March 28, 2017

Michael D. Williams Column: In Health Debate, Patients Need a Place at the Table, Not on It

In all the discussion about the proposed American Health Care Act (AHCA), an important voice is going largely unheard: patients. Much like the Affordable Care Act (ACA), the AHCA is almost entirely about insurance reform, and patients don’t seem to have a place at the table.

A wise leadership mentor of mine often said, “If you aren’t at the table, you’re on the table.” So let’s start our analysis of the AHCA with what it means for patients.

Not much is certain about the AHCA — which is backed by President Donald Trump and House Speaker Paul Ryan — but there are some likely effects. The number of uninsured Americans would rise by several million — perhaps not to the levels seen before the ACA, but a dramatic increase in that number is fairly certain. Does this provide value to the American public? It’s hard to see how.

The uninsured don’t simply disappear. They still become or remain sick. They still need hospitalization at a higher rate than their wealthier neighbors and still are less able to afford it, which is why proponents hold out catastrophic coverage as a solution. The problem is that it doesn’t take what most of us would call a medical catastrophe to spend that entire benefit. Pneumonia could easily bankrupt you, particularly if you live in poverty.

It’s also very likely that children and families will lose access to care. Insurance benefits will vary widely by state, as the AHCA largely does away with a required minimum package of benefits that insurers must provide. Depending on which state you live in, your lower-income neighbors will be at risk of having the care they need not covered by their insurance.

It is very problematic that those of us who are least able to withstand a bad set of circumstances have the most to lose. So, the proposed future for patients doesn’t look promising.


What about health-care providers? Fewer insured patients don’t translate to fewer patients for hospitals and doctors.

Safety-net hospitals across the country, like the University of Virginia Medical Center, will continue to provide high-quality, cost-effective care. The challenge comes when those uninsured patients are ready to be discharged. Those without insurance regularly linger in safety-net hospitals for days awaiting increasingly scare “charity” beds at skilled nursing facilities, rehabilitation hospitals, and nursing homes.

This creates a backlog that reaches all the way to emergency departments. In most academic medical centers, hospital bed availability is a daily challenge. Having a medically-ready-for-rehab patient unable to leave the hospital makes it harder for other patients to get the care they need, when they need it.

The challenges will be even more severe for private medical practices. If a hospital can see enough privately insured patients, they’ll be able to keep the lights on. A private medical practice doesn’t have that luxury. One can only see so many patients in a day. To stay in business, that practice has to make enough money per patient to pay all of its fixed costs, such as rent and staff salaries.

Having more people without insurance means the relatively small number of practices that see Medicaid recipients will likely decrease. Why? Because Medicaid doesn’t cover the full cost of treating a patient, while private insurers do. Faced with an increasing number of uninsured patients, more private practices will not accept patients with Medicaid as they struggle to survive.


So if patients and providers won’t benefit from the AHCA, who will? Health insurers — specifically, private insurers. Commercial insurers will be able to further narrow their network offerings, as the AHCA markedly eases provisions in the ACA that prevent “cherry-picking” patients.

The federal government will absolutely spend hundreds of billions less on health care. At the state level, governors and Medicaid directors are scrambling to figure out which beneficiaries and benefits they will still be able to offer should the AHCA become law.

State-level insurers (Medicaid) will very likely only remain solvent through steep cuts in the number of patients they serve and the benefits they provide. This represents a grim situation if you or loved ones are among the roughly 70 million people who rely on Medicaid for health care (or almost a quarter of our family members, friends, and neighbors).

The AHCA appears to fall short of the mark in offering all Americans a chance at achieving or maintaining a state of good health.

The value isn’t there. We need to find a better way.


Full article can be accessed here.

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Associate Professor of Surgery and Director of the UVA Center for Health Policy
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