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The healthcare war: Round and round it goes again, and where it stops, nobody knows

August 18, 2018 Leave a comment

The healthcare war:

Round and round it goes again, and where it stops, nobody knows

©by Leo Adam Biga

Originally appeared in the August 2017 issue of The Reader (www.thereader.com)

 

As we go to press with this issue, the Republican-led attempt to repeal and replace Obamacare struggles on..

One of the most controversial things the GOP plan broached was severely cutting Medicaid, the nation’s largest health care program. Critics see it as an entitlement grown far beyond its original scope. Most recipients are children, mothers, the disabled and the elderly. The proposed $770 billion cut – spread out over several years – would have impacted millions, particularly the working poor in rural regions, who account for many of those added to the rolls through the ACA’s Medicaid expansion.

One World Community Health Centers CEO Andrea Skolkin said far from an automatic hand-out, qualifying for Medicaid is actually “very difficult.” She added, “There’s a lot of myths about Medicaid and who’s eligible to be enrolled. If you’re an able-bodied adult, you’re not really eligible. You really have to be an advocate for yourself in getting enrolled with all the paperwork because you have to prove your income. It’s an arduous process.”

The program, said Skolkin, places severe limits on not only eligibility, but coverage for certain things. Any tightening of eligibility and reduction of spending, she said, would result in even less access to care.

“As Medicaid ratchets down what it pays to providers, providers are less likely to want to accept Medicaid and so this vulnerable population doesn’t have as much choice of provider of where to get care, and that’s a problem.”

Currently, one in five Americans is enrolled in the program. In Nebraska, which refused Medicaid expansion, one in eight or some 230,000 people are enrolled. Skolkin estimates about 70,000 Nebraskans fall in the gaps – either not eligible for the marketplace or not covered by a private plan or by Medicaid.

Nebraska Methodist Health System vice president and CFO Jeff Francis was most troubled that “draconian cuts” to Medicaid were even on the table for so long.

“The thing that still looms out there that bothers me is that there wasn’t much budge on that,” Francis said. “I  understand the partisan divisions on that, but at the end of the day that degree of cut to Medicaid is going to really impact individuals and individuals’ coverage. In Nebraska we get a bit of a double whammy, no matter what happens with the cuts because, one, we weren’t a Medicaid expansion state, so we’ve not benefited at all from some of the expanded coverage in federal dollars that went along with that. And, two, historically we’ve been lower on the Medicaid spending spectrum, and so as that translates into cuts and block grants for the states, Nebraska’s going to get hit pretty hard.”

Medicaid is crucial for millions getting treatment for maladies, and Skolkin said, “It also has an impact on long-term care in a tremendous way.”

Low weight new babies, infant mortality, STD and teen pregnancy rates are at crisis levels. The opioid epidemic got highlighted in the recent care plan debates. Mental illness is increasingly recognized as an acute public health problem. In the proposed Medicaid cut, some public schools would have lost funding for screenings and other care that students from low income families rely on.

In this high needs scenario, cutting access to care means some people will delay or defer treatment, and those with conditions that could be prevented or controlled will get sicker, while others will seek care in emergency rooms, all of which puts more pressure on providers. The system’s closely interwoven nature is such that pulling hard on one strand, like public health, will fray or undo other strands in this fragile crazy quilt.

“The tapestry doesn’t work without all the threads,” said One World pediatric nursing practitioner Sara Miller.

Nebraska Medicine CEO Dr. Daniel DeBehnke appreciates how those outside the industry often fail to see just what a tightly-knit fabric it is.

“I don’t know if it’s a disconnect or just a reflection of the complexity of it,” DeBehnke said.

In the event of cuts, he said, “low income individuals are going to need to make really tough choices about how to pay for a roof over their head and feed their family and pay for healthcare, and some may put off healthcare, and that has several domino effects. People become less healthy and when they do access healthcare, they require more services. Once they do require services, a lot of that financial burden gets shifted to the facilities caring for them, be it a local clinic, provider or large health system.”

Sara Miller envisions “life expectancy decreasing because you don’t have the opportunity to intervene in the early years, especially for kids to have healthy habits, and to do preventive medicine, so that folks don’t have diabetes or high cholesterol by the time they’re in their mid-20s.” She added, “My fear most is for the families that it affects and their deciding between food and electricity and healthcare. That’s a decision nobody should ever have to make.”

Exacerbating it all, DeBehnke said, is the “skyrocketing” cost of care.

“We should be focusing on that as well and not just in cutting the dollars that go for healthcare – but how can we decrease the cost of healthcare, the cost of prescription drugs driving a lot of the cost. How can we drive healthcare systems like ours and others to be more efficient and cost-conscious. We’re working on that every single day because we know that’s how we’re going to be paid in the future,” DeBehnke said. “But there are all those other things we should be working on as well so that we pay less for healthcare as opposed to just giving less money for healthcare.”

No matter where this all lands, he said, “When we talk about Nebraska Medicine and our mission, we’ll take care of anybody that walks in our door. That’s who we are and that’s what we do and we’re big enough to be able to do that.”

As a Federally Qualified Health Center, One World takes anyone, too, but it doesn’t have as deep of pockets as Nebraska Medicine.

“When we have increases in numbers like we have seen – we cared for over 18,000 patients last year who were uninsured, which is more than half of all of our patients – that’s an increasing burden as an organization in trying to leverage other funds so we can take care of all people,” Skolkin said. “If Medicaid reduces what it reimburses for certain services, again that’s a reduction to every provider, including us. So, whether you need an x-ray or some lab work. as things get reduced we get less payment for that and then it just has a ripple effect.

“So, cuts do impact us and at some point we won’t be able to provide the extent of care we provide. I would hate to see that happen, but at some point you have to be able to make your budget.”

DeBehnke said no matter what happens, “there’s going to be people left behind,” adding, “The idea that I hope legislators are thinking about is how do we leave the least amount behind.”

Jeff Francis said this is no time to be complacent even as Nebraska Methodist Health System is “operating well under the Affordable Care Act.” He added, “It took some time for us to be able to understand it. We’re now into the fourth year of the federal exchanges and the insurance aspects of it. Other parts of it we’ve been operating under for about six years. And so it’s going on. We’re seeing better outcomes because the focus is on quality and outcomes as opposed to just the fee for service or being paid for services.”

But just as the ACA was never meant to be a panacea for all the system’s faults, Francis said major cuts to public health would have negative consequences.

“To the extent there are less insured and so people are doing less preventive, that would be a step backwards from a public health standpoint. We still have the vulnerable populations – those with chronic conditions, in some cases multiple chronic conditions, those with mental health challenges, the working poor.”

Methodist Health and others are working to fill the gaps where they can.

“We’re reaching out to try and address that,” Francis said “by opening up a community health center in downtown Omaha to work with other entities-services to reach vulnerable populations. That center is going to have Lutheran Family Services associated with it to try to deal with that behavioral health component.”

The center is part of the Kountze Commons project on the former KETV site at 26th and Douglas. It’s an expansion of existing Kountze Memorial Lutheran Church health and food services.

Andy Hale, Vice President of Advocacy for the Nebraska Hospital Association, said his organization has been lobbying the state’s congressional delegation to “ensure all Americans can access the compassionate, patient-centered and affordable healthcare they deserve.”

“Nebraska’s hospitals serve as the safety net in each of their communities,” Hale said.

Hospital programs benefit the state, he said, by “providing free care to individuals unable to pay, absorbing the unpaid costs of public programs such as Medicare and Medicaid,” as well as “subsidizing health services reimbursed at amounts below the cost of providing the care … and incurring bad debt from individuals that choose not to pay their bills,” according to Hale.

Hale said hospitals serving more rural regions typically to treat “older, poorer, sicker populations” who tend to be on Medicare or Medicaid.

“Medicaid plays a critical role for Americans who live in small towns and rural areas,” Hale said. “Almost half of all children living in small towns and rural areas receive their health coverage through Medicaid. Research shows Medicaid provides families with access to necessary health services.”

He said any drastic cuts will be felt most in rural areas.

“Many hospital margins are already thin, but when you begin cutting reimbursement rates, it hits their bottom lines and drives those hospitals to significant losses.”

One World’s Andrea Skolkin said even in this repeal and replace mania, vital aspects of public care should not be lost in the shuffle.

“The expansion of Medicaid funding for children through CHIP (Children’s Health Insurance Program) expires on September 30. All of these things are tied together.”

DeBehnke would like whatever process follows this latest effort to undo the ACA to be deliberate.

“President Trump said at the beginning of all this, ‘Who would have thought this was so complex?’ Well, we’ve all known it’s this complex and we’ve been trying to warn it’s this complex all along,” DeBehnke said. “As opposed to rushing to try to get something done because it was a campaign promise lawmakers made to their constituents, let’s take our time and try to figure it out and get it right. Obamacare wasn’t perfect either. There are good things we can pull from there that are in the right direction.”

Behind-the-scenes, executives like DeBehnke and Francis are bending elected officials’ ears.

“We’re wanting to make sure legislators and policymakers keep that longer view perspective. I think that’s coming out in some of the town halls the senators and congressman are hearing,” Francis said.

Meanwhile, the leadership of Nebraska Medicaid is in transition. Longtime director Calder Lynch left for a federal job in May. Former deputy director Rocky Thompson is serving as interim head until a permanent replacement is found.

Andrea Skolkin is unsettled, too, by the unknown but feels something like universal care will emerge and retain a public health haven.

“We are having those conversations – trying to make our representatives aware of the patient base we care for and what the impacts of cuts would be. Many of our patients, almost all of them, fall into this vulnerable bracket. If you cut too hard, then that social compact becomes less available for the people that need it most.

“I do believe there will be something for everyone. I think Medicaid is still going to be there. There’s a lot of argument-dialogue going around right now. It hasn’t been as productive as it could be. But I am hopeful it will end in the right place. Whether the Affordable Care Act is repealed or not, there has to be a safety net in place for people who are more vulnerable.”

Read more of Leo Adam Biga’s work at leoadambiga.com.

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Who’s Going to Pay? Before and After the Affordable Care Act

March 16, 2017 Leave a comment

There’s nothing like getting current, though it’s hard to do when you write for a monthly. Still, in this cover story I wrote for the March 2017 issue of The Reader (http://www.thereader.com) I think I mostly managed to stay relevant to the topic of health care coverage in America, the forces pushing and pulling for and against the Affordable Care Act and what the ACA has meant in terms of gains and what its repeal and replacement would mean in losses. For the piece I spoke to local professionals on the provider and insurer sides of the equation for their take on how we got here and where we might be heading. The story went to press with us knowing Congress was working to repeal and replace Obamacare, though no one knew what that entailed, and then just about the time our story got published that plan was unveiled. As you know by now, the proposed new plan was met with disdain from all quarters, especially consumer rights groups and elected officials, even conservative Republicans, who heard loud and clear from constituents that they they oppose the called for cuts that would cause many people to lose insurance. As the push back continues, town halls and debates ensue, and presumably negotiations, revisions and compromises will get made. Meanwhile, America still can’t get its health care system to work equitably and efficiently.

 

Who’s Going to Pay? Before & After the Affordable Care Act

©by Leo Adam Biga

Appeared in the March 2017 issue of The Reader ((http://www.thereader.com)

One accident, one illness could be catastrophic. Not just medically, but also financially.

Families stood to lose almost everything in medical bankruptcies when health insurance companies rejected those with pre-existing conditions and capped their policies with lifetime limits.

Uncovered costs helped health care expenditures soar, more than tripling in the last 20 years according to the federal National Health Spending Report. In 2015, the federal government was the largest payer of health care, covering 37% of the total cost through its two programs Medicaid and Medicare.

The curve was starting to bend.

According to the Kaiser Family Foundation, health insurance costs increased 63% from 2001 to 2006 and 31% from 2006 to 2011. That number dropped to 20% from 2011 to 2016.

Part of the reason was the Affordable Care Act and a landmark shift in how health care was being offered. Through a series of tax increases targeting high-income earners, the ACA was able to fund experiments in in- novation while subsidizing the cost of bringing almost 30 million Americans into the health insurance system.

With the end of Obamacare at the top of the national conversation, The Reader talked to the major stakeholders about life before and potentially after the Affordable Care Act.

It’s not just the $2 billion in federal revenues Nebraska passed up for health insurance, or the 275,000 Nebraskans with pre-existing conditions that could be denied health insurance, according to the Kaiser Family Foundation. It’s not even the estimated 165,000 Nebraskans that would lose health insurance, an increase of 111% of the uninsured, according to the Economic Policy Institute, leading to almost 3,000 jobs lost and $400 million in federal health care dollars gone that we subsidize.

It’s also about the way we take care of each other.

Quality of Health Care Over Quantity

America treating healthcare as a commodity helps explain its high delivery and coverage expense. Characterized by historic lack of incentives to drive prices down, providers and insurers dictate terms to consumers. Subsidies to assist low income patients who can’t pay out of pocket get passed along to other consumers. But affording care and its coverage is a burden even for the middle classes.

Amid runaway costs and coverage gaps, America’s clunkily moving from a volume to a value-based system as part of long overdue healthcare reform. The Affordable Care Act was passed in 2010 after contentious bipartisan debate. The statute’s full roll-out began in 2014.

Nebraska Medicine CEO Daniel DeBehnke said, “The tipping point that brought the ACA forward is really the unsustainable growth in our country’s healthcare costs.”

The calculus of people not being able to afford care translates into real life implications. Untreated chronic diseases worsen without treatment. Early diagnoses are missed absent annual physicals or wellness checks.

Championed by President Barack Obama, who promised reform in his campaign, the ACA’s enacted consumer protections and mea- sures holding providers account- able for delivering value.

Nebraska Methodist Health System CFO Jeff Francis said organizations like his have “con- tracts and monies at risk for hit- ting certain quality items, not just with Medicare, but with some of our commercial insurers as well, Five or ten years from now,” he added, “we’ll probably have more at risk financially from a quality and outcome standpoint. Recent federal legislation changed the way physicians get paid by CMS (Centers for Medicare and Medicaid Services). Starting in 2019 they’re having potential penalties depending on whether they’re hitting certain quality metrics or not.”

He said the stick of such punitive measures works.

A new Standard in American Health Care

Aspects of Obamacare, such as the individual mandate and public health exchanges, have detractors. Federal lawsuits challenging it have failed. But its intact survival is in jeopardy today. A chief critic is President Donald Trump, who with the Republican controlled Congress vowed to repeal and replace, though that’s proving more daunting in reality than rhetoric. On February 16, GOP leaders shared a replacement plan with tax credits for buy- ing insurance and incentives for opening healthcare savings accounts, but no details for funding the plan or its projected impact on the insured and uninsured.

Debehnke said, “I don’t think there’s any question, regardless of where you land politically, there are components of the current ACA that require tweaking. Even Democrats will tell you it wasn’t exactly perfect – nobody said it was going to be perfect. It was understood there were going to need to be changes as things move along.”

There’s widespread consensus about the benefits accruing from the ACA. New subsidies allowed millions more people nationwide and tens of thousands more in Nebraska to be insured, in some cases getting care they deferred or delayed. Insurers cannot deny coverage for pre- existing conditions or cancel coverage when someone gets sick. Plans must cover essential care and wellness visits. Adult children can remain on their parents’ insurance until age 26.

Francis said, “A lot of good things have come out of this. We’re focusing on well- ness, we have fewer uninsured, we’re having better outcomes for patients. I think there’s satisfaction with the improvements. I just think there’s disagreement with how it’s occurring or being done.”

“You can’t believe the difference it’s made by setting minimum standards for health insurance,” said One World Community Health Chief Medical Officer Kristine McVea, “so that things like child immunizations and mammograms are covered.”

Since the ACA’s adoption, uninsured 18-to 24-year-olds in Nebraska dropped from 25.5 percent in 2009 to 12.4 percent in 2015, according to the Kids Count in Nebraska Report.

McVea said, “At One World people get assistance in enrolling for health insurance. Counselors guide them through the market- place. People are really becoming more savvy shoppers. Improved health literacy has been a result of this process, you can really compare for the very first time apples to apples in terms of different plans. That has been a tremendous boon to clients.”

Not everyone included – Nebraska drops the Kick- back

Healthcare disparities still exist though. In Omaha 24% of adults living below the poverty line

lack health coverage while 3% of adults with medium to high in- come are uninsured. Some 36% of Hispanic adults, 15% of black adults and 5% of white adults are uninsured in the metro, ac- cording to numbers reported by The landscape, a project of the Omaha Community Foundation.

McVea said, “The poorest of the poor are not eligible for the marketplace at all because that part of the Affordable Care Act carved them out thinking states would cover them with Medicaid. Well, Nebraska’s elected not to expand Medicaid, so there’s this whole gap of people not insured. Then there’s prob- ably another tier who do get assistance through the marketplace, but considering the economic pressures they’re under, even with the assistance, it still falls outside their reach to get good healthcare.”

The Kids Count Report found 64 percent of uninsured Nebraska children are low-in- come — likely eligible for but not enrolled in Medicaid or Children’s Health Insurance program (CHIP).

Past Nebraska Medical Association president Rowen Zettermen said, “In Nebraska we have somewhere in the neighborhood of 60,000 to 90,000 uninsured people that would have otherwise been eligible for Medicaid expansion. you find the highest percentage uninsured rates in rural counties. We still have 20 some million uninsured in this country. A number may have insurance but they’re underinsured for their various conditions. Ideally, everybody should be able to establish a healthcare proposition with their physician, nurse practitioner or physician’s assistant to access care whenever they need it.”

Then there are federal DSH monies to fund Medicaid expansion the state foregoes because the legislature’s voted against expansion. Gov. Pete Ricketts opposes it

as well. Disproportionate Share Hospital payments are subsidies paid by the federal government to hospitals serving a high percentage of uninsured patients. Nebraska hospitals write off uncompensated care cost while getting no money back for it.

Zetterman said, “We could expand Medic- aid and take advantage of the roughly $2 to $2.5 billion that’s failed to come into the state. It would have paid salaries for more people in physicians offices and a variety of things that would be taxed and bring in more revenue.”

DeBehnke of Nebraska Medicine said, “Being a large hospital health system that takes all comers, we have a Medicaid percentage of our business. We would be better off in a Medicaid expanded state. We would like to see more coverage for the working poor. That’s what Medicaid expansion is – providing coverage to the working poor. Those who don’t currently qualify for it would under an expansion.”

Proposed federal community block grants could expand coverage. DeBehnke cautioned, “We just have to be sure there’s good control around how those dollars are used and they actually go for healthcare coverage. Expanding coverage to all people is really the key.”

Nebraska State Senator Adam Morfield is the sponsor of lB 441, which would expand Medicaid in Nebraska. The bill is scheduled for a March 8 Health and Human Services Committee hearing.

The care-coverage-income gap may be more widespread than thought. Kids Count Report findings estimate 18.5 percent of Nebraskans are one emergency away from financial crisis.

Preventative Care is Long-Term Savings

Having coverage when you need it is a relief. Insurance also motivates people to get check-ups that can catch things before they turn crisis.

“A woman having symptoms for some time didn’t have any insurance and she waited

before she sought care,” McVea said. “By the time she came to us for diagnosis she already had a fairly advanced stage of colon cancer. She’s undergone chemo- therapy and surgery and is now living with a colostomy. That didn’t have to happen. We see things like that every day – people who’ve let their diabetes and other things go to where they have coronary artery dis- ease, and that’s not reversible. We’re trying to get them back to the path of health with treatments, but they’ve lost that opportunity to maintain a high quality of health.”

Zetterman said, “There’s good data to show patients with cancer who don’t have insurance tend to arrive with more advanced disease at the time of initial discovery because they come late to seek care.”

That pent-up need is expressed more often, McVea said, as “people have insurance for the first time or for the first time in a long time.”

“We’ve seen a lot of people come in as new patients saying, ‘I know I should have come in a long time ago, and I’ve just been putting it off.’ Many are middle-aged. They’ve been putting off chronic health conditions or screening tests or other things for years. We see people come in with diabetes or high blood pressure that’s out of control and within three months we get them to a point where everything’s in control, they’re feeling better, they have more energy, they’re feeling good about their health. We’ve maybe given them advice about diet and exercise and ways they can keep themselves healthy.”

More positive outcomes are prevalent across the healthcare spectrum.

“I would say overall the average patient is having a better experience and outcome now than they were five years ago,” Nebraska Methodist’s Jeff Francis said.

One World’s CEO, Andrea Skolkin, said, “We’ve been able to reach more people living on limited income so our services have been able to expand both in terms

of numbers of patients we care for as well as types of services and locations.” One World opened two new satellite clinics with help from ACA generated monies. “As we’ve opened new clinics we’ve seen a number of people that had never been seen or delayed being seen with very complex

medical and sometimes mental health issues – and it’s more costly. We grew from about nine or ten percent of patients with insurance to close to 15 per- cent. For newly insured patients it’s meant some peace of mind.”

Fewer insured people, Higher Costs

She and her community health center peers favor more afford- able coverage to increase the numbers of those insured.

Zetterman said high premiums and co-pays present obstacles that would be lessened if everybody got covered. “The financial burden on the individual patient and family for health- care right now is too high.”

DeBehnke said, “A lot of the

burdens of those premiums in terms of high deductibles and other things have been shifted to families. There has to be some degree of subsidization if we’re going to make this all work. Regardless of where we land with this, the financial burden on the individual patient and family for health- care right now is too high.”

For the poor, the last resort for care continues to be the ER.

“If you’re uninsured the one place you can go in this country is to the emergency room of a hospital because the laws say you cannot turn anyone away from there,” said Zetterman. “As a consequence the uninsured make use of the ER because it guarantees they’ll get cared for – at least at that moment. The ER is the most expensive place to go for things that could otherwise be handled in a healthcare office.”

Zetterman said America’s handling of its social contract and safety net means “we cost shift in the healthcare environment to pay for things.” “In Nebraska, where we didn’t expand Medicaid,” he said, “we cost shift from private insurance and healthcare providers to people who have private insurance. They help pay for the uninsured-underinsured. We’ve estimated that to be well over a billion dollars. We can’t control costs reliably until everybody is in the system with some kind of a paid healthcare benefit. That can include all the current federal and state programs as well as commercial insurance that’s out there.

“Once we no longer cost shift to pay for healthcare we can begin to address the questions where are we spending our money and why are we spending it in those areas. Then we have a chance to control the growth of healthcare costs.”

Skolkin said, “A lot of hands in the pot helps add to the cost. There’s a lot of system inefficiencies, particularly in billing and credentialing, that could be made a lot of easier. That would save resources.”

DeBhenke said, “As the healthcare industry, we have not been engaged to the degree we need to be to actually decrease overall cost of care because frankly from a pure financial standpoint it’s not been in our best interest. The health systems, providers and other organizations have to really get be- hind this whole idea of providing value, of decreasing overall total cost of care while improving outcomes for patients. That’s got to work in parallel with legislative and subsidization levels at the federal level.”

He said until there’s more buy-in from “young invincibles” – 20-somethings in good health – to broaden or balance the risk pool and thus reduce payouts, costs will be a problem.

“Certainly the pricing needs to be attractive to those individuals to broaden the pool. And frankly the benefits associated with products on the exchange need to be attractive so those individuals feel comfort- able and actually want to have coverage. Those least likely to go to the marketplace and buy individual health insurance plans are exactly the people we want to do that to broaden the pool. Healthy individuals that don’t utilize healthcare much soften the financial blow.”

Repeal Without replace is A mess, Why not repair?

The ACA’s meant adjustments from all healthcare stakeholders. Opponents have resisted it from the start and that fight continues. In early January the Republican-led Senate began reviewing ACA to try and garner enough votes to repeal it through the budgetary reconciliation legislative process.

“Unfortunately President Trump has focused on what he’s going to take away without have a plan in place,” said Kristine McVea, “I think that’s been harmful. There’s a lot of fear and uncertainty among our patients. These are people who struggled without health insurance who finally got a chance at taking care of their health and are now very afraid of the possibility that’s all going to be taken away. We hear this every day from people coming into the marketplace and coming into see us for care, I think the capricious statements made by this administration have fueled that.”

More recently, talk of flat-out repeal has given way to amend or modify in acknowledgment of the gains made under ACA and the difficulty of dismantling its far-reaching, interrelated tentacles, absent a ready-to-implement replacement. The political fallout of taking away or weaken- ing protection people have come to rely on would be severe.

“Once leadership has really started to

dig into what it would mean to repeal this outright and try to replace it they’re finding it is not a simple thing to do and the health and coverage of millions of people are at stake,” said James Goddard, an attorney with the public advocacy group Nebraska Appleseed. “So things are slowing down with the recognition they need to be careful with this, and of course they do.

“I think the change in the way it’s being discussed is a reflection of the reality that this is a dramatic thing you’re discussing altering and they need to do it the right way. Much of the ACA hangs together and one thing relies on another and if you start pulling pieces of it apart, you have the potential for the whole thing to fall down.”

Zetterman said he and fellow physicians favor a cautionary approach.

“Most of us would say the Affordable Care Act should be maintained and improved. There are dangers in taking it away and replacing it because it’s now in so many different places.”

Nebraska Appleseed attorney Molly McCleery said total repeal would affect many. “Initial Congressional Budget Office projections show 18 million people would lose coverage, and then in the out years, 32 million would lose coverage – both private and public. The Urban Institute’s state-by- state impact study found 200,000-plus Nebraskans with a pre-existing condition would be impacted if that consumer protection would be taken away.”

Jeff Francis said, “The new ‘r’ word I’m hearing is repair. The consensus seems to be to keep what’s popular and working and change what’s not.”

EDITOR’S NOTE: Details of the recently proposed GOP replacement had not been released as of this printing.

Daniel DeBehnke said of the current climate, “I think it’s extremely confusing because it’s complicated. It’s like a balloon – you poke in one area and something bulges out in another. I think people are frustrated, and rightly so, they pay a lot for healthcare. It’s not just as simple as I-pay- a-lot-for-my-healthcare, ACA is bad, let’s get rid of it.’ There are layers of complexity. We may not like exactly how things are funded or how some components are dealt with. We may not agree totally with all the tactics to get there, but at the end of the day we’ve got more people covered.

I don’t think anybody has the appetite to change that back.

“We just have to figure out how to incrementally lessen the financial burden while maintaining the real goal – more people covered and providing value for the money being spent.”

He said the best course of action now for providers is to “just take really good care of patents and decrease unnecessary utilization and duplication of services,” add- ing, “It’s what everybody wants anyway.”

Fixing the marketplace

Meanwhile, on the insurers’ side, some carriers have left public health exchanges after incurring major losses. This state’s largest healthcare insurer, Blue Cross Blue Shield, opted out of the volatile marketplace.

“Since we started selling on the ACA marketplace we’ve lost approximately $140 million,” executive vice president Steve Grandfield said. “We have a responsibility to all our members to remain stable and secure, and that responsibility was at risk

if we had continued to sustain losses. The public marketplace is unstable, which has driven increased costs and decreased com- petition and consumer choice. The higher premiums go, the more likely people, especially healthy people, drop their coverage. That means the majority of people remain- ing on ACA plans are sick, with increasingly higher claims, which drives premiums up even further.”

He cited instances of people gaming the system by buying plans when they need care, then dropping them when they longer need it.

Granfield said Blue Cross supports a well modulated ACA overhaul.

“It’s important to put in place a smooth transition. We would like to see regula- tory authority for insurance returned to the states, including rate review and benefit design and closing the coverage loopholes that lead to higher consumer costs.”

He has a long wish-list of other changes he wants made.

The leaders of two major Nebraska health provider systems say they haven’t seen any impact from the BCBS defection because there are many other insurers and products on the market. The executives were not surprised by the move given the fluid healthcare field.

Nebraska Methodist’s Jeff Francis said, “There were a lot of unknowns. I think it takes several years through the insurance cycle to be able to correct those kinds of unknowns, especially the way the federal government handles the bidding and setting of rates That’s why you won’t see craziness or changes in the rates in the years to come because they now have several years of experience with this new population and they’re then able to price accordingly.”

Daniel DeBehnke of Nebraska Medicine said, “Regardless of what happens in Washington, if the exchanges are kept in place there will be some changes made either in the pricing or pool that will help organizations like Blue Cross perhaps get back in that business.”

Quality Health Care Starts with Collaboration

Collaboration is key for containing costs in a system of competing interests. More U.S. healthcare decisions are happening outside silos.

Francis said, “A big change in the last 10 years is opportunities to work more collaboratively. In the past it would have been much more stand-alone. Now the hospitals and physicians are working more closely. Nebraska Methodist is part of an account- able care organization – Nebraska Health Network, along with Nebraska Medicine and Fremont Health. We recognize the importance of learning better practices from each other so we can pass that along to make healthcare better for the community and for employers paying for their employees insurance.”

One result, he said, is “less antibiotics pre- scribed by our family doctors at Nebraska Medicine and Methodist Physicians Clinic.”

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