By Harry R. Jackson, Jr.
Tuesday, April 22, 2014
My mother passed away just before Easter of this year.
During her last five months, she made six trips to the emergency room. Her
journey from failing health to death gave our family an opportunity to observe,
first hand, the positives and negatives of our transitioning healthcare system.
Essie Jackson was a frugal senior citizen who suffered from a rare form of
blood cancer and expired from complications of that health challenge.
Thankfully, she had my family and myself to help her navigate the last few
months of life. Most of the poor or elderly would not have been able to travel
45 to 60 minutes (each way) to take advantage of the region’s best healthcare
options.
Instead of the large, efficient hospitals where
everything is state-of-the-art; the poorest and weakest citizens must use the
clinics and hospitals that serve the patients that no one else wants. These
Medicaid patients (whose reimbursements are much smaller than those of private
insurance) and patients without insurance are on the lowest rung of the
healthcare food chain. The institutions that serve them are struggling. Many
such organizations initially welcomed ACA, believing that it would help their
uninsured patients get covered. But ironically, these are the very institutions
whose existence is now threatened.
Now that the ACA has been in effect for a few months, the
unintended consequences of the law are becoming clearer. Initially, the obvious
problem was that far more insurance plans were being canceled under the ACA’s
regulations than were being selected in the exchanges. This seemed to defeat
the ACA’s goal of expanding healthcare coverage. The higher premiums that
younger healthier adults were being charged to subsidize the care of those who
were older or who had preexisting health conditions also attracted a lot of
attention. But not much has been made of the ACA’s effect on the segment of
population it was supposed to help the most: the poor.
Little discussed in the thousands of pages of the ACA
bill were its deep cuts to Disproportionate Share Hospital (DSH) payments.
These were to begin this year, but last Fall were delayed by the Obama
Administration until 2016. DSH payments go to hospitals that treat a large
number of uninsured patients who are unable to pay their bills. Each year,
there are about 130 million emergency room visits. The 1986 Emergency Medical
Treatment and Active Labor Act (EMTALA) requires that hospitals provide
emergency treatment to anyone, regardless of ability to pay. Naturally, the
hospitals doing the most of this kind of charity care rely on the DSH payments
to stay in business.
Even with the delay of the DSH cuts, hospitals and
clinics that serve lower income populations are struggling to plan for the
future. Anticipation of the ACA’s cuts caused the world-renowned Cleveland
Clinic to announce large numbers of layoffs last Fall. In California, 1.3
billion dollars was cut from county health departments where it funded safety-net
clinics that treated the poor. Natividad Medical Center in Salinas, California
is one of many smaller facilities that have struggled with the cuts, as they
have tried to hold onto their few privately insured patients since the passage
of the ACA. The dollars were rerouted to accommodate the ACA’s expansion of
Medi-Cal, the state’s Medicaid program.
Unfortunately, this is not just an urban or minority
problem. Rural hospitals that serve the poor are also threatened. In Forkland,
Alabama, where residents earn just an average of $10,000 per year, Bryan
Whitfield Memorial Hospital relies on DSH payments to cover its razor thin
profit margins. If it has to close, or if it stops providing expensive services
like labor and delivery, Forkland residents will be forced to drive 50 miles to
Tuscaloosa for treatment.
The cuts to DSH payments, needed to help defray the other
expenses associated with the ACA, were justified by the idea that hospitals and
clinics serving the poor would start treating larger numbers of patients with
private insurance obtained through the exchanges. But this hasn’t happened at
Bryan Whitefield, and in some poorer neighborhoods, the effect has been exactly
the opposite.
The Washington Post recently reported on a local clinic,
Mary’s Center in Adams Morgan, which for decades has treated some of
Washington, D.C.’s poorest residents. They rely on DSH payments and a modest
percentage of privately insured patients to make ends meet. After the passage
of the ACA, two large MedStar clinics opened nearby. According to the Post, the
MedStar clinics have drawn the few privately insured patients away from Mary’s
Center, putting the center’s future in jeopardy. In short, the ACA regulations
and requirements may soon be unintentionally putting smaller urban clinics and
rural hospitals out of business, further restricting the poor’s access to
healthcare.
Of course the cuts to DSH payments were initially made
with the assumption that the ACA would achieve universal healthcare coverage;
with everyone theoretically covered either by Medicaid, Medicare or private
insurance through the ACA exchanges, clinics would no longer have to treat
uninsured patients. In reality, however, there are still many uninsured, both
illegal immigrants and those who simply haven’t purchased insurance. (And as
the New York Times recently reported, at least 20% of those who enrolled in the
exchanges have not paid their premiums.)
Even if the rollout of the ACA website hadn’t been so
problematic, the failure of some Americans to purchase health insurance
shouldn’t have been that surprising. Our track record with mandated insurance
coverage has been horrific. For example, despite laws requiring auto-insurance
in virtually every state; the Insurance Research Council estimates that 13.8%
of American motorists are still uninsured. The ACA is actually hurting the very
people it is intended to help. Further, it is probably time to admit that there
will be no simple fix to ACA. In fact, it may be beyond fixing - “The Jury is
Still Out!”
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