Obama's Medicaid expansion keeps gaining ground under Trump

President Donald Trump is still trying to overturn “Obamacare,” but his predecessor's health care law keeps gaining ground in places where it was once unwelcome.

Missouri voters this week approved Medicaid expansion by a 53% to 47% margin, making the conservative state the seventh to do so under Trump. The Republican president readily carried Missouri in 2016, but the Medicaid vote comes as more people have been losing workplace health insurance in a treacherous coronavirus economy.

That leaves only a dozen states opposed to using the federal-state health program for low-income people as a vehicle for covering more adults, mainly people in jobs that don't provide health care. Medicaid expansion is a central feature of former President Barack Obama's Affordable Care Act, covering about 12 million people, while nearly 10 million others get subsidized private insurance.

If present trends continue, it's only a matter of time until all states expand Medicaid, acknowledged Brian Blase, a former health care adviser in the Trump White House, who remains opposed to the expansion.

“Medicaid expansion is terrible policy, but it is attractive to states because it's almost all federal spending and the insurance companies and hospitals get lots of dollars when a state expands Medicaid,” he said.

The federal government pays 90% of the cost of covering people through the expansion, a much higher matching share than for low-income disabled and elderly people traditionally covered by Medicaid. Blase argues that's an incentive to waste federal dollars. Before the ACA most low-income adults couldn't get Medicaid unless they were caring for children.

“There's lots of political pressure to expand,” said Blase. “Eventually all states are going to expand unless the enhanced (federal) match rate changes.”

Voters in another conservative state — Oklahoma — approved a Medicaid expansion earlier this year, although the margin was much closer than in Missouri. Of the seven states that have expanded Medicaid in the Trump years, six have done so by referendum, said Rachel Garfield, a senior policy expert with the nonpartisan Kaiser Family Foundation.

“This is an indication that there is large popular support for providing health care coverage for low-income people, and it is quite possible that this support has increased given what's going on with the pandemic,” Garfield said.

The six states where voters have approved Medicaid expansion in the Trump years are Idaho, Maine, Missouri, Nebraska, Oklahoma and Utah. In Virginia, the legislature passed a Medicaid expansion after Democrats made political gains.

“That has been an interesting feature of the Trump administration, that momentum among the states to expand Medicaid has not slowed down,” said Jesse Cross-Call, a policy expert with the Center on Budget and Policy Priorities, which advocates for low-income people.

Trump is trying to persuade the Supreme Court to toss out “Obamacare,” but as long as it remains the law his administration has to carry out expansions that states approve. Democratic presidential candidate Joe Biden would ask Congress to provide coverage where states have refused.

In Missouri, support for Medicaid expansion in cities and suburbs overcame opposition in rural communities. Supporters used the coronavirus pandemic to highlight the need for health care, especially in the wake of joblessness and loss of employer-provided insurance. The Missouri Chamber of Commerce and Industry, one of the state’s most influential business groups, also pushed for expansion as a way of helping the economy recover after COVID-19.

Cindy Mann, who ran Medicaid under Obama, argues that there's also a strong fairness argument for expansion. About 4.5 million poor adults live in states that have resisted expanding Medicaid. But because of the way the Obama health law is written, they don't qualify for subsidized private insurance through marketplaces like HealthCare.gov and they're stuck in a coverage gap.

“Those people have no access to coverage,” said Mann, now with the Manatt Health consultancy. “Those are a lot of the so-called essential workers, if we think about it through the COVID lens. It's a really inequitable story and one that increasingly can't be tolerated by the public.”

No other state referendum votes on Medicaid expansion are scheduled this political season. But Mann expects the debate will percolate through legislative elections in the 12 states, mainly in the South, that have refused. The biggest prizes are Texas, Florida and Georgia.

“Now they are surrounded by states that have expanded,” she said.

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New tax law may put squeeze on rural hospitals

One of the selling points for the tax bill President Trump signed into law a few weeks ago is that it will spur job growth because corporations will use money they otherwise would have paid in taxes to hire more workers.

But for rural areas and small towns, one provision of the new law may result in the closure of one of their biggest employers – their hospital.

Rural hospitals in general operate on much thinner margins than most big city hospitals, margins so thin that dozens have been forced to close in recent years. In fact, almost all the U.S. hospitals that have been shuttered in recent years have been in rural areas. A recent study (https://www.beckershospitalreview.com/finance/state-by-state-breakdown-of-80-rural-hospital-closures-081517.html) by the North Carolina Rural Health Research Program found that 80 rural hospitals have closed since 2010 and that 673 more are vulnerable to closing. And that was before the tax bill was passed.

The part of the new tax law that puts rural hospitals in further jeopardy is the repeal of the so-called individual mandate, the provision of the Affordable Care Act that required most Americans to have health insurance. Only those who qualified for a hardship exemption could remain uninsured without paying a stiff penalty (https://www.nerdwallet.com/blog/health/how-much-is-the-obamacare-penalty-not-having-health-insurance/). 

Polls consistently showed that the mandate was the most unpopular part of the ACA. Republicans often cited it as a reason for their opposition to the health reform law that President Obama signed in 2010. 

Obama himself was once a critic of the mandate. But insurance company executives and many health policy experts told him and Congress that without it, premiums would become increasingly unaffordable for people who were in greatest need of coverage – people in their 50s and 60s and anyone with a current or preexisting medical condition. They argued that, unless they were required to enroll, many young and healthy people would stay uninsured, making it necessary for insurers to charge older and less healthy applicants much more for their coverage than if those young and healthy people were in the “pool” of insured customers. 

Shortly before Congress passed the tax bill last month, the Congressional Budget Office estimated (https://www.reuters.com/article/us-usa-tax-healthcare/repeal-of-individual-mandate-would-increase-uninsured-premiums-cbo-idUSKBN1D820Q) that repealing the mandate would increase the number of uninsured by 13 million over the next 10 years and cause premiums in the individual market to rise an additional 10 percent.

The American Hospital Association, along with groups representing doctors and health insurers, lobbied hard against repealing the mandate (https://aha.org/news/headline/2017-11-14-aha-others-urge-congress-not-include-individual-mandate-repeal-tax-bills), but their concerns went unheeded.

The repeal will have no effect this year because the mandate was still in effect during last fall’s open enrollment period for individual and family coverage purchased for 2018 on the state insurance exchanges, which were created by the ACA. But no one will be penalized for remaining uninsured in 2019, and that has many rural hospital administrators – especially those in the 19 states that did not expand their Medicaid programs under the ACA – very worried. 

Hospitals in those states are especially vulnerable because more of the patients they treat are those who have remained uninsured – and in many cases unable to pay for their care – than at hospitals in states that did expand Medicaid. 

In states that did not expand, mostly in the South and Midwest, more hospitals have closed in recent years than in states that did (https://www.beckershospitalreview.com/finance/state-by-state-breakdown-of-80-rural-hospital-closures-081517.html). Revenue for hospitals there and elsewhere is expected to decline even further beginning this year, especially in rural areas with higher percentages of older residents than other communities, as the tax bill’s cuts to Medicare (https://www.aarp.org/politics-society/advocacy/info-2017/senate-tax-medicare-cuts-fd.html) are implemented. 

The repeal of the individual mandate penalties, though, may turn out to be the final nail in the coffin of many vulnerable rural hospitals as even more local residents return to the ranks of the uninsured. Many rural hospitals already provide more uncompensated care (https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.1340) than their urban counterparts. For one thing, much of the emergency care provided by rural hospitals is classified as uncompensated because uninsured residents, unable to get care in doctors’ offices, often resort to the emergency department (https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.1340) where they cannot be turned away. 

It is called uncompensated care because many uninsured patients cannot pay their bills, and no small number of them are forced into bankruptcy. Hospitals try to make up for care their patients can’t pay for by charging insured patients more, but small rural hospitals are less able to do that than large urban hospitals that can demand higher compensation from insurance companies. That’s because small hospitals treat fewer of an insurer’s customers than big hospitals do. 

The last thing rural hospitals need are more patients who can’t pay their bills, but that is likely what they will get when the individual mandate penalties go away. Many rural hospitals will not survive. 

When a rural hospital closes, local residents not only have to travel farther for care, including potentially life-saving emergency care, but the area also loses many good-paying jobs, and in many cases, its largest employer. In the rural communities that lose their hospitals in the years to come, the tax bill may turn out to be more of a job killer than a job creator. 

Are you concerned about how Congressional action may affect the future of healthcare in rural America? Send me your questions, concerns and personal stories at Wendell@Tarbell.com.

Wendell Potter is a former health insurance executive, author and founder of the journalism nonprofit Tarbell.org.

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Hospitals feeling the early effects of Trump immigration ban

Hospitals and healthcare systems are feeling the effects of President Donald Trump's executive order banning immigrants from seven Muslim-majority countries.

The ban has caused uncertainty within the healthcare industry as providers attempt to figure out what a stricter immigration policy means for the thousands of non-US citizens who come and live in the country every year to train and work.

Some employees, including physicians, have been directly affected, while others fear that they will be. At least one hospital's human resources department is gearing up to address potential problems resulting from the policy.

“We are aware of three of our associates at this time who have been directly affected by this order,” said Ann Nickels, a spokesperson for MedStar Health, a 10-hospital system serving the Baltimore-Washington, D.C. area. She said MedStar has “a number” of staff with international backgrounds, including some that come from the countries named in Trump's order.

In keeping with its policies for visa sponsorship, “MedStar is providing support for these associates and their families,” Nickels added. She said she was not able to provide more details about who the associates were, where they were from, how they had been affected, or what support MedStar was providing.

Currently, there are roughly 15,000 doctors working in the US who are from the countries targeted in the immigration ban, according to Jim Stone, president of The Medicus Firm, a leading physician staffing agency. But the impact could reach farther when counting foreign-born doctors who are not originally from one of the countries on the travel ban list but may hold passports from those states.

“As a percentage of 800,000 doctors in the United States that's not an insignificant percentage,” Stone said. “Considering the shortage of physicians already, anything that's being done that decreases the supply of physicians is going to be a bad thing for healthcare.”

At Henry Ford Health System, a five-hospital system in the Detroit metro area, its more than 23,000 employees have not been directly affected or stranded by the travel ban -- yet.

“That could certainly change in the coming days,” said Brenda Craig, a spokesperson for Henry Ford. The system has a large number of foreign-born physicians, hailing from at least 60 countries. Some of them are from the countries named in Trump's executive order and either have temporary work visas or green cards.

Those employees still worry about the implications of the ban on future plans, They might have to cancel work-related travel, such as medical missions, or trips for family-related events, such as weddings. Their family members may also be unable to visit the U.S., Craig said. Should those employees be affected by the ban in the future, “our human resources team has put measures in place to respond immediately,” Craig added.

Other health systems have openly rejected the anti-immigration sentiment espoused in the ban and other Trump administration policies.

In a letter circulated Monday to members of the community of the Montefiore Health System, CEO and president Dr. Steven Safyer vowed not to disclose information about the immigration status of its patients, students or employees “without appropriate legal proceedings.”

The Cleveland Clinic reported over the weekend that as many of three of its physicians had been affected by the order Trump signed Friday that bans all travelers from Iran, Iraq, Syria, Sudan Libya, Yemen and Somalia from entering the US for 90 days while suspending admission for all refugees for 120 days.

While two physicians were detained but were ultimately allowed entry, a third clinician, first-year resident Dr. Suha Abushamma, was ordered to fly back to Saudi Arabia because she holds a passport from Sudan.

“Although this has been a difficult experience, I am grateful to be safe with my family in Saudi Arabia,” Abushamma wrote in a statement released by Cleveland Clinic on Sunday. “Please know that I am deeply committed to my medical career and to helping patients at Cleveland Clinic.”

The consequences of the travel ban have begun to be seen among a number of the country's most prestigious academic medical centers, who reported having staff members or patients who have been affected by traveling restrictions.

Representatives from the Mayo Clinic said they were aware of 20 patients whose travel to or from the clinic for treatment may be affected by the ban. They said roughly 80 staff members, including physicians and scholars associated with the clinics have ties to the seven countries listed on the executive order, but at this point was not aware of anyone who was directly affected in terms of barred entry into the U.S.

A spokesman for Massachusetts General Hospital stated as many as five of its employees had been affected by the travel ban, with some unable to get on a plane back to the U.S. even though they have visas, while others had visa applications that were in the approval process. Other still were awaiting interviews to obtain a visa.

The executive order has prompted widespread condemnation by some of the country's leading medical groups, who expressed concerns that the country's reputation as a medical leader could be tarnished if the best foreign-born health professionals and researchers become discouraged from coming to the U.S.

“I fear this is having a chilling effect on the view that physicians and medical scientists have of the U.S. as a welcoming place where excellence in healthcare is recognized and rewarded,” said Dr. Darrell Kirch, president and CEO of the Association of American Medical Colleges.

Kirch estimated around 1,000 non-US citizens with ties to the seven countries targeted by the travel restrictions have applied to residency and fellowship positions in U.S. medical facilities this year. He was concerned they might not come to the U.S. if the travel restrictions are extended.

“These people have been put into limbo,” Kirch said.

Trump's order inspired protests throughout the weekend. It also faces legal challenges from government and social justice agencies. On Monday, the acting attorney general was fired by Trump after she refused to defend the order.

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