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American Hospital Association Opposes GOP's Health Care Overhaul


The Trump administration's message on a replacement for Obamacare is, in essence, don't worry about it. Tom Price, the secretary of Health and Human Services, told NBC yesterday the replacement will be better than the Affordable Care Act.


TOM PRICE: I think we'll have folks that are evaluating this and modeling this come out and say yes indeed, this plan will in fact cover more individuals than are currently covered.

INSKEEP: Price said this in the face of studies that find essentially the opposite. Around 20 million extra people gained insurance under the Affordable Care Act. Studies of plans similar to the House Republican plan find that smaller subsidies and changes to Medicaid mean that many or even most of those people would lose insurance, which brings us to the hospitals that get paid by the insurance. Tom Nickels is in our studios. He's executive vice president of the American Hospital Association. Good morning, sir.


INSKEEP: Is Tom Price right, you liberate the market and more people are going to be covered in the end?

NICKELS: We're very concerned about that. And I think if you look at the substance of the bill right now with respect to reductions in the Medicaid program and the tax credits that are being offered in lieu of subsidies, we're very concerned that coverage will go down. Now, we're going to have an answer real soon with the Congressional Budget Office coming out with their estimates perhaps as early as today. But we're very concerned about coverage.

INSKEEP: You know, we had on the program earlier Hugh Hewitt, the conservative radio talk show host. And he acknowledged he thought maybe 15 million people are going to lose health insurance, mostly because Medicaid gets changed. And he says, I don't care because it's such terrible insurance hardly anybody takes it. Is that the case?

NICKELS: Well, there are certainly problems with the Medicaid program, particularly on the payment side for physicians and hospitals. And I'm not saying that it's not a program that needs help. But for 15 million people to lose coverage, that would be catastrophic.

And Medicaid, by expanding - by its expansion through the Affordable Care Act has provided coverage to 11 million people who didn't have it before. And that's a population that is in desperate need of health care. Now they can go to primary care. Now they can go to doctors. Now they can come into our institutions for surgery. So I think it would be catastrophic, as I said, if that were to happen.

INSKEEP: You represent something like 5,000 hospitals, is that right?


INSKEEP: And do most of them take Medicaid payments?


INSKEEP: In fact, many of them probably have to if it's an emergency room situation, right?

NICKELS: Yes. And most of our members take Medicare and Medicaid, and depending on the demographic in which they're located, more of one than the other.

INSKEEP: Another statement made by Mr. Price - Tom Price, the secretary of Health and Human Services - is, quote, "nobody will be worse off financially." Is there any way that that is true?

NICKELS: That's hard to figure out at this point in terms of being off financially - being worse off financially. For example, on the tax credit side for individuals who purchase coverage right now in the exchanges, in many parts of this country that tax credit will be much less than the subsidy is today. They'll have to make up that amount out of their own pocket. So I think that would be problematic certainly for that population.

INSKEEP: And let's remind people that the House Republican plan offers subsidies between $2,000 and $4000 per year to help buy insurance depending on your age, not your income. How much of a difference would that make, that low-income people would not necessarily get more to help pay insurance? It would be based on their age.

NICKELS: That's the problem, which is that right now lower-income individuals on the exchanges get subsidized so they can afford to buy coverage. And then as your income goes up, up to 400 percent of poverty, at which point the subsidies are cut off, you get less. So that's really important for that population to be able to access additional dollars to purchase health care.

INSKEEP: Although could it - why would, like, essentially middle class people be given more under this than lower income people?

NICKELS: Well, it could potentially be so. I mean, age is a relevant metric to use. But you also have to look at income. And I think if we don't look at both, it's going to be problematic.

INSKEEP: Paul Ryan, the speaker of the House, has defended this by essentially saying, I don't want to be a nanny state Republican. The implication being, and this is something that a lot of Republicans say flat out, like, why are we even in this business? Why is the government in this business? Can you justify to a Republican on a basic, basic level why the federal government should be involved in the health insurance market?

NICKELS: Sure. Well, keep in mind that we're already quite involved in health care through the Medicare program. And that's been long established. And nobody's complained about that. The Medicaid program is for the poor and disabled, et cetera. What the ACA did was expand Medicaid to more individuals - adults, primarily childless adults. And these are folks who need help with their care. And keep in mind that if they don't get insurance, they still come to our institutions. They still will get the care that they need. And that is a cost to society overall.

INSKEEP: How's that going to get paid if they don't have health insurance?

NICKELS: That's the problem. Prior to the ACA, our uncompensated care was much higher than it is today. The uninsured has gone from 18 percent to 11 percent of the population. It's been very beneficial, particularly to my members who are in lower-income neighborhoods and lower-income parts of this country and rural hospitals, too. So it will be a burden on the hospitals to have to have additional uncompensated care.

INSKEEP: So somebody's listening to you and following along and realizing, OK, your hospitals have made more money because more people are insured. Are you able to pass - because some of them are public institutions - able to pass the savings back on to me, the taxpayer, like, is the public gaining in some way because people are insured?

NICKELS: Well, there's no question that the public gains because again, we don't have the uncompensated care that gets passed onto private pay. For example, individuals like you and me who have private insurance had to pay more because we had to compensate for the losses over here. So it definitely has an impact and a positive impact on everybody throughout the system.

INSKEEP: Did Republicans consult hospitals or your organization specifically when shaping their health insurance plan?

NICKELS: We've met with all of them. And they're very open to listening to us. And they have a different view right now of what they want to pass. Now, this is the House bill. We still have the Senate. There's more to come here. But we've certainly had conversations with them.

INSKEEP: If you had an opportunity to change one thing, what would it be?

NICKELS: Medicaid expansion. I think extending right now the Medicaid expansion to that population is terminated in 2020. Individuals who are on then can stay on but nobody else can. We would definitely want to continue that Medicaid expansion into the future.

INSKEEP: Just keep going with the broader definition of Medicaid...

NICKELS: Yes, correct.

INSKEEP: ...Which would include not just mothers and children. It would include childless adults. It would include men, that sort of thing.


INSKEEP: That would be OK with you. You would - that is the most vital thing for you, not anything else?

NICKELS: I think if you look at - I mean, there are many vital things. But if you look at the population that was coming into our institutions without insurance and therefore all the ripple effect of that - not being able to go to primary care doctors, not being able to have regular services. That's the population that needs the coverage the most. That's the most important part.

INSKEEP: Tom Nickels, thanks for coming by, really appreciate it.

NICKELS: Thank you, Steve.

INSKEEP: He is executive vice president of the American Hospital Association. Transcript provided by NPR, Copyright NPR.

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