Iowa Health Groups Worry About AHCA Changes

May 21--WATERLOO -- Iowans have been making emotional appeals to Congress to keep the Affordable Care Act since Republicans -- who had vowed for seven years to repeal the law -- were sworn in for the 2017 term.

Their efforts kicked into high gear after the House narrowly passed the American Health Care Act on May 4 to dismantle the ACA, largely known as Obamacare.

But it isn't just health care users who have been speaking out against the attempt to "repeal and replace Obamacare." Providers, too, have concerns, particularly with the AHCA as passed.

"I do think it's hard sometimes for people who have always had the luxury of having coverage to understand what it's like to not, and it's not necessarily a situation that you can personally control," said Jennifer Lightbody, executive director of Peoples Community Health Clinic in Waterloo.

Lightbody said if the bill passes that rolls back coverage for people who get insurance through the newly expanded Medicaid and the marketplace, then "there isn't a system, and people just depend on luck or advocacy or charity care to get done what they need to do, and that really is not a meaningful way to provide health care in this country."

Peoples Clinic is hardly the only organization with concerns about the health care proposal. Patient advocacy groups and providers also have opposed the AHCA in its various forms.

Biggest concern

Both the Iowa Primary Care Association, of which Peoples Clinic is a member, and the Iowa Hospital Association say their primary concern is the fate of the ACA's Medicaid expansion.

"It would decimate the program across the country, and here in Iowa, by rolling back the Medicaid expansion that Iowa approved along with about 30 other states over the last few years," Scott McIntyre, vice president of communications at IHA, said about the AHCA.

Obamacare made adults without children who live at 133 percent of the poverty line eligible for coverage through Medicaid.

In Iowa, that meant about 138,500 people newly eligible for coverage, according to the Kaiser Family Foundation. Lightbody said Black Hawk County experienced a 42.7 percent increase in people covered by Medicaid between 2010 and 2017.

The AHCA would restructure Medicaid and effectively end the expansion, though the legislation could still change in the U.S. Senate.

McIntyre said the Affordable Care Act's Medicaid expansion was meant in part to limit charity care costs. In Iowa, charity care costs decreased by $88.4 million for Iowa hospitals between 2014 and 2015. The ACA passed in 2010, but several provisions, including the Medicaid expansion and marketplaces, did not fully roll out until 2014.

"The thing about charity care that you have to keep in mind is obviously it's not free; the hospitals have to offset that somehow, and they offset it through what they charge people who do have insurance," McIntyre said. "In that way, we're all paying for folks who are uninsured one way or another."

Lightbody said the expansion has freed up time for Peoples Clinic staff, including physicians, to see patients rather than bargaining with hospitals to see which would treat an uninsured patient who needed care for, say, breast cancer. Because they are now insured it's easier to find treatment. Lightbody said that is "double good news" because those patients also now access preventive care that may prevent such conditions in the first place.

Both McIntyre and Lightbody also note concerns with the marketplace -- for people who do not qualify for Medicaid or Medicare and don't have health insurance through their employer -- because Iowa's providers are expected to drop out in 2018.

At Peoples Clinic, it's a lesser concern as 4 percent of its patients get insurance through the marketplace. But across the state, about 51,500 Iowans got insurance through the marketplace in 2017.

"Access to health care services is what is top of mind for UnityPoint Health," said Sabra Rosener, vice president for government and external affairs at UnityPoint Health. "In some of our markets, we are looking at a situation, in 2018, where some of our patients will have no insurance plan options available to them, which is a big problem."

Positive changes

Lightbody and McIntyre are quick to note the Affordable Care Act is not perfect. Their hope, though, would be for tweaks around the edges rather than a repeal that decreases the number of people insured.

Both said the goal should be to ensure most people are covered, leading to stability for patients and providers.

"Our system of health care is set up and based on people being insured; that's how it works best," McIntyre said.

Between 2013 and 2016 in Black Hawk County, there was a 9 percent decrease in the number of uninsured. Statewide, since the ACA was fully enacted, uninsured rates have dropped from 8 percent in 2013 to 5 percent in 2015, according to the most recent data available.

Another concern is stability and certainty in health care.

Lightbody said patients and employees have concerns about what will happen with the AHCA. There's also uncertainty about funding for Peoples Clinic when a federal grant it typically receives comes up for renewal this year.

"We just need to convince Congress and whatever legislation comes out that it's stable and predictable reimbursement for hospitals, because there's a lot going on in health care right now," McIntyre said.

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