times editorial, or for that matter, a retweet from singer-songwriter John Legend!

I mention all of this not for reasons of self-promotion, but to share with readers of this blog why I firmly believe that the GOP “repeal and replace” bill, expected to be voted on later today in the House of Representatives, will, if enacted, do more harm to health than any I have seen in nearly four decades of advocacy on behalf of internal medicine.

Here are my reasons:

First, never before I have I seen legislation advanced to the floor of either the House or Senate that would take health insurance coverage and consumer protections away from tens of millions of Americans; not once, not ever.  In fact, I doubt there is any time in history where Congress is being asked to vote to take health care away from so many.  Instead, the trajectory has been to expand health insurance coverage, not take it away: from enactment of Medicare and Medicaid in 1965, to the bipartisan Children’s Health Insurance Program becoming law in 1997; to creation of the Medicare Part D prescription drug program, signed into law by President George W. Bush on December 8, 2003; to the Affordable Care Act becoming law on March 23, 2010, exactly seven years ago.   Up until now, no President of either political party, and no Congress, has championed a measure that would result in a wholesale rollback of coverage and access to care for people who have gained it under prior laws.

Second, and most importantly, the American Health Care Act would do incalculable harm to the health of tens of millions of Americans.  This is not a political assessment, it’s based on what the bill actually proposes to do and evidence (from independent and non-partisan researchers) on how patients will be affected.

  • It makes radical changes to the Medicaid program’s structure and financing; the non-partisan Congressional Budget Office (CBO) estimates that 14 million low-income kids, adolescents and adults will lose their Medicaid coverage as a result. By putting a per-enrollee cap on the federal contribution to Medicaid, or offering states a “block grant” option (both of which means that the states are left having to make up any difference between the federal contribution and the costs of providing benefits to Medical enrollees), and phasing out the higher federal contribution for states that have expanded Medicaid to persons with incomes up to 138% of the Federal Poverty Level (FPL), the CBO found that the total federal contribution would be cut by $890 billion over the next decade, a whopping 25% cut!  Because most states are required by law to balance their budgets, a reduction in and/or a cap on federal matching funds will necessarily require them to greatly reduce benefits and eligibility and/or impose higher cost-sharing for Medicaid enrollees, most of whom cannot afford to pay more out of pocket—or alternatively and concurrently, reduce payments to physicians and hospitals (including rural hospitals that may be forced to close), enact harmful cuts to other state programs or raise taxes.  The phase-out of funding for Medicaid expansion, and the retroactive (to March 1) freeze on providing enhanced funding to any additional states that might have expanded the program, will eliminate one of the most effective programs ever in driving down the uninsured rate to historic lows.  Some Republicans surely recognize the importance of preserving funding for Medicaid expansion in their states: just yesterday, Michigan (GOP) Governor Rick Snyder wrote to the state’s congressional delegation urging them to vote against the AHCA.

  • It would reward states with higher federal funding if they impose punitive work or job search requirements on certain Medicaid enrollees.  If states adopt such requirements, current Medicaid enrollees (or those seeking to enroll) would not be eligible for the program if they are unable to prove to state Medicaid officials they have a job or are in job-training, or that they meet the conditions specified in the statute to be exempted from the requirement.  Medicaid is not a cash assistance or job training program; it is a health insurance program and eligibility should not be contingent on whether or not an individual is employed or looking for work.  While an estimated 80% of Medicaid enrollees are working, or are in working families, there are some who are unable to be employed because they have behavioral and mental health conditions, suffer from substance use disorders, are caregivers for family members, do not have the skills required to fill available positions, or there simply are no suitable jobs available to them.  Skills- or interview-training initiatives, if implemented for the Medicaid population, should be voluntary, not mandatory.  ACP’s Ethics, Professionalism and Human Rights Committee has stated that it is contrary to the medical profession’s commitment to patient advocacy to accept punitive measures, such as work requirements, that would deny access to coverage for people who need it.

  • Although not final, it’s been widely reported that Speaker of the House Paul Ryan will add to the version of the bill being voted on today a repeal of the ACA requirement that private insurers in the individual insurance market must cover 10 categories of essential services including physician and hospital visits, prescription drugs, cancer screening tests and other preventive services, mental health treatment, and many other services.  Even before this change, the AHCA repeals the requirement that Medicaid programs cover such benefits.  Any reduction in Medicaid coverage for substance use disorder treatments would exacerbate the grave opioid misuse epidemic that is devastating individuals, families and communities across the country.  Women’s access to health care would particularly be at risk, because the AHCA eliminates required coverage for childbirth and maternity and for contraception. 

  • Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance use disorder services, 18% did not have mental health services and 9% did not have coverage for prescription drugs. A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care.  Such increased costs would make it practically impossible for many patients to avail themselves of the care they need.  The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.

  • The AHCA’s regressive age-based tax credits, combined with changes that will allow insurers to charge older people much higher premiums than allowed under current law, will make coverage unaffordable for poorer, sicker, and older persons, as well as for persons who live in high health care cost regions. The AHCA replaces the ACA’s income-based and cost-sharing subsidies with age-based advance refundable tax credits worth only $2,000 to $4,000 for an individual.  These subsidies will be inadequate for most people to be able to buy affordable coverage, and would especially put vulnerable persons at risk, including low-income families and children, children and adults with special health care needs, and older persons with chronic illnesses who are not yet eligible for Medicare.  Indeed, a study based on the value of these tax credits determined that only 34% of a beneficiary’s medical costs would be covered. This is much less than the ACA, which ranges from about 60% to 94%, depending on the level of plan. By repealing the current law cost-sharing subsidies for persons with incomes up to 250% of the FPL, the AHCA would make out-of-pocket costs too high, and health care unaffordable, for many poorer patients. Without cost-sharing reductions, enrollees will be exposed to higher deductibles, co-payments and other cost sharing, potentially discouraging patients with limited financial means from seeking medically necessary care.  The AHCA also establishes a set amount for the tax credits per individual, without any adjustment for differences in the cost of care by locality.  This will result in the tax credits being insufficient to make coverage affordable for patients in high health care cost areas, especially older, poorer  and sicker ones.

  • The AHCA discriminates in the awarding of federal grant funds and/or Medicaid and Children’s Health Insurance Program funding to women’s health clinics that are qualified under existing federal law for the provision of evidence‐based services including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.  This provision, targeted at Planned Parenthood, reduces women’s access to evidence‐based services offered through the clinics including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.

  • The AHCA eliminates funding for Prevention and Public Health Fund, which provides billions in dollars to the Centers for Disease Control and Prevention to prevent and control the spread of infectious diseases like flu, Zika, and epidemics and pandemics.  

I could go on and on with other reasons why Congress should vote down the American Health Care Act but I think (hope) you get the point: this bill is a monstrous and unprecedented assault on coverage and access to care for many millions of Americans, and especially, the most vulnerable of our neighbors: those who are older, poorer and sicker.  It is by far the worst piece of health-related legislation I have seen since I first started working for the American Society of Internal Medicine (which merged with ACP in 1998) when Jimmy Carter was president.  It must be stopped, now.

Today’s questions: What do you think of the AHCA, and what are you doing about it?