July 30--The
Affordable Care Act remains law, but its future will be uncertain until after
the upcoming elections, University of Arizona health policy expert Dr. Daniel
Derksen says.
"Depending on
what happens in the midterms, we could certainly go back to some tough
times" for health economics in this state, said Derksen, who is a
professor of public health policy and director of the Center for Rural Health
at the University of Arizona.
"The midterms
make an extraordinary difference in what happens in the subsequent two years.
Surely if it stays as-is, we'll see similar bills to what went on before."
Last year, the
Republican-led Congress attempted to repeal the Affordable Care Act (ACA, also
known as Obamacare) in proposed legislation that would have cut billions of
dollars from the country's Medicaid program, a government health insurance
program for low-income people.
When the
government-run Children's Health Insurance Program is included in the count,
Medicaid in the U.S. covers about 75 million Americans. Cuts to Medicaid would
lead to more uncompensated care, Derksen and other experts have predicted.
"We continue
in Arizona to see some of the best rates we've seen for hospitals -- operating
margins are going up, uncompensated care has really gone down. That has really
fueled the strong growth we've seen in the health sector," Derksen said.
"We don't really want to regress. We don't want to go back to the days of
1.2 to 1.5 million uninsured Arizonans."
The Star talked to
Derksen by phone last week while he was in Flagstaff for the 45th annual
Arizona Rural Health Conference, hosted by the Arizona Center for Rural Health
in collaboration with the Arizona Rural Health Association.
Here are excerpts
from the interview:
The Affordable Care
Act is still the law of the land. But in 2019 there will no longer be an
individual mandate that all Americans have health insurance. What's going to
happen with that?
You can't make
insurance work if people only get coverage and pay into it when they get sick.
Or if you only have people with chronic diseases -- if those are the only
people signing up for coverage, it makes it hard for the insurance model to
work.
If there's no mandate,
insurers are worried that all they'll get are people who have a reason to have
health insurance. There are waiting periods and other ways insurers will have
to mitigate that risk, based on the pool they have.
But the individual
market -- the non-group, non-employer -- has always been in the last 10 years
the most vulnerable to these types of changes, the most volatile.
Most Americans do
not buy their health insurance on the marketplace. Those who do are such a
small group -- 155,000 Arizonans, for instance. So why do we talk about the
marketplace so much?
Even though the
individual market may represent a small percentage, if for some reason you
undermine that and it becomes unstable and goes away, the uninsured,
uncompensated care gets shifted to private insurance and to some degree to
public payers.
You are not really
saving money, you are just shifting the costs to hospitals and health providers
and insurers. ... And you get back to where we were before the Affordable Care
Act, with 50 million (Americans) uninsured.
If there is an
increase in uncompensated and charity care, it also makes it harder for rural
and critical-access hospitals to provide care, stay in a good fiscal position
and make their margins work.
What do you predict
will happen to the ACA moving forward?
We are one of the
top states in reducing our numbers of uninsured. But depending on what happens
in the midterms, we could certainly see that go back to some tough times for
our health sector and state economics.
A lot of consumer
protections (contained in the ACA) are at risk, and it's hard to tell which
ones will continue and which ones won't. One of the most popular is not being
denied or charged more for having a pre-existing condition. That is an
extremely popular provision that came about because of the ACA.
What we need is
more stability ... in the individual market. If we don't stabilize the
individual, non-group health insurance market, it will leach into
employer-sponsored insurance, too. We've already seen that. This is a trend
that has been going on well before ACA.
More and more
companies that provide employer-sponsored insurance are shifting costs to
individuals, and more of the risk. That shifting of cost and risk to
individuals has not been covered by increases in peoples' compensation.
If you further
destabilize the individual market, more costs will shift to employer-sponsored
insurance and get into a spiral that makes it hard to predict what will happen.
Why are you so
concerned about Medicaid?
One-quarter of
Arizonans get their coverage from Medicaid. Only one-quarter of people on
Medicaid are in the eligibility category of disabled and the frail elderly, but
they generate 62 or 63 percent of the Medicaid costs.
So when you talk
about cutting Medicaid, as these various (congressional) bills did, $800
billion or $900 billion from U.S. Medicaid over 10 years, that is going to
shift to those really vulnerable populations. That's what states should be
anxious about.
We have some
special challenges in Arizona because we've been one of the states with a lot
of growth in our low-income elderly -- a lot of these issues disproportionately
affect Arizona when you talk about Medicaid funding.
Two, possibly three
companies could be selling marketplace insurance to Pima County residents on
the Arizona marketplace for 2019. There was only one company in 2018. How did
that happen?
When this started,
if you remember, we had seven different insurance companies offering about 70
different plans on the marketplace in Arizona. As a result, we had the
second-lowest silver premiums in the country.
Some people
(companies) didn't get enough enrollment to mitigate the risks and they
withdrew. That is basic market principles.
There are a lot of
covered lives potentially to be had. Most folks would like to see more than one
choice, and competition does keep the prices down a bit.
But they (insurance
companies) are going to have to pay close attention to how many enrollees they
get and how they spread the risk. They will have to be very careful in how they
price and what they do to encourage enrollment.
What about the
Trump administration's cuts to navigator grants that help people find health
insurance? The reduction in Arizona has been 82 percent since 2016.
At a time when
there are lots of questions -- there are people who don't understand that this
(ACA) is still in place -- I think it's helpful to people to have non-biased
assistance. If you have a complicated situation, having someone with a
background and a couple of years of training really helps.
Despite these
things, in the last couple of years enrollment has been relatively stable. The
people who have enrolled and re-enrolled certainly understand it. That's good,
because when we see a decrease, there can be a related increase in
uncompensated care.
It's no different
than Medicare. Medicare is not an easy system to understand when you first get
into it. A lot of people get their information from friends or family members.
You are also
talking about opioids at this week's conference. What are the public health
issues with opioid misuse in rural Arizona?
The resources can
be quite thin for people with opioid use disorder.
The data is showing
that people are seen two, three or four times in hospital emergency rooms for
opioid overdoses before that tragic event of an overdose death. We have to keep
trying to get people into treatment programs to address the underlying
disorder. Sometimes they aren't ready.
I think we are
going to see from CDC (the U.S. Centers for Disease Control and Prevention) a
series of funding opportunities, especially directed at rural areas. We are
looking for ways to really enhance the resources we have on this issue. It is
truly a public health emergency.
Contact health
reporter Stephanie Innes at 573-4134 or email sinnes@tucson.com.
On Twitter: @stephanieinnes
(c)2018 The Arizona Daily Star (Tucson, Ariz.)
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