The Transylvania Times -

By Derek McKissock
News Editor 

Commissioner Worries About ACA Repeal Impact – Brevard NC


March 6, 2017

Transylvania County Commissioner Mike Hawkins believes the current proposed plans being floated to replace the Affordable Care Act (ACA) would be a “disaster” for the working poor, small business entrepreneurs and others.

During the recent commissioners’ meeting, Hawkins said he’d like to find a way for the board to reach a “comfort level” and be able to discuss the issue with elected officials, particularly U.S. Congressman Mark Meadows, who represents the 11th District, which includes Transylvania County.

Hawkins told the board that he doesn’t “want to get into the politics of it,” but he’d like to “provide information, so (lawmakers) can make a good decision.”

“I truly, sincerely, believe it is a moral issue, but even if you don’t, I think it’s a public policy issue, in the sense that it is in our best interest that as many citizens as possible have access to quality health care,” he said.

About 2,700 Transylvania County residents, or roughly 8 percent of the county’s population, currently have health insurance coverage through the ACA.

The uninsured rate in Transylvania County dropped from 18 percent at the beginning of ACA in 2013, to 14 percent in 2014, then back up to 15 percent in 2015.

In Buncombe County, 9.1 percent of the population has ACA coverage. In Henderson, it’s 5.9 percent, while in Polk, it’s 6.9 percent and in Madison, it’s 7.7 percent.

After the commissioners’ meeting, The Transylvania Times reached out to Hawkins to get more information and his feedback on the proposed plans.

Hawkins replied by email, which he also shared with the rest of the board and the county’s administrative staff.

Hawkins said that it’s a “complicated subject made more complicated by the uncertainty and competing replacement plans being floated.”

The 8 percent of the county’s population receiving ACA coverage did so, Hawkins said, because they couldn’t, for a variety of reasons, get insurance coverage through traditional channels but “mostly centering around affordability.”

Those who make up ACA enrollees largely include the working poor, those whose jobs don’t offer benefit plans and small business entrepreneurs, along with those with pre-existing conditions, which ACA requires insurers to cover at an affordable rate.

Many of those people tend to be older but not yet at retirement (Medicare) age, Hawkins said.

Replacing The ACA

The two main replacement proposals come from U.S. Rep. Paul Ryan, of Wisconsin, and U.S. Sen. Rand Paul, of Kentucky, respectively.

Hawkins said Paul’s plan has been endorsed by Meadows, chairman of the House Freedom Caucus, which Hawkins characterized as a “group of extreme conservative Republicans.”

Hawkins said both plans would see large numbers of ACA enrollees losing their coverage but for different reasons.

The problem with Ryan’s plan, Hawkins said, is that it will make coverage unaffordable for those currently served by the ACA. The plan would:

•eliminate premium and cost sharing subsidies;

•change tax credits from income-based to age-based;

•change tax credits from an up-front credit to a retroactive credit. This is important, Hawkins said, because the working poor don’t have cash flow to “float” the benefit to the end of the year;

•change Medicaid funding from an open funding to a per capita funding; and underfunds high-risk pools, which were created to take care of the pre-existing condition demographic. It also raises Medicare retirement age to 67 and places additional taxes on employer-provided health plans.

Hawkins said the problem with Paul’s plan is accessibility.

It would, he said:

•eliminate most of the inclusionary components of ACA, including, most notably, the requirement to guarantee issue and the pre-existing condition requirement;

•remove many ACA consumer protections, including independent reviews of denied claims, unrestricted transfer from a current plan to a new plan and limits on actuarial restrictions of policies offered.

Unlike the Ryan plan, Hawkins said, the Paul plan keeps much of the ACA’s affordability assistance and does not suggest changes in Medicaid funding support.

“Both plans lean heavily on market-driven strategies for cost containment, promoting things like Health Savings Accounts and interstate insurance sales,” he said. “The realism of this strategy is the subject of much debate.

“The fact that both plans would result in reduction of people covered is a huge concern. Access to quality health care services should be available to as many citizens as possible. That is a fundamental goal of good public policy. If that is limited because of affordability (Ryan plan) or accessibility (Paul plan), then we are failing as elected officials. And it is widely understood that these plans will remove millions of people from the insurance rolls.”

The National Governors Association, Hawkins said, was recently told that 50 percent of ACA enrollees would lose their insurance in states which did not expand Medicaid, such as North Carolina.

“A combination of the ‘good’ aspects of the Ryan and Paul plans would be the best outcome, I think.” Hawkins said. “I hope commissioners will be willing to express these concerns in a respectful way to our federal elected officials. I will be working up a possible letter for the commissioners’ consideration.”

Possible Impacts

Hawkins said ACA replacement is also a “serious economic development issue.”

At a meeting last Tuesday with Mission Health executives, Hawkins said he, Commissioner Page Lemel and County Manager Jaime Laughter were told that all new capital projects system-wide were on hold because of the potential negative effects of a repeal/replace.

Rural hospitals especially, Mission officials said, will be hurt from a reduction in insured citizens, as their unreimbursed expenditures will rise dramatically. Mission estimates it will lose half a billion dollars through 2026 under that scenario.

A Mission Health handout entitled “Healthcare Reform Talking Points” said it was “imperative” that elected officials don’t repeal ACA “without a simultaneous and effective replacement.”

Mission Health calls for a replacement plan that “builds upon what has clearly worked —insuring many more Americans, preventing discrimination based upon pre-existing conditions or gender, allowing market-based approaches such as competitive insurance exchanges to play a role, etc. — while improving upon what clearly hasn’t worked — not enough insurers in many markets, bad estimates of newly insures utilization that led to large premium increases, failure to attract enough younger, healthier enrollees, etc. —should be the goal.”

Mission said its patients and families are the “most likely to hurt due to a lack of coverage.”

Mission serves nearly 1 million patients who are, on average, older, poorer, sicker and less likely to be insured that state and national averages:

•75 percent of its patients are on Medicare and/or Medicaid or they are uninsured.

•More than 50 percent of Mission’s patients are covered by Medicare and 20 percent are covered by Medicaid.

•Mission provides more than $40 million to offset unreimbursed care provided to patients covered by government programs.

In a Feb. 14 memo, Elaine Russell, the county’s health director, told the county’s Board of Health that ACA repeal would eliminate about $45,000 annually to Transylvania from the Public Health Prevention Fund.

During the ACA’s creation, long-standing and new public health funds were placed in the Public Health Prevention Fund.

Some of the funds, Russell said, had been around for more than 40 years.

The fund, she said, was intended to protect the money from continual cuts by Congress.

Russell said the impact on N.C. Public Health would be about $20 million.

“A loss of funds at this volume can not be absorbed at the state level and will impact funds/services available to the local level,” she said.

The regional impact from the loss of the Public Health Prevention Fund would be money awarded to MountainWise, a collaboration of the eight most Western county health departments, including Transylvania.

The funds, roughly $234,000, are used to address obesity, diabetes, heart stroke prevention, and other efforts to improve chronic disease in the region.

In her memo, Russell also asks the Board of Health to table a request of two additional school nurses in the upcoming county budget.

“At this time, I am not advocating any program or staffing expansions for the agency until the impact of the ACA repeal/replace is further understood for local health departments,” she said.

Hawkins said that access to quality health services has been an expressed public policy goal for decades.

“That’s why taxpayer dollars are purposefully used to subsidize Medicare, Medicaid and employer-provided health care plans — through their tax deductibility,” he said. “Some politicians are currently describing ACA subsidies as ‘entitlements,’ but they’re engaging in selective outrage because they are not saying the same thing about the subsidies in these other health insurance mechanisms. I don’t understand that.”


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