The ACA: Repeal & Replace
Congress is currently considering changes to the Affordable Care Act (ACA). The Republican alternative, which narrowly passed the House of Representatives in early May on a party-line vote, has been coined the "American Health Care Act" (AHCA, for short). While the AHCA will make significant changes in the health care landscape it is far from a "repeal" bill. In fact, much of the ACA will remain even if the AHCA is signed into law as passed by the House of Representatives. For example, cuts to Medicare designed to pay for Medicaid Expansion will remain in effect even though the AHCA ultimately winnows away and eventually does away with Medicaid Expansion.
Sometimes our position is influenced by the finer details such as these. However, with the AHCA our position is rooted in a much more basic philosophy.
When considering advocating for or against any particular piece of legislation, BJC's first order of business is always to assess the impact it will have on patients. Many of the 24 million Americans projected to lose coverage if the AHCA is signed into law are our neighbors, friends, or family. And, many of those who would remain insured may be again subjected to discriminatory pricing because of pre-existing medical conditions or because of their age. Because we believe the AHCA falls short of ensuring that patients have access to affordable coverage, we are opposed to its passage and are actively engaging members of Congress to that effect.
Update June 26, 2017
Last Thursday, the U.S. Senate unveiled its version of "repealing" and "replacing" the Affordable Care Act. Much to our dismay, the Better Care Reconciliation Act, as it's named, contains many of the same provisions as the AHCA that passed the U.S. House of Representatives. In some ways, it may be worse. We remain opposed to removing tens of millions from reach of affordable, accessible care and will continue to advocate that position to members of Congress.
Update August, 2017
We now know that efforts to repeal and replace the ACA have failed in the Senate. However, Congress is set to return its focus to health-related matters in September when funding for the Children's Health Insurance Program (CHIP) will expire. BJC Government Relations will continue to monitor and will engage when and if necessary.
CMS is in a vast transition period as it shifts its reimbursement methods to emphasize performance and outcomes over volume of services delivered. In theory, this is a laudable endeavor. In practice, however, it has had severely negative implications.
The most glaring problem in CMS’s revised methodology is the failure to account for differing patient populations’ socioeconomic (also referred to as sociodemographic) status. That is, hospitals across the country that care for poorer populations (which are generally sicker) are held to the same outcome standards as those that treat wealthier (and generally healthier) populations.
One succinct example lies in the new penalties that are applied to hospitals that have lackluster outcomes in hospital 30-day readmissions. As the American Hospital Association (AHA) notes, there are a variety of factors outside of a hospital’s control which contribute to an individual being readmitted within 30 days. Socioeconomic status is one such factor. The result is that many of the nation’s urban and academic hospitals are being penalized for caring for our nation’s inherently sicker and more vulnerable patient populations.
Simply put, socioeconomic status affects a patient’s health outcomes regardless of the quality of care they receive. Our institutions, like Barnes-Jewish Hospital and Christian Hospital, that care for these patients should not be penalized for caring for all populations.
Hospital Outpatient Departments
In late 2015, Congress passed the Bipartisan Budget Act which, in an instant, changed reimbursement rates for services delivered in an off-campus hospital outpatient setting (HOPD). While those HOPDs that were already operational were held harmless, those under construction, like our Center for Advanced Medicine – South County and Boone Hospital Center’s south campus, will see significant reimbursement cuts (in many cases up to 50%) beginning in 2017. Worse, these two facilities were only weeks away from opening.
Our investments in the health and wellness of Columbia and south St. Louis County were severely undermined by the failure of Congress to grandfather facilities under construction that had received all other regulatory approvals, including Certificate of Need approvals by the State of Missouri. While we understand Congress’s need to control costs within the Medicare program in order to ensure its long-term solvency, HOPDs provide care to patients with higher acuity and are also responsible for a number of additional community benefits that a doctor’s office or ambulatory surgical center simply do not provide (higher life safety standards and emergency/disaster preparedness, for example). There are efforts underway by sympathetic members of Congress and we are hopeful a solution will be passed before the cuts are scheduled to take effect at the end of 2016.
Prescription Drug Costs
Federal law requires that prescription drug companies sell drugs at their best price to state Medicaid programs (most Medicaid services funded by roughly 60% federal funds). The 340B program was established in recognition that certain providers, like Critical Access Hospitals and Disproportionate Share Hospitals, see a large number of patients either covered by a government insurance plan or that are uninsured altogether. Similar to the Medicaid best price mandate, providers using the 340B program are eligible to receive high-cost drugs at a significantly reduced price, allowing their patients to receive more affordable care.
Recent court rulings have altered the 340B program landscape and some in Congress, at the behest of pharmaceutical companies, are working to rescind or significantly restrict the 340B program. BJC will continue to stand in opposition to these forces that will negatively impact patient care.
Similar to our concerns with CMS’s readmissions penalties, we have joined hundreds of hospitals around the country, the Association of American Medical Colleges (AAMC) and the American Hospital Association (AHA) in echoing concerns about CMS’s new star ratings system. Similar to how a movie critic judges a film, CMS is attempting to boil hospital quality ratings down to a 5-star ratings system. To quantify health care quality in such a simplified way is inherently flawed, from our perspective. And, again, CMS has not factored in the socioeconomic status of a hospital’s patient population into the scoring methodology.
While successful in delaying the release of the star ratings from April of 2016 to July, we continue to make a case for a shift in CMS’s underlying methodology.
Since 1989, Congress has recognized that certain types of business relationships in the health care industry can contribute to improper care recommendations and overutilization. Hospitals that are owned by physicians are one such example where the conflict of interest is simply too great. We have long concurred with Congress that a physician that has the authority to refer a patient for care should not own outright or in part a facility to which he or she is referring patients. We continue to monitor Congress’s proposals to ensure that this longstanding policy remains the standard.
Children's Health Insurance Program (CHIP)
The Children’s Health Insurance Program (CHIP) is a federal/state collaboration that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but too little to afford family health insurance. Today, 92,918 Missouri children have health insurance provided by CHIP. The program has been reauthorized federally until 2019, but funding is only authorized through September 2017.
Congressional support for CHIP funding is needed to ensure children do not lose insurance as they transition between CHIP and the marketplace. St. Louis Children’s Hospital has a long standing history of supporting our patients and families through the Congressional reauthorization and funding process.
Medical Education (Adult and Children’s)
Training the next generation of physicians requires teaching hospitals to assume an increased financial burden. Graduate Medical Education (GME) payments are designed to help cover the costs of training new residents. For example, these payments go toward residents’ stipends and fringe benefits, the salaries and benefits of supervising faculty, designated overhead costs associated with teaching in a hospital setting, and direct costs such as administrative and location fees. Coupled with GME Payments, Indirect Medical Education (IME) payments assist with the higher costs associated with the accommodation of medical students in the patient care setting.
Though teaching hospitals provide millions of dollars in critical patient care services to a diverse patient population, they are faced with the potential of up to a 70% reduction in GME/IME payments from Medicare – a situation which is complicated by the fact that teaching hospitals are not fully reimbursed for the costs of graduate medical education. Every year, there is a multimillion dollar gap between the cost of educating new physicians and GME/IME payments we receive. The current model is simply unsustainable. Children’s Hospital GME is separately appropriated by Congress and we continue to push for training the next generation of professionals caring in the pediatric space.
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