The president of the Ohio Hospital Association says the 'root-and-branch repeal' of the Affordable Care Act would greatly disrupt healthcare delivery in the Buckeye State, especially if it's not immediately replaced with a workable alternative.
Regardless of which party is in power, the Patient Protection and Affordable Care Act is in need of a considerable overhaul, says Ohio Hospital Association President and CEO Michael Abrams.
Failing co-ops, anxious payers, and unaffordable premium hikes are among the many facets of the sweeping legislation that need to be revisited, assuming that the Trump Administration and Congress don't eliminate the law altogether, he said.
Abrams spoke recently with HealthLeaders Media. The following is a lightly edited transcript.
HLM: What needs to remain in place for hospitals if the ACA is repealed?
Abrams: Whatever we replace it with, those one million Ohioans who gained coverage under the ACA need to maintain that access to healthcare.
As we talk about replacing [the law] we need to make absolutely sure that coverage remains a priority. If they want to go back and ask why the co-ops failed, why the insurers are skittish about functioning on the exchanges, and why premiums are going up, those are fair questions that a President Clinton would have had to confront as well.
But repealing root and branch and throwing those one million Ohioans into the ranks of the uninsured is ill-advised for hospitals, the Republican Party, and for the one million people who would lose coverage.
HLM: Given the importance of Ohio as a swing state, is Washington listening?
Abrams: Trump's victory in Ohio was decisive. We have eight statewide office holders in Ohio who are Republicans and both chambers of our state legislature are overwhelmingly Republican.
The largest employer in the state of Ohio is the Cleveland Clinic. Community hospitals in our state employ 250,000 people. We are important because of the work we do, but we are also an important part of Ohio's economy. A quarter million people get a paycheck from a community hospital.
Our members are running multibillion dollar companies in these large health systems. They are reporting to boards that are made up of bankers and other business people. We are not an industry that is characterized as hand-wringing liberals.
But by the nature of the work we do in all 88 counties, we do have a community benefit and community service foremost in our mission.
HLM: Is "access" enough or does it have to be affordable?
Abrams: There is a real possibility that the answer to that question is no. I would be concerned if I were a payer. They have talked about retaining the ban on pre-existing conditions but doing away with the individual mandate.
I don't know how the insurance industry can underwrite for that. People are going to have the ability to gain insurance coverage, but they won't have to. Mathematically that is going to be impossible for the industry underwrite.
Premiums that are already going up exponentially could reach into the heavens at that point. I would be very concerned about whether that is manageable.
HLM: Would Ohio hospitals support a transition to block grants for Medicaid?
Abrams: I would find it unimaginable that Congress would want to do unrestricted block grants. At some point they're going to want to put policy guard rails around that. I can see states that are less-conservative than the Republican Congress might implement those block grants in a way Congress would find distasteful.
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Looking at my neighbor in Indiana, it is probably a fair indication of where they might be going philosophically, in that Mike Pence is now vice president and Seema Verma is presumably going to be CMS director.
They talk about skin in the game and potentially charging premiums, copays, and deductibles and things like that that frankly, in many states, like Ohio, would be a step back. In some other states that have done no Medicaid expansion, that would be considered some level of progress.
HLM: Could Ohio hospital survive significant Medicaid funding cuts?
Abrams: Depending upon how the funding cuts were to be layered in, it's possible. I don't want to say no cuts no how. But I do fear that large draconian cuts that are blind to policy impact and the impact on beneficiaries are very ill-advised for the Republican Party and for the states.
But if they were to say to me 'we think that there are some pharmaceutical efficiencies that can be gained, or there are some programmatic things we could do differently to gain some efficiencies in state Medicaid programs,' I would be all ears.'
Much of what makes healthcare expensive is not subject to legislative remedy. For example, we have a major opioid and heroin problem in Ohio. Because of that, we have a major problem with neo-natal abstinence syndrome. You can save their lives, those babies, but they are very expensive to treat.
What makes healthcare expensive very often are things like obesity and smoking and opioid-addicted mothers. I hope Congress is at least intellectually curious about some of those cost drivers as they look to gain efficiencies in how we allocate resources in taking care of poor people.
HLM: What about the push to negotiate lower drug prices in Medicare?
Abrams: It could have a positive effect on that piece of the pie. Macro-economically, when you look at the totality of the Medicare program, I cannot imagine that that will have a gigantic impact.
Again, some of the things that make healthcare expensive extend so far beyond one element, but that doesn't mean you shouldn't address it. It's still smart to talk about it and do what you can. But, some of the other things that are making healthcare expensive are not necessarily going to be captured by those policies.
HLM: Would Ohio hospitals oppose Medicare vouchers?
Abrams: From a hospital standpoint, the devil would be in the details. Our people would have a lot of concerns about it.
The whole reason that the Obama Administration took up healthcare is because it's an important economic force in our country. I am not surprised it is back in the spotlight because the law was flawed.
There are lots of opportunities to make positive reforms, but there are also opportunities to make the situation far worse. I am just hoping that they are slow and measured as they consider all these options.
HLM: How debilitating is this lack of certainty for hospitals?
Abrams: I used to feel guilty about not knowing until I would go to meetings and listen to people far smarter and more plugged in than me. But there is just a big shoulder shrug among well-placed policy wonks who just don't know what to predict.
It's all a parlor game and speculation, which can be entertaining. But, I am talking to hospital members for whom it's not a parlor game. They are putting together organizational budgets and they don't know how to budget for the next couple of years. It's a stressful time to be in this segment of the economy.
HLM: What are hospital leaders telling you?
Abrams: There is a lot of anxiety because of the big question marks. In any industry, no one likes uncertainty. There is so much uncertainty because of the political earthquake that this country delivered last November. It's created a lot of anxiety.
People are hiring. They are putting together service lines. They are addressing service lines such as behavioral health, and they are saying 'well, should we continue to build in this method? Should we continue to invest as our long-term strategic plan directs us, or do we need to revisit those plans based on what might happen to us economically?'
I don't talk to anybody who thinks that the situation is going to get easier.
HLM: How is it affecting hospital operations?
Abrams: I don't think it is affecting day-to-day operations at all. When we go to hospital board retreats, a lot of the conversation is around what's going to happen, and they are bringing in experts from the political world and they're all saying 'we're just not sure."
HLM: How do you keep OHA above the politics?
Abrams: I tell our advocacy squad that we have the ability to influence what adjectives people use when they describe us. I prefer that they use words like 'learned,' 'thoughtful,' 'measured' and 'scholarly,' as opposed to hiring a bunch of lobbyists to scream at lawmakers.
We have hired analysts, an economist, and people with that kind of expertise so we can chew through the policy and say this makes sense, or this is what we would not prefer, it's a step back.
We have to be curious about other options beyond expanding Medicaid. We have to be open-minded to other ideas. If they offer something that works, we have to be open-minded. That allows us to transcend partisan politics.
John Commins is the news editor for HealthLeaders.