Republican bills threaten to greatly disrupt health care

WASHINGTON — Congressional Republicans, after years of blasting the Affordable Care Act for disrupting Americans' health care, are pushing changes that not only would strip health coverage from millions but threaten to upend insurance markets, cripple state budgets and drive medical clinics and hospitals to the breaking point.

President Donald Trump and GOP leaders have touted their proposals to repeal the health care law — one passed by the House last month and a Senate version unveiled last week — as a critical fix to the Affordable Care Act.

But in physicians' offices and medical centers, in state capitols and corporate offices, fears are growing that the unprecedented cuts proposed in the GOP legislation would create even larger problems in the health care system.

'These reductions are going to wreak havoc,' said Tom Priselac, chief executive of Cedars Sinai Health System in Los Angeles, one of the country's leading medical centers. 'It will be a tragic step backward not just for the people most affected, but for the country as a whole.'

Trump, however, in his weekly radio address Saturday, pledging anew to save Americans from rising health care costs he blames on the Affordable Care Act.

'The American people are calling out for relief, and my administration is determined to provide it,' he said.

More instability

Even supporters acknowledge that the current law needs adjustments, especially to insurance markets, where premiums have risen sharply and many insurers have pulled out.

But there are few indications the GOP repeal bills would bring much stability.

The nonpartisan Congressional Budget Office estimated that the House repeal bill, which Trump celebrated in a Rose Garden ceremony last month, would nearly double the number of Americans without health coverage over the next decade, pushing the ranks of the uninsured to more than 50 million.

And the Senate bill, which includes even deeper cuts over time, would be unlikely to be much less disruptive.

States Concerned

The cascading effects of such a retrenchment would reach far beyond those who lose coverage, according to doctors, hospital leaders, insurance executives, patient advocates and state officials across the country. To date, no leading patient group or physicians organization has supported the GOP repeal bills.

Governors and state legislators, facing huge reductions in federal Medicaid funding, soon may have to decide whether to reduce services, limit who can enroll in the health care safety net or make cuts to other state programs, such as education.

On Friday, Nevada Gov. Brian Sandoval, a Republican who expanded his state's Medicaid program through the Affordable Care Act, said the Senate bill would cost Nevada nearly half a billion dollars.

'That's a cost that the state cannot sustain,' he said.

And though the Medicaid cuts may be phased in over several years, many states that have two-year budgets would have to begin confronting the cuts sooner.

Medicaid cuts

Overall, the House bill slashes more than $800 billion in federal Medicaid spending over the next decade, according to the CBO, slashing close to a quarter of federal aid for a program that now covers more than 70 million poor Americans.

The Senate version caps federal Medicaid spending even more aggressively over time than the House legislation, fundamentally changing the program's coverage guarantee.

Over the past half-century, the federal government has paid a share of all medical costs incurred by Medicaid patients. But under the GOP plans, that funding would be replaced by fixed payments to states, regardless of what it costs to care for patients.

Under the Senate plan, because that cap would increase only at the rate of inflation, states might bear a growing share of medical costs, which historically have increased faster than inflation.

Coverage losses

In addition to the Medicaid reductions, the House and Senate repeal bills would dramatically scale back financial assistance to low- and moderate-income Americans who buy health plans on Affordable Care Act insurance marketplaces.

Those cuts would make health coverage substantially more expensive for many consumers, forcing some to drop their insurance coverage altogether, independent analyses, including from the CBO, have concluded.

Those coverage losses, in turn, will put pressures on doctors, clinics and hospitals as they face growing numbers of patients with no insurance who are unable to pay their medical bills.

Marshfield Clinic, a large health system that serves more than 2 million patients in central Wisconsin, is anticipating that passage of the GOP plan would lead to a major increase in the amount of care it would have to provide for free, said Susan Turney, the system's chief executive. At Valley Health, a network of clinics serving mostly poor patients in West Virginia, southern Ohio and eastern Kentucky, fewer patients with insurance probably would force cutbacks in services, such as extended pediatric hours that allow working parents to bring in sick children evenings and weekends.

'There will be kids and families that will suffer, and the health care in our communities will suffer,' said Valley Health CEO Steve L. Shattls

Strain on employers

The cost to employers, which provide health coverage to more than 150 million workers and their families, could rise as hospitals and physicians try to make up for losses they incur caring for uninsured patients.

'Ultimately, if there is inadequate insurance coverage, medical providers will try to get the revenue they need by increasing prices,' said David Lansky, head of the Pacific Business Group on Health, a consortium of large West Coast employers. 'That hits employers.'

It also probably will hit employees, whose insurance premiums would increase and wages would stagnate as businesses shift health care costs onto workers, as has happened repeatedly in the past.

In recent years, in contrast, workers' health care costs have increased at historically slow rates, data show.

Strain on markets

Insurance markets, too, could suffer as states eliminate national standards that require all plans to cover a list of basic benefits and forbid charging sick patients more, pushing insurance companies back to designing health plans tailored to attract cheaper, healthier consumers.

The CBO's analysis of the House bill, which is broadly similar to the Senate legislation, estimated that insurance markets serving about a sixth of the country would become unstable.

Adding to the instability, the Senate bill would eliminate the unpopular mandate that all Americans buy insurance, while not replacing it with any kind of penalty on people who don't get coverage until after they get sick.

Such penalties are widely viewed as critical to functioning insurance markets because they induce younger, healthier people to get coverage. Before the Affordable Care Act, insurance markets in several states, including New York and Washington, collapsed when state leaders tried to guarantee coverage without any insurance requirement.

'No one in any community in New York wants to see history repeat itself,' said Karen Ignagni, chief executive of EmblemHealth, one of the state's leading insurers.