America's Essential Hospitals CEO Dr. Bruce Siegel on healthcare reform, proposed Medicaid DSH payment cuts and the safety net

As Americans continue to debate healthcare, many issues come into play, such as potential changes to the ACA and proposed cuts to Medicaid Disproportionate Share Hospital allotments under the current health law.

In recent months, federal Republican lawmakers have made continued healthcare reform efforts. The House passed the American Health Care Act to repeal and replace the ACA in May. Then the Senate took up repeal and replace legislation, called the Better Care Reconciliation Act. However, those efforts failed earlier this month. Senate attempts at a straight repeal of major portions of the ACA without a replacement also failed, as did efforts for a "skinny" repeal bill. Moving forward, the future of healthcare reform is uncertain.

In addition to healthcare reform efforts, CMS issued a proposed rule last week that includes a methodology for implementing Medicaid DSH payment cuts. The payments, which help compensate hospitals that provide care to a large number of poor and uninsured patients, would be cut by $43 billion by fiscal year 2025.

America's Essential Hospitals President and CEO Bruce Siegel, MD, recently spoke to Becker's Hospital Review about these issues and other issues facing safety-net hospitals.

Question: How will healthcare reform affect safety-net hospitals, regardless of what Congress does?

Dr. Bruce Siegel: Nothing good is going to come with everything we've seen so far. Every bill has been an assault on the safety net. We have seen proposed policies that included per capita caps that gut Medicaid, rolling back expansion, undermining the exchanges. All of that is going to rip apart the safety net, and lawmakers have done little to address other issues like the looming Medicaid DSH cuts. One of the problems is lawmakers have gone far beyond simply going to roll back the ACA. Per capita caps have nothing to do with the ACA. Per capita caps are simply a long-term objective of some folks in Congress, and they're using this opportunity to try to jam it through.

Additionally, looking at what happened last week, for instance, we're watching 100 senators throw spaghetti at the wall and trying to see what sticks. We're talking about revamping one-sixth of the U.S. economy and possibly taking away health insurance for 16 million to 32 million people, and it was done in utter chaos. We literally did not know from hour to hour what is going to be voted on in Congress. I've been in health policy for 30 years and I have never seen anything like this.

Q: How would Medicaid DSH cuts affect safety-net hospitals?

BS: Medicaid DSH cuts would have implications for most Americans. It's not simply about the safety net. So when we look at Medicaid DSH, it's supporting hospitals that do things no one else does — that's what we mean by essential hospitals. So the payments support hospitals that provide the only Level I trauma center, they support hospitals that provide the only burn unit in the community, they support hospitals that are the first line of response to emergencies like Ebola or Zika virus or a mass-casualty event. We need to realize that entire communities depend on the special services that Medicaid DSH helps support. Those services are not covered in regular insurance payments or Medicaid. DSH allows that higher level. It's about more than just poor people. It's about the health and well-being of hundreds of millions of Americans.

Q: What are the equity and disparity issues affecting safety-net hospitals?

BS: The ACA has been the biggest tool we've had to close disparities. The ACA had a big impact on equity by covering millions of Americans who are poor, Latino, black or other minorities. The ACA had a huge impact on economic equity and on equity between races and ethnic groups. It really tries to level the playing field, and rolling that back will reopen disparities in this country. So they're linked issues. We saw for people who make less than $25,000 a year a huge increase in coverage.

The good news is hospitals and health systems are really confronting disparities in their communities. They are asking hard questions about the care they provide. Hospitals are trying to make sure they're part of the solution to the disparities and not part of the problem. That's really good news. I think the challenge we've had is: How do we go beyond the four walls of the hospital? What is the hospital's role more broadly in the community? We know most of what drives disparities and health outcomes is rooted in where people live, their housing, the availability of healthy food. Those are some of the demographic drivers of disparities. We're now at the very early stages of defining the hospital's role in painting the picture. Around the country I see health leaders grappling with this conundrum, and nobody has the magic formula. One of the things I hear a lot of leaders talking about is the anchor hospital in their community. These institutions are the biggest caregivers, but they're also the biggest economic engines. They're the major employer. They're the major purchaser. They have the biggest footprint. They affect the fabric of the community profoundly.

One of the reasons I'm so worried about repeal and replace and the Medicaid DSH cuts is those things will make it impossible for hospitals to fulfill these things. We'll be fighting fires rather than promoting health. We're at the early stages. We don't really know what works yet. We have a grant from the Robert Wood Johnson Foundation that is helping us create a learning community of essential hospitals to address social determinants of health and address population health. So this is a top priority for us as an association. Our hospitals are often the anchor in the community. They have a mission of service, so we are taking this on as a top priority, but with that said, I think many hospitals are thinking about this, and I think every hospital in the country has a role to play here.


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