AHCA draws mixed opinions from local health care officials

May 18--After an abortive attempt in March, the U.S. House of Representatives passed on May 4 its health care plan to "repeal and replace" the Affordable Care Act, also called the ACA or "Obamacare."

House Resolution 1628, alternatively called the American Health Care Act, AHCA or "Trumpcare," passed by the slim margin of 217-213. It uses "budget reconciliation," meaning it deals only with tax, spending and debt limit issues, is subject to no more than 20 hours' debate in the Senate and cannot be filibustered by the Democrats.

Technically, HR 1628 does not repeal Obamacare, which would draw a filibuster. But reconciliation measures can reshape the ACA into a Republican plan.

Despite the controversy, it may be too early to fret over the plan, because it has virtually no chance of hurdling the U.S. Senate without adjustment. Senators of both parties have suggested HR 1628 is dead on arrival and that the Senate will craft its own health care bill.

The House has endured withering criticism after rushing passage of the resolution, and critics claim it is a huge shift of wealth from the middle and poorer classes to the rich.

Jim Berry, Northeastern Health System administrator and vice president, said the AHCA is "a mixed bag" as it stands, and that NHS will provide its services under whatever rules and regulations are in effect.

"One thing that would help us and other 'medium-sized' Oklahoma hospitals is restoration of the cuts to Medicare in the ACA," Berry said. "When the ACA passed, funding went down for Medicare and up for Medicaid. They will remove those cuts more quickly in states like Oklahoma that did not accept the Medicaid expansion. I don't know if that is due to party loyalty or whatever, but it is written into the plan."

Conversely, Berry believes some AHCA changes could result in the closure of some of the state's smaller hospitals. Furthermore, the uncertainty in Washington, D.C., has Blue Cross Blue Shield -- the lone remaining insurer for Oklahomans on the federal ACA marketplace -- delaying any guarantee to participate in 2018.

"If the marketplaces cease to exist, that could stop coverage for many in Oklahoma," Berry said. "That could land the hospital back where we were before the ACA."

The AHCA calls for $880 billion in cuts to Medicaid over the next 10 years and mandates program funding be awarded to the states in block grants, which Jim Wilson, a member of the NeoHealth board of directors, said would be "devastating." NeoHealth operates a network of health centers, and many patients are either covered by Medicaid or uninsured. NeoHealth also receives additional money from Medicaid.

"Medicaid has to be matched by the states," Wilson said. "As a rule, we get $2 for every $1 we put in. If they block grant Medicaid, and take the federal requirements away, you can easily see the Oklahoma Legislature taking that money out of health care and using it to balance the budget. The more money we can put in to Medicaid, the more money we get for health care, but a lot of legislators resent having to make that match."

Pointing to Oklahoma's revenue shortfalls and agency cuts in recent years, Wilson said he does not believe state lawmakers could be "good stewards" of Medicaid money without federal strings attached. Wilson himself termed out as a state senator a few years ago.

"There have been demands by insurance companies like Blue Cross Blue Shield to administer Medicaid money," Wilson said. "If you just block $2 billion in Medicaid to the state and say 'you can handle that how you want,' the state may decide to let Blue Cross Blue Shield administer that money with up to 40 percent taken in administrative costs. Under Obamacare, the limit to administrative costs is 20 percent."

Neither Berry or Wilson believes the Senate will pass the House version of the AHCA.

"I like to think that the upper chamber is a more august body and typically less knee-jerk," Berry said. "One thing they could include is an individual and employer mandate that works. If you assess a $695 tax penalty for not carrying health insurance that costs $2,000 a year, that isn't much of an incentive."

Berry and Wilson also deplored the politicization of the health care debate, and echoed each other almost verbatim that, "In America, we equate health care with health insurance."

Berry said insurance is irrelevant to whether the injured and ill are treated at the emergency room, and that some patients without insurance deal with their primary physicians on a cash basis. Wilson argued that "we don't even need insurance" and suggested lowering Medicare eligibility to age 50 or 55, "because the insurance companies don't want to cover those people."

"How about we examine these things outside politics and find a way to cover everybody at reasonable rates and cost?" Berry asked. "Let's have an honest conversation about what is good in Obamacare and the AHCA, instead of just wiping out one system over the other. Let's come to some sort of compromise. I hope the Senate can look at this plan and say that some of this stuff is goofy and realize some of it isn't good for anybody. But we are so polarized, I don't see us being able to agree."

Several organizations -- including the AARP, American Medical Association, American Hospital Association, and Academy of Family Physicians -- have expressed opposition to the AHCA as passed by the House.

Some Republican lawmakers have bragged that the text of the AHCA is much shorter than that of the ACA. But despite its brevity, the GOP bill still makes enough changes to potentially confuse the constituent on the street. Among the changes:

--The GOP health plan removes the requirement of individuals and employers to carry health insurance. However, polices can charge a 30 percent increase for one year on those who permit their coverage to lapse 63 days or more.

--Under the Republican plan, Obamacare's subsidies to help qualifying people afford health insurance would end on Jan. 1, 2020.

--Effective Jan. 1, 2018, individuals or families could contribute, respectively, up to $6,550 and $13,100 into tax-free health savings accounts.

--The GOP plan delays application of the "Cadillac" tax on high-cost employer plans by five years, until 2025. It also repeals four taxes assessed under Obamacare: the 3.8 percent tax on investment income, the 0.9 percent tax on persons with annual income above $200,000 or families above $250,000, the 2.3 percent tax on medical devices, and fees on the firms of health insurance providers based on their plans.

--While the AHCA repeals the tax penalty on big employers that do not provide health insurance, it also repeals the tax credits for small businesses that pay low wages. The tax credit repeal would be effective Jan. 1, 2020.

--Coverage of 10 essential health benefits -- inpatient care, outpatient care, emergency services, prenatal and newborn care, mental health and substance abuse services, prescriptions, lab services, rehabilitative services, pediatric services and preventive services -- are required under the AHA. The AHCA would allow states to seek waivers to exempt health insurers from the requirement.

--Annual and lifetime limits on individual policies -- not permitted under Obamacare -- would be allowed.

--Planned Parenthood would lose its federal funding support for a year.

--Under the AHA, dependents are able to keep health coverage under their parents' plans until age 26, and the GOP bill retains that provision.

Learn more

There are numerous other adjustments called for in the House plan. The Kaiser Family Foundation has posted a summary of AHCA changes at:

http://files.kff.org/attachment/Proposals-to-Replace-the-Affordable-Care-Act-Summary-of-the-American-Health-Care-Act

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