Board Chair’s Message
ACA: Repeal, Replace or Repair
I have been hesitant to comment on Washington’s legislative attempts to deal with health care reform. My concern has been over the lack of progress in Congress to pass legislation that would correct the deficiencies of the current Affordable Care Act (ACA). The American Health Care Act of 2017 (AHCA) was passed May 4th in the Republican controlled House. It is, in my opinion, a terribly flawed bill that will likely be totally reworked in the Senate. If the Senate version is passed and is significantly different than the House bill, then some compromised version would need to be negotiated and passed by both legislative bodies before it can be sent to the President for signature and enactment. Given all the political drama in the current Capital environment, it seems unlikely that there will be any quick conclusion to the “repeal and replace” promise that was the basis for much of the 2016 election campaign.
The current version of the AHCA is being scored by the Congressional Budget Office (CBO). Based on the scoring from a previous version of the bill, millions of people would lose their health insurance including many of the poor and elderly. There is also concern that patients with pre-existing conditions may be denied coverage or pay significant premium increases. Polling on the AHCA shows it to be unpopular with the most Americans. Professional health care organizations such as the American Medical Association (AMA), the American College of Physicians (ACP) and the American Hospital Association (AHA) oppose the current bill.
Rather than total repeal and replacement of the ACA, there is discussion to repair the parts of the 2010 legislation that are not working as intended. The health insurance market needs to be stabilized so consumers have a choice of plans and premiums. Costs need to be controlled especially over high deductibles that prevent people from using the very coverage that they enrolled in. Price inflation for pharmaceuticals, medical devices and services needs to be restrained.
As health care reform is being debated, two concepts are frequently mentioned:
Access to coverage versus access to care
“Access to coverage” generally means the ability to obtain affordable health care insurance that includes the more common and important services and conditions. “Access to care ” assumes the ready availability of health care services when medically necessary and appropriate. In the ideal health care setting, both conditions are met. Some of the confusion in the current discussion is considering one aspect without the other. For example, I have heard a member of Congress state that everyone in America has access to emergency room care. This statement ignores the fact that ER care is the most expensive and least effective for minor illness/injury or chronic medical conditions. Another concern is coverage for costly chronic medical conditions and illnesses. High risks pools are part of the AHCA meant to address this population. High risk pools are very expensive to support and past efforts have been significantly underfunded and therefore unsuccessful at meeting either of the above identified criteria, “access to coverage” and “access to care” for this chronically ill population.
The fact is health care coverage and care are dependent on the market, infra-structure and professional staff to function. The next iteration of health care reform needs to consider the total picture and not just a political ideology dependent on winning the next round of elections. The provision of acute and chronic health care services is expensive and highly individualized to the patient care needs. “One size fits all” legislation is not a workable or acceptable solution.
Complicating the situation in Illinois is the ongoing budget stalemate in Springfield. Social service agencies, mental health centers and substance abuse clinics are facing an existential funding crisis. Medicaid providers that service patients covered by Medicaid managed care organizations are experiencing long reimbursement delays and underpayment. Home care agencies are laying off their workers due to lack of funding from the state. As in Washington, the political environment in Springfield is toxic to any legislative solutions very soon.
The Board of Directors and staff of the Washington Square Health Foundation (WSHF) have been considering potential funding priorities in this uncertain health care environment. As Howard Nochumson, our Executive Director, frequently states “all the private health care and social service foundation money in the world is not enough to solve the prevailing health care crisis.” Neither private, nor public health care and social service foundations can solve the twin access challenges of coverage and care. However, foundations can continue to fund some of the gaps in the health care system, after the government at the federal and state levels both fund in whatever financing formula is finally decided on, the essential components of providing health care at a reasonable cost, including infra-structure, equipment, supplies, facilities and staff.
Our grant making always considers the impact on a community, the needs of the underserved and the resources needed to be a grantor that enhances health care as an essential human service, through ” filling in the gaps “of the health care system, not in funding the operational components of the system. Meanwhile, our state and national political leaders need to find the courage and wisdom to restore and maintain our health care system and not to erode it any further.
William N. Werner, M.D., M.P.H., F.A.C.P.