Docs, Insurers, Hospitals Pan Revised Senate Bill Even Diehard Affordable Care Act opponents Decline

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WASHINGTON -- Most doctors, insurers and hospital groups are as disappointed with the revised version of the Senate's healthcare bill, the Better Care Reconciliation Act (BCRA), as they were with the original proposal.

Medical groups, on the whole, are frightened by new provisions that would allow the sale of partial coverage insurance, are skeptical that new opioid dollars would be sufficient to fend off a burgeoning opioid crisis, and continue to be dismayed by the push to cap the Medicaid program.

Medicaid, along with the Children's Health Insurance Program (CHIP), covers about 75 million beneficiaries, pays for half of all births in the country, and is one of the primary payers of nursing home care.

Emergency physicians and hospitals are particularly anxious about changes that impact coverage of the 10 essential health benefits, given that hospitalization is one of those ACA mandated benefits.

"[W]hether it's a state applying for a waiver, or the skinny plans, the 'consumer choice' plans in the updated bill, there's a concern that people won't have coverage for emergency care," said Laura Wooster, MPH, associate executive director for public affairs at the American College of Emergency Physicians, in a phone call with MedPage Today.

The consumer choice plans Wooster mentioned are part of the so-called "Consumer Freedom Option," a provision introduced by conservative Sen. Ted Cruz (R-Texas) and Sen. Mike Lee (R-Utah) to allow insurers to sell bare-bones insurance that would not cover higher cost expenses. Cruz and Lee argue such steps would drive down the cost of premiums.

There are two problems here, Wooster said. The first is that emergency departments are required to treat patients regardless of their ability to pay because of the Emergency Medical Treatment and Labor Act (EMTALA). So, if essential health benefits like hospitalization are rolled back, patients will still be admitted and receive care, further straining hospital budgets, consumers, and the nation's health spending overall, she said.

The second problem is that patients may actually avoid seeking needed emergency care, knowing that their plans don't cover it, and their conditions could worsen, Wooster said.

Alternatively, young people might buy consumer choice plans believing they're a "great bargain," then have an emergency and wind up in the hospital with a huge bill that forces them into debt, she said.

Finding Many Faults

Others in the medical community echoed Wooster's concerns over comprehensive care coverage.

"The nation's medical schools and teaching hospitals see firsthand that when our patients do not have sufficient coverage, they often delay seeking much-needed care, turning manageable conditions into dangerous and costly emergencies," said Darrell Kirch, MD, president and CEO of the Association of American Medical Colleges in a press release.


The revised bill continues provisions "that would cripple Medicaid and put added financial pressure on state budgets and healthcare providers," Kirch wrote. And giving insurers the option to sell plans lacking "meaningful coverage" would not only destabilize insurance markets, it would also be dangerous for people with pre-existing conditions, he said.

Pediatricians also hammered the bill: "[T]his bill is not fixable," said Fernando Stein, MD, president of the American Academy of Pediatrics, in an email.

"The bill fails children by dismantling the Medicaid program, capping its funding, ending its expansion and allowing its benefits to be scaled back. This bill fails children living in or near poverty, children in foster care and children with complex healthcare needs whose parents have private insurance – all of these children depend on Medicaid, and if this bill passes, Medicaid will no longer be there for them," Stein continued.

The American Medical Association also rejected the Senate's second draft of the healthcare bill, citing the cuts to Medicaid and insufficient subsidies that would result in millions of Americans losing coverage.

"The additional funding to address the opioid epidemic is a positive step, however, those suffering from substance use disorder have other healthcare needs that are not likely to be addressed if they lose coverage through a rollback of the Medicaid expansion," said AMA President David Barbe, MD, in a press release.

Hospital groups shared physicians concerns.

"If enacted, BCRA would mean real consequences for real people – among them people with chronic conditions such as cancer, individuals with disabilities who need long-term services and support, and the elderly. Unfortunately, in the latest update released today, the unacceptable flaws of BCRA remain unchanged, and there are no significant changes to the massive Medicaid reductions," Rick Pollack, president and CEO of the American Hospital Association, said in a press statement.

"Instead of merely tweaking a proposal that would harm our most vulnerable, we again call on the Senate to advance a solution aimed at protecting coverage for all Americans who currently have it," continued Pollack.

For once, insurers and hospitals were on the same side and more than one insurer rejected the Cruz-Lee concept outright.

"A fair, stable health insurance system requires an adequate number of both sick and healthy people who contribute to the pool of funds available to pay medical claims," said Andrew Dreyfus, president and CEO of Blue Cross Blue Shield of Massachusetts in a press release. "Whether for individuals or small businesses, provisions of the BCRA deepen this divide and would create an unfair and unstable market making coverage out of reach for those who need it most. This division would be further intensified with the inclusion of the 'Consumer Freedom Option' because it undermines pre-existing condition protections. As a health insurance CEO, this is not an option that we want or need."

Does Anyone Support the Bill?

The American Association of Neurological Surgeons/Congress of Neurological Surgeons, a group that opposed the ACA when it passed, has "not yet taken a position on the totality of the legislation," said Katie Orrico, director for the Washington Office of AANS/CNS in a phone call.

Overall, "we would like to see more people have coverage not fewer," she said.

However, Orrico cited "state flexibility" and allowing insurers to buy products "tailored to consumers' needs" -- boilerplate Republican talking points -- as ideas AANS/CNS members support.

The group also strongly favors repeal of the medical device tax, a provision in both the House-passed bill and the Senate versions, because neurosurgeons rely on cutting edge advances, Orrico explained.

"We have been concerned that a tax of this nature would adversely effect innovation and stifle these kinds of advances, and that would be detrimental to quality patient care," she said.

Orrico said the AANS/CNS hasn't issued a statement on the bill because it's still a "moving target," but plans to take a public stance following the release of the Congressional Budget Office score.

Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, said the bill has some good points, such as allowing health savings accounts to be used to pay premiums, and the Medicaid overhaul.

"Medicaid is a cash cow for managed care, for hospitals, for providers, [and] for bureaucrats," she told MedPage Today in a phone call.

"Last year, Nevada Medicaid paid as much as $213 million to managed-care companies for more than 30,000 people who received no care at all," wrote Orient in a follow-up email, citing an article from the Reno Gazette Journal.

She supports the Cruz-Lee amendment, but noted that the revised BCRA's version "puts more price controls on insurance companies and doesn't allow them to charge actuarially fair premiums."

Ultimately, Orient does not support the bill. Anything less than fully dismantling the ACA will not be enough for her.

"This is not a repeal of Obamacare ... it really does not do anything toward making medical care more affordable, less costly, and less strangled by all kinds of regulations," she said.


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