The sprint to dismantle the Affordable Care Act has Houston’s hospital leaders worried about a potential fallout that could sweep beyond the poor if the uninsured rate rises again.
Texas already leads the nation with more than 4 million uninsured, with Harris County topping the state at about 740,000. A recent analysis by the Urban Institute predicts that the Texas uninsured rate could climb to as high as 6.9 million by 2019 should the law known as Obamacare be repealed without a swift and comparable replacement.
At Harris Health System, one of the largest public hospital systems in the nation, more than 62 percent of the 330,000 patients across the currently are uninsured.
“If people think Harris Health can absorb this, that is a miscalculation,” said George Masi, president and CEO.
Events in Washington, D.C., are moving quickly, with Congress voting to establish the framework for repeal and President Donald Trump signing an executive order allowing agencies to lift or ignore some of the restrictions and enforcements under the current law. His action, signed hours after he assumed the presidency, appears aimed at the individual mandate that requires most people to carry insurance or be penalized.
For two months now, Masi, who oversees a system with 48 facilities, has been watching with a growing sense of unease.
“This is not just about me,” he said, gazing over the crowd of fellow administrators at a gathering at the Texas Medical Center just after the election. “This about all of my colleagues in this room.”
It’s unclear what will replace the ACA, so no one knows how the changes will play out. The biggest worry is that a spike in the local uninsured rate could trigger a chain reaction – one so hidden even the insured middle class who have never set foot in a public hospital will feel it and never know why.
Without coverage and regular treatment, people will get sicker and eventually flood emergency rooms, because by federal law hospitals have to see them regardless of ability to pay, Masi said.
Overburdened public facilities, which care for the bulk of the uninsured, won’t be able to keep up. Wait times could double or even triple. And while the most critically ill will be treated at the public hospitals, others with lesser needs will migrate to other hospitals.
But those non-taxpayer supported facilities do not have sufficient federal funding to offset the bad debt of unpaid medical bills. Prices for everyone could rise, Masi said.
“It’s how you get $12 Tylenol,” he said. “It’s because the person in the next room can’t pay. As the insured patient, you’re going to pay for the uninsured patient.”
The ripple effect could show up in premium prices.
Before the ACA, Families USA, a nonprofit consumer health advocacy organization, reported that a family of four paid just over $1,000 more per year in their health coverage to compensate for the uninsured.
Lydia Mitts, a senior policy analyst at the organization, said it examined data from the reimbursement rates between hospitals and insurance carriers and concluded the cost of treating the uninsured is baked in.
“It trickles down into everyone’s premiums,” she said.
Vivian Ho, a health economist at the Baker Institute for Public Policy at Rice University, is skeptical about that piece of the puzzle, calling it unproven. But she predicted the impact could be felt in other ways.
Since public hospitals in Harris County are funded through a portion of property taxes, homeowners’ tax bills could rise, Ho said. Hospitals also may begin to reduce services, including staff.
“The Memorial Hermanns, the Methodists, they’re going to have to try to figure out a way to cut corners,” she said.
“It could be very bad for all of us,” said Dr. Benjamin Chu, the new president and CEO of Memorial Hermann Health Service, the region’s largest health care system, which treats nearly 2 million patients a year, about 10 percent uninsured.
Chu said so much remains unknown that it is hard to prepare.
“You have to make up costs somewhere,” he said.
Houston Methodist would not comment for this story.
The amount of uncompensated care needed to serve the uninsured and underinsured in Texas is already more than $8 billion each year, both from shortfalls in Medicaid payments and about $5 billion in unreimbursed care, according to a report by the Texas Health and Human Services Committee.
This month the Urban Institute projected that without a comparable replacement plan, the total amount of uncompensated care in Texas could rise to $70 billion between 2019 and 2028.
Rep. Kevin Brady, R-The Woodlands, who has been leading the charge against the ACA for years, said the anxiety is overblown.
Last week, the Congressional Budget Office released a report that estimated 18 million people nationwide would lose their insurance in the first year if the ACA is repealed without a replacement. But Brady struck back quickly, saying the prediction “doesn’t even tell half the story.”
He joined a chorus of Republicans who called the report flawed because it based its finding on a previous repeal model that did not include the replacement piece.
At a Chamber of Commerce meeting with constituents in The Woodlands the same day, Brady sought to reassure a skeptical crowd that repeal will happen next month and a replacement plan will be unveiled by year’s end.
The full implementation of the undetermined replacement plan, he said, will occur in stages and could take years. But he stressed that no one who wanted insurance will be left stranded.
Despite Trump’s push for speed, agreement among Republicans on how to proceed remains elusive.
“Everyone says Republicans don’t have a plan. I think the problem is they have too many,” said Sally Pipes, president of Pacific Research Institute, a California free market think tank.
She has analyzed several plans floated by Republicans, including one by Rep. Tom Price, R-Georgia, who is Trump’s nominee to head the U.S. Health and Human Services Department. Under his plan, the federal subsidies used by most ACA enrollees to lower premium prices will be replaced with age-based tax credits. Those buying individual coverage, regardless of income, would get set amounts ranging from $1,200 to $3,000 per year to help with the purchase. A prohibition against denial of coverage because of pre-existing conditions or chronic illness is expected to remain untouched. But getting there could be tricky.
Instead of the mandates requiring that most everyone have comprehensive insurance to enlarge risk pools, most of the Republican plans favor letting people decide their own range of coverage, including opting out. The sickest will be offered plans through a return of high-risk pools.
As the clock ticks toward repeal, the nation remains almost evenly split on a law that could soon end.
Gary Benson wants a new law because he has grown frustrated with the uncertainty and expense of coverage under the ACA.
The owner of an insurance agency in The Woodlands who does not sell health coverage, he is now on his third insurance plan after losing previous ones when they were discontinued. He has a Blue Cross and Blue Shield of Texas health maintenance organization plan, or HMO. It costs $1,500 a month for him and his wife and carries a $6,500 deductible.
“I feel like I’m being forced to buy an inferior product,” he said.
A Republican who voted for Trump but not because of health care, he looks to Congress to come up with something broad enough to cover the doctor he prefers and stable enough to give him peace of mind.
Benson applauds the ACA for insuring those who could not get it before but is skeptical that universal coverage is ever achievable. He has little doubt the uninsured rate will rise after repeal.
“I think there will always be a segment of the population that will never buy insurance,” he said.
Thirty-five miles away in Houston’s Fifth Ward, Beverly Bryant believes the ACA saved her life. The 64-year-old worked for two decades for the plant company that gave her insurance. When she hurt her knee and had to quit, she lost her insurance, too.
She missed the enrollment deadline for 2014, so she went an entire year doing without.
“I was praying, please don’t let anything happen,” she remembered.
She signed up quickly for 2015 and got a plan that cost $60 after a $500 subsidy. She made an appointment for a checkup at Legacy Community Health, and there her doctor found an aggressive form of breast cancer. It is unknown how long it had been growing.
She had her right breast removed in late 2015 and a series of reconstructive surgeries in 2016. Her last follow-up appointment was in December. The early Medicare she applied for two years ago has now come through, but she worries others might fall into the uninsured ranks like she did.
“You never know what life has in store for you,” she said.