ND hospitals, residents wait to learn future of health care system

April 03--Jamestown residents Dick and Dennette Christensen aren't happy with the Affordable Care Act, commonly known as Obamacare.

After Dick retired, the couple signed up for health insurance through the ACA, he said. Dennette's income was unpredictable, but they took a guess and qualified for a subsidy through the program. But she made slightly over their guess, so the couple had to pay back the subsidy and the difference in the deductible, Dick said.

The couple both had surgeries that year, so it was a huge difference, he said. They had to borrow money from Dick's individual retirement account to pay it off, and borrow money again to pay off high taxes, he said.

"It looks like a good program on the outside," Dick said. "But it didn't work for us."

Dick said he is now covered by Medicare and Dennette is getting coverage privately, not through the ACA, which seems to be working for now. He said the deductible is high, but the premium is not quite as much as it was when they were getting coverage through the ACA.

Health insurance premiums on the Affordable Care Act's marketplaces are expected to increase faster in 2017 than in previous years, according to the Kaiser Family Foundation. Lowering premiums was one of the goals of the Republican plan to replace the ACA.

The proposed Republican American Health Care Act was withdrawn March 24 without a vote from the U.S. House.

The American Health Care Act would have repealed the ACA's individual and employer mandates, standards for health care plans, premium subsidies, replaced subsides with tax credits and made cuts to Medicaid.

The Congressional Budget Office score of the original proposed bill estimated 24 million people would be uninsured by 2026, relative to the current law. The increase would be disproportionately larger among older people with lower income, the office estimated.

Rep. Kevin Cramer, R-N.D., said a conservative take on the CBO's estimation that more people would be uninsured under the AHCA than the current law would be those people now have the freedom to decide what they want regarding insurance.

"The flaw of Obamacare was that it mandated people to buy something they didn't want," Cramer said. "They would now have a choice to buy insurance if they want to."

The high premiums and lack of insurer competition in the individual health insurance markets have made insurance out of reach for people in North Dakota, Cramer said.

"What I want to see is the safety net giving people a tax credit so they can purchase the insurance they want or need," Cramer said.

The Republican bill proposed using tax credits based on age, rather than the ACA's income-based subsidies. Cramer said this system gives more help to people who use health care more. The AHCA proposed the tax credits would be available for individuals who make up to $75,000 or couples who make $150,000.

Cramer said that eligibility level is pretty generous, and an improvement he would like to see would be to lower the eligibility income level and raise the tax credit amount.

"That would get to the need more in North Dakota," Cramer said. "Then I think you're getting to where people can buy a plan that covers them better."

K.C. DeBoer, Jamestown Regional Medical Center CEO, said the hospital will be watching closely to see what will happen next with the health care system.

Going forward, it's important to look at why the ACA was passed in the first place, DeBoer said. About 10 percent of the population are uninsured now, compared to 14 percent, or 47 million, in 2008, he said.

The increase in people insured doesn't mean that the ACA is perfect, but the focus shouldn't be on "repeal and replace" but instead, "repair and improve," DeBoer said.

Many people disliked ACA's regulations, but some have made the system better, such as requiring preventative services to be covered and setting requirements of what constitutes a health care plan, DeBoer said.

A necessary change to ACA would be to stabilize the health insurance exchange, DeBoer said. The health insurance marketplace, also called the exchange, is where people who don't have coverage through their job or another program apply for insurance.

Health insurance rates on plans outside of the ACA also continue to go up, which is reflective of many issues, including increasing costs of care and less insurer participation in the markets, DeBoer said.

According to the Kaiser Family Foundation, the average number of insurers participating in the marketplace in 2017 will be 3.9 per state, compared to 5.4 in 2016. Something needs to be done to get more insurers participating in the markets, especially in places where there is only one insurer and no competition, DeBoer said.

Health insurance costs increase because the cost of health care services increase, utilization rates increase and how the plan was used in the past year influences how it will go forward, DeBoer said.

If the employer and individual mandates are removed, the concern is only people with health issues will participate in the markets, which would drive up utilization and service costs as well as premiums even further, DeBoer said.

Cramer said rates can't decrease in the current system because there is no real incentive for young, healthy people to buy insurance. Even with the mandate, many people will pay the penalty rather than buy insurance, he said. There needs to be a natural incentive, such as low costs or a tax credit, so those people will want to buy coverage, Cramer said.

"We want a safety net, equity and for the health care system to make enough money to serve people," Cramer said.

Health care costs could decrease overall if more people took preventative action and addressed health issues when they are on a smaller scale, DeBoer said. If people have health care coverage, they are more likely to get care when their problem is still small, rather than delaying treatment until it is an emergency, he said.

"We want the health care policy to help us take care of people," DeBoer said.

Effects of Medicaid expansion in North Dakota

DeBoer said anything done to cut Medicaid will decrease coverage, which is not good for hospitals or people in North Dakota.

Medicaid results in a $1.5 million impact per year to JRMC, and if expansion is cut, most of the money will go back to being bad debt for the hospital because it will still treat patients who don't have coverage, DeBoer said.

"It would put a financial burden on JRMC and other hospitals in North Dakota," DeBoer said.

Cramer said Medicaid is a big part of the safety net, but it has grown and gotten costly, so less funds are available for the people it was designed for. A new plan should also give the states more flexibility regarding Medicaid funding and eligibility requirements, while still covering the most vulnerable population, he said.

The ACA currently funds Medicaid through open-ended federal support tied to state spending on the program. The Republican plan proposed funding Medicaid using a per-capita allotment and gave states the option to receive a block grant for non-expansion adults and children or non-expansion adults. Non-expansion adults and children are those covered by the regular Medicaid program, not Medicaid expansion.

DeBoer said he would like to see a better way to fund Medicaid because less money coming into the system means less people covered.

The hospital's goal is to break even, and taking that money away may impact the services it offers and could take JRMC from breaking even to operating at a loss, DeBoer said.

"Our goal is to add services that the community wants and needs to help keep them from having to travel for care," DeBoer said.

For example, the addition of an ear, nose and throat physician is something JRMC wanted to bring to the community that people were traveling for, among other services, DeBoer said. All those things take an investment by the organization, and that loss of funding could potentially have a negative impact on expanding services, he said.

North Dakota Hospital Association President Jerry Jurena said Medicaid expansion has allowed about 20,000 people in the state to have coverage who hadn't before.

North Dakota hospitals received about $190 million in additional reimbursement due to Medicaid in the last year, based on information from the Sanford Health Plan, Jurena said.

Before individuals covered by Medicaid expansion had insurance, they would delay seeking help until their injury or health issue became a crisis, Jurena said. When someone without insurance leaves the emergency room with a large bill and no way to pay, it becomes bad debt, he said.

Jurena said the higher rate of insured has lowered amounts of bad debt among hospitals and patients across the state.

"People are being more proactive and taking care of their issue before it becomes a crisis," Jurena said. "Just having access and insurance is an improvement for individuals."

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