Graham-Cassidy, Congressional inaction rain 'unprecedented' drama on Tennessee health care

From the Tennessean
by Holly Fletcher

Federal debate and Congressional inaction on extending key safety net funding are creating an unprecedented amount of uncertainty on millions of Tennesseans and the state’s health care infrastructure.

Change is persistent in health care — yet health care leaders from across the state said the current threat of upheaval surpasses any other point in this generation of executives' climb up the ladder.

"There has never been a time when it's not changing. What's happening now is not like that. What's happening now is unprecedented in the size and scope of the impact," said David Jarrard, co-founder of Jarrard Phillips Cate & Hancock, a Brentwood-based health care communications firm. "We will need to pay close attention for the next 10 days and over the next many days because the consequences are far reaching."

Health systems plan years in advance, but the steady stream of policy proposals in 2017, combined with the existing industry-shifting trends, is blurring the horizon.

There's a resurgent effort to repeal and replace the Affordable Care Act, overshadowing a commitment to funding the safety net that treats some of Tennessee's most vulnerable people.

"Right now — more than any time I can remember in my 30 years of doing this — there's more uncertainty with the revenue stream than we've ever seen," said Alan Levine, CEO of Mountain States Health in Johnson City.

For people who wake up every day to treat those who need care, when they need it, the endless game of political football obscures how they will keep serving their communities.

"Just when we think there can't quite possibly be one more hill or mountain we have to climb, one more thing creeps in," said Caroline Portis-Jenkins, co-CEO of Connectus Health, a community health center in Nashville. "It's a lot. Please, Lord, don't let there be anymore."

Patients and providers face 'scary' time as Congress adds to murkiness of the future

Around Tennessee, hospitals, physicians and clinics face daunting challenges that range from decreasing payments to fast-moving, expensive technology to patients, and employers, who don't want to pay any more for care. 

Health care, even without the layer of federal debate, is facing seismic changes. Hospitals in rural parts have closed — and more teeter on the cusp of solvency as costs outpace payments. 

Community clinics around Nashville are bustling with people who can't pay high deductibles — a growing class of uninsured. 

"The structure of the health delivery system is so big and so slow-moving you can't keep changing these policies as quickly as they keep changing, because the system can't keep up with it," said Levine. "At some point, we've got to create, we've got to decide what the policies are and give them a chance to take hold."

The next week is pivotal. 

Decisions in Washington, D.C. have the potential to sweep across the state — hitting clinics, hospitals and patients. 

"I'll be honest with you, I don't know that anybody doing what we're doing would say it's ever been as scary as it is right now," said Suzanne Hurley, co-CEO of Connectus Health.

Here's what's up in the air over the next week:

  • Graham-Cassidy, the latest ACA repeal-and-replace bill

Proposed 17 days before the Senate will have to have a 60-vote majority to pass a bill, the sweeping legislation would overhaul the nation's health care policy, turning the individual insurance market and Medicaid into block grants and allowing states to apply for waivers to structure access to coverage as well as what plans cover and cost.

Haslam has thrown his support behind Graham-Cassidy, and an early analysis from Avalere Health indicates the state could see an $3 billion over roughly a decade before facing a funding cliff in 2026. 

"Graham-Cassidy is not perfect" but that the block grants could be a way to bring policy certainty, said Levine, who penned an op-ed for Time with former Florida Governor Jeb Bush, whom he worked for as secretary of Florida's Agency for Health Care Administration.

"Frankly, I believe that would create far more certainty, particularly in Tennessee and Virginia," said Levine. "You have this much concentrated power in Washington (and) every two years, depending on who's in charge, the rules are going to change. This is, to me, the biggest challenge." 

The bill doesn't solve the issues that Karen Springer, CEO of Saint Thomas Health, wants to see Congress "reach across the aisle" to preserve coverage, improve the safety net and continue the push toward paying for value over volume. 

"Unfortunately, the Senate instead may vote next week on a bill that doesn't achieve those three goals," said Springer. "So we're concerned about the direction they are headed."

  • Community health center funding

Clinics serving the uninsured, poor, homeless, and increasingly people who are underinsured, are bracing for a potential 70 percent funding cut because Congress hasn't reauthorized the money. Many clinics can operate about 45 days before having to start making "really tough decisions" about staffing and services, said Hurley.

Community health centers serve an estimated 400,000 Tennesseans, and reduced services could send people to already busy faith-based clinics or into emergency rooms. 

Hurley said patients are asking a lot of questions and they've seen an uptick in demand for mental health services in recent months as people begin to "have anxiety about what they will do for care if this all comes to fruition."

Connectus and their peers have long had bipartisan support, and just this month received some new federal money to help fight opioid abuse. But what's the use of new money if Connectus has to cut its patient load by 53 percent because it doesn't have an operating budget asked Hurley.

"Our question is, where will people go," said Portis-Jenkins. "We've fought (the funding cliff) before but it's never been this hard, especially with health care competition. There's repeal. There's CHIP. The exchange. You name it."

  • Insurance for kids whose families fall in the coverage gap

Congress hasn't extended funding for the Children's Health Insurance Program, which is complimentary to TennCare, and called CoverKids in Tennessee. It provides coverage for 72,000 children whose families make too much income to qualify for TennCare but don't have private insurance as well as some pregnant women. TennCare estimates it has funding through spring 2018.

The uncertainty over CHIP funding "is just another thing that's creeping into our reality," said Portis-Jenkins. 

  • ACA open enrollment, Nov. 1 - Dec. 15

The state approved premiums for 2018 but insurers have until Sept. 27 to sign contracts with the federal government.

Shoppers will see another year of premium increases from BlueCross BlueShield of Tennessee and Cigna, but this year federal uncertainty is a bigger factor than costs associated with the risk pool.

There is no guarantee from the federal government that cost-sharing reductions, a payment made to insurers to offset out-of-pocket costs will be made, and with ongoing repeal-and replace proposals, so if Graham-Cassidy is enacted the individual mandate would be repealed immediately.

Sen. Lamar Alexander, R-Tenn., backed off an effort to find bipartisan support to shore up competition, and possibly lower premiums, ahead of 2018. 

Springer said the "immediate challenge" that Congress should work on, instead of Graham-Cassidy is finding steps to "stabilize the insurance market exchange."

Jay Sheridan