Area hospitals fear cuts with repeal of ACA

Washington County's 31,600 residents could be at risk of losing significant portions of their healthcare infrastructure if the repeal of the Affordable Care Act (ACA) is not replaced with a carefully constructed replacement. Healthcare organizations in the county and state are concerned about what such a repeal could mean to their ability to maintain staffing and service levels.
The potential impacts are complex, says Eastport Health Care (EHC) CEO Holly Gartmayer‑DeYoung, because the ACA is not just about insurance. "It's a culture shift aimed at promoting a healthier nation. So the core is preventative measures that go away if it's repealed. Free access goes away. We would go back to unequal access." Of the 5,300 patients her organization services, she expects that more than half would be affected by repeal of the ACA.
In a report issued by the Maine Center for Economic Policy, a total of 95,000 Mainers are expected to lose health insurance if the ACA is repealed without adequate replacement. Currently one in three Mainers in the ACA marketplace is over 55, a demographic particularly relevant to Washington County. Gartmayer‑DeYoung points to Eastport as an example of what that means. "What is significant is that the population in the city is dropping, and we're [EHC] growing because of the older population."
At stake is an annual infusion of at least $4 million that supports the county's two critical access hospitals, Down East Community Hospital (DECH) and Calais Regional Hospital (CRH). That number does not include the clinics, such as Eastport Health Care, the Regional Medical Center at Lubec and independent providers, that also serve the county's 31,600 residents. For the state as a whole, the Maine Hospital Association estimates the loss to hospitals would be about $215 million per year in revenue, with the Maine Center for Economic Policy estimating a reduction in healthcare spending in the state of $560 million in 2019 and $4.4 billion over the following decade. Uncompensated care costs for Maine's hospitals, clinics and individual providers would triple, resulting in additional costs of $475 million in 2019.
Translating such revenue losses, Calais Regional Hospital CEO Rod Boula says that an impact report estimates his hospital would suffer $1.1 million in annual losses. He points to the reduction in Medicare reimbursement rate from 101% of costs to 99% of costs during the sequestration two years ago as another hit with ongoing implications. In addition, there are potential cuts to MaineCare enrollment eligibility and reimbursement rates that could increase the amount of free care and debt to the hospital. Loss of funding would mean "repercussion on staffing." However, he adds, "We can't really do anything until we know what's going to happen." But depending on what the replacement does to revenue streams, "We may have to look at services and what would need to go."
Gartmayer‑DeYoung translates further with estimates from the Maine Primary Care Association. If the ACA funding is repealed but not replaced, statewide there would be about 14 healthcare site closures and 259 layoffs, with 28,000 patients affected. "The health center would have to seriously look at having to maintain three sites," she says. In addition to those numbers, if payment reimbursements disappear because "they are also woven into the ACA," the association estimates that statewide another 282 layoffs and 16 site closures would occur, with 44,250 patients affected.
If repeal occurs without careful replacement, the EHC "would have to seriously look at budgeting and consider layoffs," says Gartmayer‑DeYoung. The health center currently has 52 full‑time employees. At least half could be at risk. "We would be impacted across the board," she says, noting the dental, mental health, podiatry, nephrology, care management and other departments that provided care for almost 25,000 patient visits in 2015. As an example she points to the dental department that saw 452 new dental patients in FY 2016. "Without the ACA we wouldn't have the second dentist and dental hygienist," she says.

A $4 million loss to county's hospitals
Breaking down the $4 million in potential losses to the two hospitals in the county is Jeffrey Austin, vice president of Government Affairs and Communications of the Maine Hospital Association. He says that the impact of losing payments for individuals who buy subsidized policies on the exchange is around $3 million for Washington County hospitals. "This is only for those patients who get subsidies, not all people with policies on the exchange," and, he adds, the number does not include the rest of the county's providers such as clinics and individual offices. From 50% to 75% of people on exchanges receive subsidies. The U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation reports that in 2016 there were a total of 84,060 enrolled statewide in the marketplace exchange, with 2,500 in Washington County.
"There are other parts to repealing the ACA that would hurt Washington County hospitals," says Austin. The "340B" discount drug program infuses another $1 million to the two hospitals. The program allows the county's hospitals to provide qualifying patients with prescription drugs for a reduced cost. The ACA included critical access hospitals as qualifying organizations for the 340B program. "If the ACA is repealed with no replacement of the program, it will be an immediate hit," says Boula. Each hospital would stand to lose about $500,000 a year.
Gartmayer‑DeYoung relates the Maine Primary Care Association data that estimate that if the 340B program goes away for the state's hospitals, there would be 121 layoffs, seven site closures and over 72,000 patients affected. She adds, "The ACA has been a remarkable safety net, especially in rural areas where access is so unequal."
In addition, the ACA has provided significant resources for substance abuse and mental health services. "We have an epidemic," says Gartmayer‑DeYoung. "I'm very worried about that unraveling, the access to the network of support."
The Maine Center for Economic Policy reports that about a quarter million Mainers have a mental illness, including substance abuse. Maine did not take advantage of the ACA's Medicaid expansion provision. If the state had done so, the Medicaid expansion would have brought an additional $346 million annually to insure 75,000 low‑income Mainers and save the state $40 million annually by utilizing federal funds for state services, the report notes. Much like the other expansion of services through sites and staffing seen through the ACA, the state would have garnered "additional economic activity, and support or retain 4,500 jobs in healthcare and related fields," the report states.
Down East Community Hospital CEO Dennis Welsh says, "With regards to the ACA and current attempts to repeal, at this point I am really interested to see how this plays out. Without taking a position either way, we can all agree that any effort by Congress has to be done responsibly."
Gartmayer‑DeYoung says, "Illness and disease don't know the day of the week, the month or whether you have insurance." She adds, "We need community members to pause and consider, 'What would your life be like without health centers and critical access hospitals?'"

Senators King and Collins speak to issue
Senator Angus King issued the following statement in response to a report released by the nonpartisan Congressional Budget Office (CBO) stating that a repeal of the ACA would cost 32 million Americans their health insurance and force premiums in the individual market to nearly double over the next decade. "This nonpartisan report is another startling affirmation of the far‑reaching and disastrous consequences that a rushed repeal of the ACA would have for millions of Americans and tens of thousands of Mainers," he said. "Simply put, this is not a responsible way to govern -- and people across Maine are unfairly and needlessly going to pay for the price by having their health insurance ripped away and by having to reach deeper into their pockets for vital health services."
On January 23 Senator Susan Collins introduced the Patient Freedom Act of 2017 with Senator Bill Cassidy of Louisiana and other senators. It repeals a number of ACA mandates, including mandates that cover individuals, employers, plan categories and benefit requirements. It keeps the prohibitions on: annual and lifetime limits, pre‑existing condition exclusions, discrimination. It also preserves coverage for mental health and substance abuse disorders. Children under 26 would be allowed to stay on their parents' plans. There are two options to the plan. The first is a state option with three different choices. The first choice would be for reimplementation of the ACA, with states continuing to receive federal premium tax credits, cost‑sharing subsidies and Medicaid dollars, but they could not exceed the amounts that would be made under the second choice. Under the second choice, the state would create a new market‑based system and could receive funding equal to 95% of federal premium tax credits, cost‑sharing subsidies and federal match for Medicaid expansion. Funds would be deposited in Roth Health Savings Accounts (HSA) belonging directly to the patient. The third choice of option one would return the power to the individual state to design and regulate insurance markets that work for their specific populations, without any federal assistance.
The second option under the Patient Freedom Act is called a "new state alternative with federal assistance." It would be a basic health plan for legal residents who do not receive health insurance through their employer, Medicare, Medicaid or other public programs. It would provide a Roth HSA, a high deductive health plan and a basic pharmacy plan.