What the AHCA Could Mean for Patients and Providers

Since his days on the campaign trail, President Trump has vowed to repeal and replace the Affordable Care Act (ACA). Over the past several months here on Perspectives, we’ve analyzed what the new administration could mean for healthcare reform and how an ACA repeal could unfold.
Now that the GOP’s American Health Care Act (AHCA) has passed the House of Representatives, it heads to the Senate for a vote. Needless to say, the stakes are high for healthcare reform in the coming months.
As an emergency physician, healthcare has always been personal to me, and I know many of my colleagues feel the same way. You don’t really think about emergency care until you need it. It’s a safety net. I feel the same way about healthcare in general. Healthcare is one issue where both parties need to come together to do what’s right for the people.
Today, I’ll share my perspective as an emergency physician about how the AHCA could impact hospitals, providers, and, most importantly, patients.

The AHCA: Just the Facts  

First introduced in the House on March 6, 2017, the AHCA has changed shape over the last two months with the introduction of a number of amendments to the original proposal. While the future of the bill is uncertain as it heads to the Senate, the final AHCA as passed by the House combined the original bill with subsequent amendments. Highlights of the bill include:
  • Removes the requirement for people to buy insurance through the marketplaces.
  • Eliminates the income-based tax credits and subsidies available under the ACA, replacing them with age-based tax credits ranging from $2,000 a year for people in their 20s to $4,000 for those over 60.  
  • Eliminates nearly all the taxes that were included in the ACA to pay for the subsidies that help people buy insurance.
  • Phases out enhanced funding for Medicaid expansion and would either give states a set amount of money for each Medicaid enrollee or let states choose to receive a fixed-dollar block grant.
  • Permits states to apply for waivers that would allow insurance companies in their states to waive the ACA’s essential health benefit requirements and charge more for or deny coverage to people who have pre-existing conditions.
  • Imposes a penalty on individuals who do not maintain continuous coverage.
  • Creates funds of $138 billion to assist states in dealing with high-cost consumers and for other purposes.

Physician and Hospital Groups Call for Changes to the Bill

A Congressional Budget Office report from May 2017 estimated that over 10 years, 23 million fewer people would be covered under the bill who otherwise would have had insurance under the current law. The CBO’s analysis also predicted that the House bill would cut federal deficits by $119 billion over those same 10 years.
Older, sicker, low-income people would be hit hardest by the changes, according to the CBO, because the proposed tax credits are less generous than those in the ACA, while insurance for those older than 50 is the most expensive.
The rollback of the ACA’s Medicaid expansion would result in an estimated 14 million people losing coverage, which accounts for most of the savings under the bill.
Restructuring Medicaid is very concerning to me, because many of the newly uninsured would wind up seeking care in the emergency department (ED). As emergency providers, we’ll take care of everyone who walks through our doors, regardless of whether we’re reimbursed, because that’s our mission. But these patients then face enormous medical bills that they often can’t pay, sending them into debt and forcing taxpayers and the insured to eventually cover the cost of care.
Already operating on shoestring budgets, safety net hospitals would absorb much of the cost of uncompensated care. That means less money for facilities, staff, and equipment. And many hospitals simply wouldn’t survive
The American Hospital Association weighed in on the issue, saying that the proposed restructuring of Medicaid will "have the effect of making significant reductions in a program that provides services to our most vulnerable populations, and already pays providers significantly less than the cost of providing care."

Putting Patients First?

As we saw in the days before the Affordable Care Act, when more people are uninsured, the personal bankruptcy rate increases, and patients seek care in EDs and safety-net clinics.
Those with pre-existing conditions could face far higher premiums under the AHCA. This could price many people out of coverage. Over the years, I’ve seen patients come into the ED with unmanaged chronic conditions such as diabetes. They often wind up incurring thousands of dollars in intervention when all they needed were regular insulin doses and other simple interventions.
Many patients with pre-existing conditions can be managed with relatively inexpensive care. But when they don’t have access to care, they become frequent, expensive ED visitors.
Under the AHCA, states could also apply for a waiver to exempt insurance plans from including essential health benefits in their plans. That means people in need of specific essential health benefits, such as maternity care or mental health treatment, would likely face higher premiums.

Shifting Public Sentiment

Public reaction to the ACHA has grown increasingly unfavorable. A May 2017 Kaiser Health Tracking Poll found that more Americans have an unfavorable view of the plan than a favorable one (55 percent vs. 31 percent, respectively).
Is the Affordable Care Act a perfect model? No. But it has done an admirable job of providing coverage to those who need it. And access to basic healthcare services is a human right.
The time is now to get involved and voice your opinion on the direction of healthcare in our country. Your professional society can be a great resource when it comes to making a difference. Or you can contact your representatives directly.

What are your thoughts on the AHCA? We’d love to hear from you in the comments below.