Hospitals urge scalpels, not machetes, as Obamacare goes on block

Jan. 20--With Donald Trump's inauguration just hours away and the repeal of the Affordable Care Act possibly not far behind, Coulee Region hospital officials hope that Trump and Congress wield a scalpel rather than a meat cleaver.

In the interim, amid confusion not only in the health care and insurance industries but also among both friends and foes of Obamacare, local officials have adopted a wait-and-see attitude, with fingers crossed for good measure.

For good reason: If President Barack Obama's signature legislation were axed without a replacement plan in place, thousands of people in the region -- and 18 million to 20 million nationwide -- who had secured insurance and health care under the law will be tossed out of the waiting room again.

To a person, the medical officials expressed uncertainty, with Tomah Memorial Hospital CEO Phil Stuart saying, "I wish I had the crystal ball. If, in fact, they repeal it, my understanding is that it will not go back to what it was before but will be different."

Michael Richards, executive director of external affairs at Gundersen Health System, opined, "Everybody knows they want to repeal it, but we don't know what the replacement will be -- whether it takes a day, week, or hour -- what it's going to look like."

The mention of such time elements is reminiscent of Trump's boast last week that both the repeal and the replacement of the 2,700-page ACA might happen that fast. It's unclear whether that would include the more than 20,000 pages of regulations tacked onto the law.

Joe Kruse, chief administrative officer at Mayo Clinic Health System-Franciscan Healthcare, noted the popularity of some of the law's hallmarks and their value in helping the previously uninsured and underinsured -- in particular the coverage of pre-existing conditions and allowing young people to stay on their parents' policies until the age of 26.

Access has improved

"It's not lost on anybody that the ACA has provided better access to health care for everybody," Kruse said, adding one of the Mayo Clinic Health System's talking points that "fixing the ACA is going to require a surgical approach with careful assessment, evaluation and action -- with more focus on patients and treatments and less on premiums and websites."

Echoing the notion of the ACA's value to the uninsured is Sandy Brekke, director of the St. Clare Health Mission in La Crosse, who said, "It had a big impact, because those who traditionally came to the free clinic didn't have access to health care."

The number of people seeking care at St. Clare fell by 50 percent, and mission volunteers helped more than 2,000 people apply for insurance coverage through the federal marketplace, Brekke said.

However, St. Clare remained a resource for hundreds of people who fall through the cracks for one reason or another, she said. They can include people whose workplaces offer insurance but who still can't afford the care, people caught up in the criminal justice system, and some who lose BadgerCare for one reason or another.

For example, if a month has three paydays, BadgerCare recipients' pay might exceed eligibility limits, and the system would force them off of BadgerCare. Such people then have qualifying again, Brekke said.

Local officials generally agree that Obamacare has many positive aspects that have improved delivery of care, while parts of it need improvement.

For his part, Trump vowed last week that everyone would have insurance and that deductibles would be much lower, a position that many insist reveals a basic misunderstanding of the insurance industry and actuarial tables.

Full impact unknown

Tomah Memorial's Stuart expressed concern that the 2010 law could be derailed even before it is fully implemented, as many parts have not taken effect.

"It's a concern to me, because I would like to see the full impact of the ACA. Parts of the ACA are very good," he said.

Asked whether Obamacare has had enough time to settle in, Mayo-Franciscan's Kruse said, "I do not believe so -- but that's just Joe Kruse's opinion."

Stuart said, "The long and short of it for us is what it did to our bottom line. We had less charity care, which dropped by about $100,000 a year, but there also were less contractual write-offs" for Medicare and Medicaid services.

Richards and Kruse concurred with that assessment, as well as citing offsetting increases in bad debt, although they said being able to attribute specific figures to those factors is a difficult task.

"By law -- and we would do it anyway because we should -- we care for anybody who needs it," Stuart said.

"One of the things that didn't happen was that emergency room service didn't drop," he said. "The ACA's intent in getting out of the ER didn't work.

The law's aim to do so is grounded in the fact that ER care is the most expensive delivery method.

ER use at Tomah Memorial has grown 2.5 percent to 5 percent a year both before and after the law, he said.

Access also remains a problem, Stuart said, adding, "Try to get an appointment. People who have insurance still can't get in. You can give people insurance, but if they can't get in ... "

Stuart expressed concern that some Republicans seem bent on repealing the entire law.

"That would not be very good," he said. "Take the good side, and fix it."

Gundersen's Richards said, "Right now, we've got more questions than comments, (but) I think we will know relatively soon, at least what that replacement will be."

Richards also cited the complexity of the law, saying, "I tell people that the law isn't just about health care reform. It is primarily about the health insurance aspect."

Despite increasing premiums, "the vast majority on our plan (Health Tradition) were able to receive premium subsidies," Kruse said.

Mission able to start services

Even though the lines of those seeking care at St. Clare have diminished, no volunteers quit, Brekke said. Their shifts were spread out, and the mission has been able to work on new projects, she said, including a dental initiative that has been in the works and may be realized soon.

"We also have started a Community Health Worker Program, where people will be out on the ground in neighborhoods, filling the gap between the health systems and the community," Brekke said.

Working with Brekke to develop the program is Luke Zellmer of La Crosse, an activist who founded Wheels for All, in which he repairs bicycles and gives them to people who otherwise couldn't afford them.

On Thursday, Zellmer was able to work with a La Crosse school to straighten out a problem with a student's medication, Brekke said.

When the Health Worker Program is cranked up, it will operate in conjunction with the La Crosse Collaborative to End Homelessness, said Brekke, one of the organizers of that effort.

Health care officials remain skittish this inauguration, wondering what the next weeks and months will bring.

"I hope lawmakers heed Mayo's opinion" in calling for a delicate approach, Kruse said. "It doesn't seem that apparent they will, and I'm not sure they and Trump share that perspective.

"Most of us in health care -- if we had a voice -- would want to make less drastic changes," he said. "We have to keep voicing, with many voices, that access to health care should be for more patients.

"That should be our moral imperative, as rich as this nation is," Kruse said.

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