The Affordable Care Act is teetering on the brink of a Trump presidency.
After six years of consistent, emphatic but ultimately unveto-proof chants of "repeal, repeal, repeal," Republicans in Congress finally see their opportunity with Donald Trump in the White House to make good on their unwavering campaign promise to take a wrecking ball to former President Barack Obama's historic health care law.
With both the Senate and House of Representatives, each under GOP control, primed to begin the demolition, having already passed procedural legislation along party lines, leaders in Catholic health care join in concerns about the impact of repeal without a comparable replacement.
"The ACA is imperfect, and it needs to be improved. But irresponsibly repealing it will create serious problems for those covered by it, those with employer-based coverage, the insurance industry in general, the health care industry, and the United States economy," said the Catholic Health Association president, Sr. Carol Keehan.
"Neither the individual or the common good is being valued in this race to repeal," said the Daughter of Charity at a recent symposium at The Catholic University of America.
In particular, she and others have pointed to the 22 million people at risk of losing insurance coverage they obtained, many for the first time, through marketplaces established under the Affordable Care Act.
"When you create a crisis in the insurance industry, it does impact the poor first, but let me tell you, it impacts everybody with employer-based insurance," Keehan told NCR. "So we need to be very, very clear in making sure people understand that. People are playing with fire when they do this."
Repeal's impact uncertain without replacement bill
The repeal of the Affordable Care Act appears inevitable at this point, said Colleen Scanlon, chief advocacy officer for Catholic Health Initiatives, the nation's third-largest nonprofit health system, with facilities in 18 mainly Midwestern states. What that will mean for Catholic health care, and for the wider health care industry, remains uncertain until a replacement GOP bill materializes.
As they ready for a second round of major health care debate in a decade, Catholic leaders in the industry recognize imperfections in the existing law that warrant a second look. But their first priority for any replacement legislation, they say, starts with ensuring gains in health care coverage made under the Affordable Care Act are not lost.
"We think everyone should have access to affordable insurance. And that has been a premise of Catholic health care for decades, so we want to protect the gains we have," Scanlon said.
According to a report Tuesday from the nonpartisan Congressional Budget Office, 18 million people would lose insurance coverage through a repeal of the Affordable Care Act's individual and employer mandates, and as many as 32 million people by 2026 would be without insurance with the elimination of Medicaid expansion and of subsidies for coverage purchased through ACA marketplaces. At the same time, premiums, already on the rise, would continue to skyrocket.
The Kaiser Family Foundation tracking poll on the Affordable Act in December showed the nation split, with 46 percent of U.S. adults viewing the law unfavorably, with 43 percent holding a favorable opinion. And while addressing health care was a top issue for Americans in an early January survey, particularly lowering out-of-pocket costs, 47 percent said the 2010 law shouldn't be repealed; 28 percent said a repeal vote should wait until replacement details develop.
"Why there is such an absolute push to dump people's health care coverage on the first day of the Senate and the House and the Inauguration Day just doesn't make sense to me. … these are Americans, these are our fellow citizens," Keehan said.
A day after the CBO report, Bishop Frank Dewane, chair of the bishops' Domestic Justice and Human Development committee, wrote to members of Congress urging them to "work in a bipartisan fashion to protect the vulnerable Americans and preserve important gains in health care coverage and access."
The bishop of Venice, Fla., said that while his fellow bishops ultimately opposed the ACA — primarily due to a trifecta of abortion expansion, unsatisfactory conscience protections and the lack of health care access for immigrants — they "supported the general goal of the law to expand medical coverage for many poor and vulnerable people."
Dewane's Jan. 17 letter to Congress said that any repeal absent a concurrent replacement plan would put those who've recently gained coverage in jeopardy.
"Particularly for those who would otherwise be required to use limited resources to meet basic needs such as food and shelter rather than seek medical care, the introduction of great uncertainty at this time would prove particularly devastating," he wrote.
Six days before taking the Oath of Office, Trump told The Washington Post that his plan to replace to Affordable Care Act is near completion, and will provide "insurance for everybody."
"There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us," he said, adding that people "can expect to have great health care … much less expensive and much better."
Keehan said of Trump's comment: "If that's the way they change it, then that's certainly workable. But that isn't what we were hearing from all the voices in Congress."
Coverage vs. access to coverage
One of the plans that's been floated comes from U.S. Rep. Tom Price (R-Ga.), a physician and Trump's pick to lead the Department of Health and Human Services. It was his repeal bill, one he's introduced four times, that the Congressional Budget Office analyzed in its report estimating significant losses in coverage. Critics of Price's bill, and others proposed by Republican lawmakers, have pointed to the distinction between coverage for all and access to coverage for all.
During Price's Senate confirmation hearing, he was grilled on the distinction by Vermont Sen. Bernie Sanders. Responding to a question about whether the U.S., like other countries, should guarantee health as a right for all Americans, the Georgia congressman replied in part, "I believe, and I look forward to working with you, to make certain that every single American has access to the highest quality care and coverage that is possible."
Sanders: 'Has access to' does not mean that they are guaranteed health care. I have access to buying a $10 million home, I don't have the money to do that.
Price: And that's why we believe it's appropriate to put in place a system that gives every person the financial feasibility to be able to purchase the coverage that they want for themselves and their family, again not what the government forces them to buy.
Sanders: Yeah, but if they don't have any — well, it's a longer story. Thank you very much.
Price: Thank you.
The idea that health care is a basic human right has been long embedded in Catholic social teaching, Dewane noted in his letter to Congress, with St. Pope John XXIII addressing it in the 1963 encyclical Pacem in Terris. More recently, Pope Francis told a group of doctors in May that "Health, indeed, is not a consumer good, but a universal right which means the access to health care services cannot be a privilege."
Keehan said she was not familiar with all the details of Price's plan, but "I can just tell you that it's certainly not a comparable replacement." She said it fell short in terms of comprehensive care and questioned the ability of health savings accounts — a long-held GOP reform espoused by Price, Trump and Speaker of the House Paul Ryan — as a viable substitute to cover medical costs, particularly for the working poor.
"These are people who don't have the ability to put a lot of money in a health savings account. We really need to get real," she said.
Scanlon identified the rising premiums and regulatory complexity as two areas to re-examine. Keehan left a wide opening for discussion on potential reform, from a public option, to interstate insurance markets, to negotiating drug prices with pharmaceutical companies, to repealing the "Cadillac tax" on employers offering high-cost health plans.
"Those kinds of things all need to be looked at. But you don't just repeal it and leave people hanging. We have to address those things. It is irresponsible to do that on something as important as people's health care," she said.
Preserving ACA's advances
For all the possible changes to health care, what can't be lost are the advances the Affordable Care Act has achieved, Catholic health officials said.
The uninsured rate sits at a historically low 10.9 percent, a drop of 6.2 percentage points since 2013 ahead of the individual mandate requiring most people have insurance going into effect, according to Gallup. The greatest gains occurred among Americans making less than $36,000 a year (10 percent decrease), Hispanic Americans (down 11 percent) and young adults (roughly a 9 percent decrease).
Among the states with large portions experiencing uninsured rates decreasing by more than 14 percent from 2013 to 2016: Kentucky, West Virginia, Michigan, Arkansas, New Mexico and California.
The Catholic Health Association, through its news publication Catholic Health World, has begun a series sharing the stories of people who have seen their lives change for the better due to securing insurance for themselves and their families. A middle-aged youth minister in Texas and father of six was able to afford the medication associated with his kidney transplant. A soon-to-retire supervisor for a Baton Rouge, La., Catholic hospital was able to find more affordable coverage before Medicare kicks in after experiencing "sticker shock" at what COBRA coverage would has cost her.
Beyond increases in those insured, other advances include no limits on health expenses, the closing of the donut hole for Medicare patients and free preventive care for all.
"There's just a lot of pieces of it that were incredibly important and need to be kept. And that's why it is important not to do the bill as a political slogan or a political payback," Keehan said.
Scanlon of Catholic Health Initiatives said the law has led to numerous reforms in terms care delivery, payment and reimbursement, and a general shift in health care models from volume to value.
"There are many dimensions of the Affordable Care Act beyond access and coverage that have now been put into regulation that we're relying on in terms of how we structure our organization," she said.
Many of those elements had bipartisan support, Scanlon added, and said it would be important to protect those in any future legislation. She said Catholic Health Initiatives has encouraged all their ministry leaders, among them hospital CEOs, physicians and others working in their clinics, to reach out to their policymakers to articulate the concerns of their patients and protect important gains made in health care.
Keehan said a day doesn't go by without someone on her staff working to talk with someone in Washington about the future of the Affordable Care Act and American health care. After Trump's election victory, she said in a statement that the Catholic Health Association "stands ready to work" with his administration "to make health care delivery worthy of the dignity of all the people in our country."
Support by Catholic groups, and the Catholic Health Association in particular, were credited as crucial to the passage of the Affordable Care Act, and Keehan said they stand ready to play their role once more. Catholic health care, which serves one in six patients in the country, she added, has a privileged view into the issue, acutely aware of the importance of health care in people's lives, and conversely, what occurs in its absence.
"There are so many of our brothers and sisters who do not have a voice, in addition to so many other basic rights they do not have," she said during the Catholic University event. "To take away health insurance and health care they have finally been able to get, and leave their lives and their children's lives at risk is something we must find intolerable. Intolerable to the point that we speak up and firmly reject market solutions that neither understand nor care that health care is not a market commodity."
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