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Wednesday Mar 22, 2017

AHCA Won't Help Patients Who Need It Most

Editor's Note: The House of Representatives is expected to vote on the American Health Care Act(www.congress.gov) (AHCA) on March 23. According to the Congressional Budget Office(www.cbo.gov), the Republican effort to repeal and replace the Patient Protection and Affordable Care Act (ACA) would lead to 24 million fewer Americans being insured by 2026. It also would drastically alter the way Medicaid programs are funded. We asked some of our new physician bloggers how the proposed legislation would affect their patients. Here are their responses, listed in alphabetical order. We’d love to hear from other members, so please share your perspective in the comments field below.

Kimberly Becher, M.D., Clay, W.V.
Here in West Virginia, we are faced with a possible loss of access to care from multiple angles. The repeal of the ACA -- including the reversal of Medicaid expansion -- would result in 184,000 patients losing their insurance(www.wvpolicy.org).  Although that number may seem small, it is 10 percent of the state's population.

Of the remaining population, it is estimated that 800,000 have pre-existing conditions. The most at-risk groups are active and retired coal miners. Benefits addressed in the Miners Protection Act(www.congress.gov) are currently funded on a continuing resolution that is set to expire April 28. This includes health care benefits to retirees, widows and others who were supposed to be supported by pension funds of now-bankrupt coal companies. Of the estimated 22,000 individuals covered, almost half are in West Virginia or Pennsylvania(www.npr.org).  

These patients not only have small fixed incomes, they are more likely to have serious health problems -- from black lung to lung cancer. They need health care, and they need it to be affordable to survive.

Natasha Bhuyan, M.D., Phoenix
The AHCA is good for one group of people. Not women, of course. Not people with chronic health conditions. Not those who are on Medicare or Medicaid. Not kids with disabilities.

The AHCA is great for people who are very, very rich. The plan gives large tax cuts to the wealthiest Americans while making health care nearly inaccessible to everyone else. The AHCA actually cuts taxes for insurance companies with executives who make more than $500,000, along with giving drug and medical device companies a tax break.

What about Americans making less -- far less -- than $500,000? The AHCA promotes health savings accounts (HSAs) as a way for Americans to pay for health care. HSAs are tax-exempt savings accounts intended to help people with high-deductible health plans pay for health care expenses. The AHCA would change the current cap on HSAs -- $3,400 for individuals, $6,750 for families -- to at least $6,550 for individuals and $13,100 for families.

HSAs serve as great tax shelters for people who want to lower their income-based tax burden. People can contribute annually, and after they are 65, they can use the accounts for retirement savings. This is ideal for Americans who have the ability to save.

Unfortunately, HSAs are virtually useless to low-income patients who can't afford to contribute to them. Nearly half of American households can't even save $400 for an emergency(www.federalreserve.gov), let alone $13,100.

I've seen my patients decrease their insulin dosage to extend its use. Patients forgo labs, imaging, medications and procedures due to cost. For many Americans, HSAs -- like the rest of the AHCA -- are not a viable solution to the nation's health care woes.

Kurt Bravata, M.D., Buffalo, Mo.
What I have learned from the battle between the ACA and the AHCA is that third-party payer involvement in the patient-doctor relationship can easily become an obstacle to the delivery of good medical care. Of course, there is a need for federal government programs and subsidies to help the poor, disabled and the otherwise disenfranchised, be it where I was trained in the urban South Bronx or where I currently practice in rural southwest Missouri.

I think that attempting to create a one-size-fits-all insurance model is as equally bad an idea and losing proposition as trying to artificially create a "market-driven" model for health care. At the bare minimum, I might have some confidence in any proposal that was worked on in a bipartisan way. At least, maybe the AHCA has a chance of growing into something useful when all is said and done because divisions within the Republican Party will drive a process of refinement through amendment and revision.

Ultimately, we won't effectively fix our broken health care system until both parties agree to put politics aside for the good of their constituents -- all Americans, not just the ones who got them elected.

Kyle Jones, M.D., Salt Lake City
Conservative lawmakers have long supported funding Medicaid programs with block grants, which would provide a set amount of federal funds (usually per capita) to each state. This then theoretically gives increased flexibility to each state on how to run Medicaid, but many (myself included) are concerned with the coverage and accessibility options that will be lost for those most in need.

Utah, and every other state, would receive less money through block grants. All of my patients have Medicaid because each of them has a developmental disability. Many of them could conceivably lose coverage when our state feels the budgetary squeeze this Medicaid reform would create. Even if none of my patients loses coverage, they likely would receive fewer benefits as the state adapts to decreased funding.

My patient population is the most vulnerable population in our society. Restricting or eliminating coverage through Medicaid block grants, as presented in the AHCA, would mean not only a worse life for them, but likely a shorter one, as well.

Margaux Lazarin, D.O., M.P.H., Redwood City, Calif.
The AHCA already has had adverse effects on my patients. Even before it was introduced, my patients were worried about what was coming. As a family physician providing primary care in a reproductive health care clinic, the recent weeks and months have been filled with anxiety for my patients. My elderly Medicare patients with multiple chronic diseases have asked if I will still be able to care for them, and patients with diabetes who are on Medicaid are worried about what will happen when they cannot afford their medications, labs and visits.

One of my patients, a 55-year-old male, has been trying to "wean" himself from his blood pressure medicines in anticipation of the possible loss of coverage. The number of women in my practice requesting long-acting reversible contraceptives has increased significantly, with specific interest in methods that will last for more than four years.

Overall, I have seen an increase in anxiety and depressive symptoms shadowing many of my visits. I am grateful to have an on-site behavioral health specialist who is helping me and my patients navigate this uncertain future.

Ryan Neuhofel, D.O., M.P.H., Lawrence, Kan.
Republican health care reform proposals, including the AHCA, have received mixed reactions within the direct primary care (DPC) community. One thing most DPC doctors desire is to see control of more health care dollars return to patients themselves.

The most natural vehicle for this effort would be HSAs. So expanded use of HSAs -- which is being touted by Republicans -- holds some promise for DPC patients and practices, but there are some major flaws in the AHCA that need to be addressed.

Specifically, the IRS has interpreted membership in a DPC practice as a "second health plan." This potentially voids a patient's eligibility to contribute to an HSA. As it stands today, this has not been clarified by the AHCA. (Of note: a stand-alone bill, the Primary Care Enhancement Act(www.congress.gov),  may clarify this matter separately.) 

I question how many extra Americans would get HSAs under the AHCA. Due to a recently introduced provision, "leftover" tax credits paid to individuals may no longer be rolled over to fund an HSA as was allowed in an earlier draft of the bill. Although states may get more flexibility with Medicaid to incorporate innovative payment models, the AHCA doesn't meaningfully reform Medicare.

So without some major changes, the AHCA will not help expand HSAs much beyond people who already are able to save. Given this, I am not confident it will move us to a more patient-centered system.

Beth Oller, M.D., Stockton, Kan.
Rural areas such as mine have populations that tend to be older and poorer, groups that will be among those hardest hit by proposed cuts to insurance subsidies and the resulting increased premiums. Patients aged 50-64 need preventive care, but many won't be able to get it (think mammograms, colonoscopies, cervical cancer screening). This age group also is at increased risk for type 2 diabetes, hypertension, hyperlipidemia and other chronic conditions that without monitoring and treatment lead to significant morbidity and mortality.

Though House Republicans and the administration are trying to sell this bill as a positive change for consumer choice, the reality is there is no choice when you can't afford any of the options.

Gerry Tolbert, M.D., Burlington, Ky.

The biggest change facing both my private practice and my work as medical director of the local health department is the decreased resources for state Medicaid programs. Many of the other beneficial changes made by the ACA -- including coverage of preventive services and restrictions on refusing coverage for pre-existing conditions -- remain in the current iteration of the AHCA.

For my patients that benefited from the Medicaid expansion, as well as my patients who have continued to receive services through Medicaid, the change to a block grant system under the AHCA likely would mean fewer resources on a state level for addressing their ongoing medical issues. Although not all of my patients with Medicaid have complex, expensive medical issues, there are many who only recently received coverage for diabetes or heart conditions that require significant resources for appropriate management. It will be interesting to see if the proposed changes truly change my day-to-day practice.

Posted at 01:49PM Mar 22, 2017 by Kimberly Becher, M.D.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.