Access to Care

Major patient groups join AMA to voice concerns on House bill

Kevin B. O'Reilly , Senior News Editor

When Laurie Merges lost her corporate job in Cleveland two years ago, she enrolled her children—including one on the autism spectrum who needs treatment—in Ohio’s Medicaid plan. Told of her eligibility for Medicaid under the expanded version of the program that Ohio implemented, at first Merges thought the coverage might be superfluous, as she expected to soon regain employer-sponsored insurance when she found a new job.

“But then I thought, ‘It’s a good safety net,’” Merges said today at a news conference held by the AMA and three major organizations representing patients, the American Cancer Society Cancer Action Network, the American Diabetes Association and the American Heart Association. The availability of that expanded Medicaid safety net, under which nearly 700,000 Ohioans were enrolled as of 2015, may have saved Merges’ life. She was soon diagnosed with stage 3b breast cancer, underwent bilateral mastectomy, 33 rounds of radiation and, 15 months later, is still taking oral chemotherapy.

“Without that coverage, I never would have been able to do it,” Merges said. “Thanks to my treatment, I’m hopeful I’ll be around to watch my children grow.”

The potential negative impact on the medical safety net of the American Health Care Act (AHCA)—the House leadership’s legislation designed to repeal and replace the Affordable Care Act (ACA)—was one major reason why this coalition of patient advocates and physicians spoke out forcefully today at the National Press Club in Washington.

“Right now, America’s health care system is being reshaped and rehashed, which is why we are here: to demand that our lawmakers put patients before politics in this critical process,” said AMA President Andrew W. Gurman, MD. “That’s why we are here today. To take a stand for patients. To offer an urgent call to congressional leaders to go back to the drawing board to craft legislation that will address problems with the Affordable Care Act but avoid harming patients who have gained coverage.”

Dr. Gurman and others cited the Congressional Budget Office (CBO) assessment of the AHCA, released this week, which estimates 14 million Americans could lose insurance coverage in 2018 if the proposal becomes law. By 2026, the CBO report says, as many as 26 million more patients could become uninsured as a result of the law.

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That report “was a wake-up call for all of us,” said Mark Schoeberl, executive vice president of the American Heart Association. “The simple fact is that individuals with cardiovascular disease who are uninsured have poor management of risk factors like hypertension and poorer outcomes. Those who have strokes have greater neurological impairment with longer, costlier hospital stays and higher risks of death than identical patients who have insurance.”

Under the AHCA, the expansion of Medicaid eligibility up to 138 percent of the federal poverty line—the provision under which Merges received coverage—would be repealed. The AHCA would also change the funding for the traditional Medicaid program to one that is paid per capita. That is a plan that the AMA says would limit states’ ability to respond to changes in demand for medical services and could force states to limit coverage and lead to an increase in the number of uninsured.

Insurance coverage also makes a huge difference in the area of cancer prevention and treatment, said Chris Hansen, president of the American Cancer Society Cancer Action Network. In 2015, he said, 1.5 million cancer patients and survivors between the ages of 18 and 64 were covered by Medicaid. Almost one-third of pediatric patients with cancer are on Medicaid at the time of diagnosis.

“The American Cancer Society has done studies and research, for years, that show the importance of insurance status and the direct impact it has on our ability to save lives from cancer,” Hansen said. “Those without appropriate health insurance are more likely to be diagnosed at a later stage of disease, are more expensive to treat, are less likely to survive and their experience is more painful when compared with their appropriately insured counterparts.”

The consequences of a medical safety net that penalizes sick patients who make strides in their career were put into stark relief by Jose Sanchez, a patient from New York with type 1 diabetes. From 2003 to 2009, he was enrolled in the traditional Medicaid program. When he took a new job in 2009—prior to the expansion of Medicaid under the ACA—his new income put him $100 over the eligibility limit under the program.

“For months, I had to ration out my insulin to take care of bills and support my family,” Sanchez said. “Often, I wound up in the hospital. And I’d leave my children with relatives in order to take care of myself.”

LaShawn McIver, MD, MPH, interim chief advocacy officer at the American Diabetes Association (ADA), said she is particularly concerned about the AHCA’s impact on the nearly 30 million U.S. children and adults living with diabetes and an estimated 86 million Americans with prediabetes.

“Access to affordable, adequate coverage is critical for people with diabetes and prediabetes,” Dr. McIver said. “When people are not able to afford the tools and care necessary to manage diabetes, they scale back or they forgo the care they need, which often leads to tragic and costly complications and suffering that could have been prevented.”

The ADA is “deeply worried about the tax-credit proposal, changes to Medicaid access and cuts to funding for diabetes prevention programs in the AHCA,” Dr. McIver added. Among other things, the AHCA repeals funding for the Prevention and Public Health Fund, which has supported work on immunization, childhood lead poisoning and health care-associated infections. The fund makes up 12 percent of the budget of the Centers for Disease Control and Prevention.

Dr. Gurman also raised concerns about the AHCA’s tax-credit provisions, which would be based on age rather than income and provide much less financial assistance than is available now.

“While the AMA has long supported refundable tax credits to assist people in purchasing insurance, credits need to be inversely related to income to provide true purchasing power for low- and moderate-income people,” he said.

Everyone who spoke at the press event agreed that health care reform is needed.

“The current health care law needs improvement,” the American Cancer Society’s Hansen said. “But changes should improve it and not reduce coverage.”

The AMA has been engaged with Democratic and Republican leaders since this session of Congress began in January, Dr. Gurman said in response to a reporter’s question. He said that the coverage gains made in recent years must be maintained because “people who don’t have insurance live sicker and die younger.” The AMA is eager to work with Congress, Health and Human Services Secretary Tom Price, MD, and other members of the Trump administration to craft policies that will improve access to affordable, meaningful coverage and high-quality health care.

“Let’s not forget that health care is about people, about families, and about our communities,” Dr. Gurman said. “We can do so much better, and we must do better. Lives are at stake, and the very health of our nation deserves the most patient-centric approach we can offer.”