The U.S. Senate’s Better Care Reconciliation Act of 2017 was designed to repeal and replace the Affordable Care Act passed during the Obama administration. But it appears to be a hastily developed plan without the input of stakeholders who could craft legislation resulting in better and more affordable care.
I spent my Fourth of July holiday attempting to read and understand this difficult bill. Because I am a pediatrician, I decided to limit my understanding to how it might affect health care of Alabama’s children. By my count, children are mentioned only about six times in the document. However, since 71 percent of Alabama’s Medicaid population are children, I focused on the changes to that program.
Section 125 of the bill removes a hospital or physician’s ability to make presumptive-eligibility determination. I imagine this scenario: a very sick child whose parent works for minimum wage and can’t afford family coverage shows up in a rural hospital emergency room. The child has no insurance but is clearly eligible for Alabama Medicaid. The child is stabilized, admitted and successfully treated. Ten days later, he is well and discharged. Social Services helps the family apply for Medicaid. Sorry, hospital and doctor, no payment made. He wasn’t enrolled the day he got sick.
In similar fashion, section 128 of the bill does away with the ability to bill Medicaid for the month a child becomes eligible and the previous two months. Consider the grandparent who has recently taken in two children whose parent is incarcerated or in a drug rehab program. You are working and need to enroll one child in preschool and the other in daycare. You call the local pediatrician for an emergency visit to catch them up on immunizations and fill out the health forms for school. The doctor helps you apply for Medicaid but you don’t yet have the legal authority — that takes two weeks and it is the next month. Sorry, pediatrician, two well-child visits and six immunizations won’t be paid for.
Or consider an expectant mother who shows up in the emergency room of a rural hospital in premature labor. She is eligible for the Medicaid Maternity Waiver Program but has not applied. She can’t be transferred the 90 miles to the tertiary care unit, so she is delivered. A three-pound baby is born and stabilized over the next two hours while waiting for the Newborn Intensive Care transport team to arrive. Mom is sick with hypertension and untreated gestational diabetes. She requires inpatient care for the next week and can’t apply for Medicaid. Sorry, rural hospital; sorry, obstetrician and pediatrician. Medicaid won’t pay for the life-saving care you just gave.
This is one of the reasons our rural hospitals’ very existence is threatened by this bill. How much uncompensated care can you give and survive? (Sending the patient a bill is absurd on its face. She works for minimum wage and doesn’t even have a car — that’s why she hadn’t applied for Medicaid.)
Section 130(b) of the bill requires a maximum recertification period of six months and allows for even more frequent recertifications. Right now, we have continuous eligibility in Alabama for 12 months. This has helped the program run smoothly and has been cost effective. Recertification is not an easy process, especially if you live in a rural area and do not have access to a computer (or the skills to use one).
A child is brought in for his 15 months well-child checkup. Mom has taken the day off from work and is sure the child is still eligible for Medicaid. Nothing has changed in her salary since he was a year old. However, Medicaid’s computer system is down and there is no way to check eligibility. The doctor performs a complete physical, administers a development test and gives two immunizations. Anticipatory guidance includes talking with mom about a rear-facing car seat, smoke detectors in their home and a bedtime routine that includes reading to her child.
Mom’s questions are answered about the child’s new ability to say “no” (his favorite word) and how to provide for “calm-down time” in dealing with temper tantrums. You talk about nutrition and limiting fruit juice. The claim is filed and you learn the child needs to recertify. Under the present system that would be fine — you can file for last month’s visit, mom didn’t have to take another day off from work and she places the 15-month old back in the rear-facing car seat.
With this bill: no payment for that visit. So, your state can decide to make people recertify every three months — think of what can be “saved” when Alabama is getting less money from the federal government and more uncompensated care is given.
Section 132 phases down the Medicaid provider tax threshold — further decreasing funds available for Medicaid. Alabama depends heavily on provider taxes.
Section 133 would reform Medicaid financing to a per-capita cap model. States could choose this or a block grant discussed in Section 134. As I understand it, either of these two means will decrease federal funds to the states for Medicaid and would save the federal government almost $800 billion over the next 10 years. For Alabama in the year 2022, the state funds would be decreased by 21.4 percent. A program that is now a partnership between states and the federal government with many mandatory requirements would shift much of the cost and the decision-making to the states. This would certainly limit the safety net for an increased need in the event of an outbreak of the Zika virus, a severe flu epidemic or some other unanticipated high-cost need. If a state uses more than its cap, it would receive a reduction to its Medicaid funding for the following year.
Beginning in 2020, section 134 would allow a state to choose what is called a Medicaid Flexibility Program or block grant for a minimum period of five years. Benefits would have to be limited or enrollment cut off if an economic downturn occurs. If the money runs out in any quarter, the state would be responsible for funding the rest of the program.
Primary care doctors in Alabama have seen this before. In August and September 2016, before the BP oil-spill settlement money was appropriated, our pay was cut and we were told to give vaccines for $8. (It costs $30 to give a shot). When the BP money was appropriated, Medicaid did not make up the lost revenue for those two months.
If the state does not use all of the funds for a given year on health care, “the HHS Secretary shall not prohibit the use of rollover funds or a program not related to health care — the current Medicaid requirement that Medicaid funds cannot be used to pay for roads, bridges, stadiums, or any other item or service not covered under a Medicaid state plan would not apply.” Alabama could decide to build a new football stadium instead of funding health care.
A block-grant choice would also allow states to impose premiums, deductibles, cost sharing or other similar charges as long as the total aggregate amount does not exceed 5 percent of the family’s annual income. For a family of four with an income of $24,000 a year, that’s $1,200 dollars. A needed medication might have to be skipped to pay the rent or buy food. An impossible decision made: I can’t take my child to the doctor because I don’t get paid until next week.
Section 134(d) spells out program requirements. Nothing is mentioned about the services unique to children. The backbone of Medicaid for children now is EPSDT (Early Periodic Screening Diagnosis and Treatment), which determines and funds the special needs of a child. Many of these services as well as prescription drugs would now be optional. This section also does away with the mandate that services have to be equal throughout the state. It is possible that children in rural Alabama won’t get the same services provided in Huntsville, Birmingham or Mobile. Too bad for us.
Freedom to choose care would also be lost. A parent might not be allowed to take a child to one of our two Children’s Hospitals if a service can be found locally. Years ago, an infant patient with a severe birth defect required care at Boston Children’s Hospital. Medicaid paid, she was cured and is now a healthy teen. Too bad for the child whose state has limited funding due to a per-capita cap or a block grant.
Section 205 sunsets the medical loss ratio requirements. Each state is allowed to set its own requirements on how much an insurance company has to spend on health care rather than non-claims costs (including the CEO’s salary or income for stockholders).
Allow me to close with one of the most outlandish provisions in this bill and in the House version: Section 118 repeals the tax on indoor tanning services. Why is this in a health bill? I think tanning establishments should be taxed to the max as New York taxes tobacco -- or, even better, outlawed. Use of indoor tanning beds prior to age 35 increases the risk of melanoma (the deadliest form of skin cancer) by 59 percent. In 2010, the industry had a $2.6 billion-dollar revenue. The estimated cost of treating skin cancer attributed to indoor tanning is $343.1 million a year, leading to a total economic loss of $127.3 billion over the lifetime of those affected.
If we want to save health-care dollars, look elsewhere. Don’t force our rural hospitals to close, our Children’s Hospitals to limit services and our youngest patients to suffer.