Monday, June 9, 2014
The New York Times
June 8, 2014
Shifts in Charity Health Care
By The Editorial Board
Health care reform was supposed to relieve the financial strain on
hospitals that have provided a lot of free charity care to poor and
uninsured patients. The reform law, known as the Affordable Care Act,
was expected to insure most of those patients either through expanded
state Medicaid programs for the poor or through subsidized private
insurance for middle-income patients, thereby funneling new revenues to
hospitals that had previously absorbed the costs of uncompensated care.
In return for the new income streams, hospitals that treat large numbers
of the poor and get special subsidies to defray the cost would have
those subsidies reduced on the theory that they would no longer need as
But after the Supreme Court ruled that the reform law could not force
states to expand their Medicaid programs, 20 or more states declined to
do so. That failure has hurt some big urban hospitals, because their
charity care burden remains essentially the same even as their federal
aid has been cut. Even in California, which has expanded its Medicaid
program, public hospitals that serve the poorest patients could face a
big funding shortfall in future years, according to a study just
published by researchers at the University of California at Los Angeles.
A recent report in The Times by Abby Goodnough found that some hospital
systems have started tightening the requirements for charity care in
efforts to push uninsured people into signing up for subsidized health
plans on the insurance exchanges created by the reform law. In St.
Louis, for example, Barnes-Jewish Hospital has started charging
co-payments to uninsured patients no matter how poor they are. Those at
or below the poverty level ($11,670 for an individual) are charged $100
for emergency care and $50 for an office visit.
But some medical centers have seen their charity care costs decline. A
report late last month in Kaiser Health News and USA Today said that
Seattle's largest "safety net" hospital, run by the University of
Washington, saw its proportion of uninsured patients drop from 12
percent last year to a surprisingly low 2 percent this spring, putting
the hospital on track to increase its revenue by $20 million this year
from annual revenues of about $800 million.
How all of this will shake out is still uncertain. Some vulnerable
groups may find it even harder to get the care they need. Through a
quirk in the reform law, residents below the poverty line in states that
have failed to expand Medicaid are not eligible for either Medicaid or
for subsidized coverage on the insurance exchanges. Undocumented
immigrants are not eligible for Medicaid or the subsidized coverage. And
some low-income people who have enrolled in subsidized health plans may
have trouble paying their cost-sharing.
There are some ways to address these gaps. All states ought to expand
their Medicaid programs since the federal government is offering very
generous matching funds. Hospitals should move aggressively to help
people enroll in Medicaid or in subsidized plans on the exchanges. And
federal health officials need to review regularly whether health plan
co-payments are actually affordable to those living on very modest incomes.
paradocs2 San Diego
It has been little appreciated that one of the most important
accomplishments of the Affordable Care Act was to create universal
national health insurance for all poor legal residents of the United
States who earned less than 138 percent of the federal poverty level.
This magnificent and compassionate action of social innovation and
national unity was frustrated by the insensitive, tragic and immoral
decision of the Supreme Court. The consequences described in this
editorial go beyond costs and inefficiencies to the persistence of the
lack of medical services in many areas of our country with appallingly
poor health statistics. The problem is more than "the financial strain
on hospitals that have provided a lot of free charity care to poor and
uninsured patients," for it extends to the suffering of those millions
of people excluded from ongoing medical care. In addition, the
circumstances described in this editorial highlight the conundrum of our
country's health care system, based as it is on on a commercial market
model and profit generating insurance companies. The best solution to
these problems, both the economic inefficiencies and the human
suffering, is the creation of a universal, national, single payer health
system looking like Medicare expanded to cover all residents. It is
profoundly upsetting that our individualistic contemporary culture and
the politicians who represent it are blind to both the moral and
economic consequences of their position.
Comment by Don McCanne
PNHP's Jeoffry Gordon, MD (paradocs2, above) stated it so well that no
additional comment is being provided today.
at 2:29 PM