If Republican leaders in Congress are successful, the structure of health care coverage in the United States will change dramatically. Although most attention has centered on how the proposed legislation would affect individuals, the Republican plans would also create substantial shifts for medical providers.

LAKELAND — If Republican leaders in Congress are successful, the structure of health care coverage in the United States will change dramatically.

Although most attention has centered on how the proposed legislation would affect individuals, the Republican plans would also create substantial shifts for medical providers.

The leader of Polk County’s largest hospital doesn’t like what she has heard about the American Health Care Act, which passed in the House of Representatives, or a companion Senate bill released in June.

Elaine Thompson, president and CEO of Lakeland Regional Health, said in her view both measures would move American health care backward.

“Why I am not a fan of either the House or Senate’s (bills) is because it is limiting access, and we’re all about getting everybody access to preventive care,” Thompson said. “We believe at the end of the day (access) will create a better lifestyle. It will help us not have two sets of classes here, and it’s just the right thing to do.”

Thompson is one of a few local medical executives who shared their views of the proposed Republican plans with The Ledger. She oversees a network that includes LRH Medical Center, home to one of the busiest emergency departments in the country.

The Republican proposals represent a yearslong quest to overturn the Affordable Care Act, enacted in 2010 as a primary objective of former President Barack Obama. The measure has reduced the number of Americans without health insurance, but critics say it has resulted in higher insurance premiums and created a network of government-subsidized health care that is economically unsustainable. Detractors also dislike a provision that requires all Americans to buy insurance or pay a fine, although those with low incomes are exempt.

The House narrowly passed the American Health Care Act in May without a single “yes” vote from Democrats. Reps. Dennis Ross, R-Lakeland, and Tom Rooney, R-Okeechobee, voted for the bill.

Republican leaders in the Senate spent weeks privately drafting a companion bill, the Better Care Reconciliation Act, and unveiled it June 22. Senate Majority Leader Mitch McConnell pushed for a vote before the July 4 recess but delayed action when it became apparent Republicans did not have enough votes for passage. All Senate Democrats have expressed opposition.

The Congressional Budget Office, a nonpartisan agency that assesses major bills, released an analysis predicting the Senate bill would result in 22 million more Americans without health insurance by 2026.

The Senate bill would cut federal spending on Medicaid by $772 billion over a decade, according to news reports. The CBO has said the House bill would slash Medicaid spending by $834 billion over the same period. The two bills would have to be reconciled before becoming law.

Medicaid is a federal-state partnership that provides health insurance for three low-income groups: children and their parents, the elderly and those with disabilities.

The Affordable Care Act, commonly called Obamacare, created a funding pool for states that chose to expand their Medicaid programs. Thirty-two states did so, but Florida Gov. Rick Scott chose not to expand Florida’s Medicaid coverage.

Wary about cutting

The proposed reduction in Medicaid funding worries Bill Gardam, president and CEO of Peace River Center, a Bartow-based nonprofit that provides behavioral health care. He said most Peace River Center patients are on Medicaid.

“Any time there is a limitation on access to care and eligibility for care and capping benefits to care, I have concerns,” Gardam said.

President Donald Trump and many Republicans in Congress have argued that the Affordable Care Act is failing and must be replaced. Thompson doesn’t agree.

“I haven’t really seen where it has failed in that data,” Thompson said, pointing to several pages of charts she shared with The Ledger detailing trends in health care. “What we’re seeing is we have the highest rate of people covered in the country and we’ve bended the cost curve in really significant ways in a short period of time.”

As to the criticism that Obamacare has brought higher insurance deductible costs for many Americans, Thompson said though some have seen their deductibles rise, the overall costs of health care have remained flat since the law’s passage. She said costs had been rising dramatically in the years before the ACA took effect.

Thompson and Michael Spake, LRH’s vice president of external affairs, offered a detailed critique of the Republican proposals. Citing the CBO estimate that 22 million fewer Americans would have coverage under the Senate plan, Thompson said that amounts to the populations of Alaska, Delaware, Hawaii, Idaho, Kansas, Nebraska, New Mexico, South Dakota, Montana, North Dakota, New Hampshire, Maine, Rhode Island and West Virginia.

“Let’s not see how many people we can kick off to save money,” Thompson said. “Let’s talk about what’s the most cost-effective way we can have total coverage.”

The LRH executives expressed deep concern about the potential reduction in Medicaid spending. Thompson said the cuts would indirectly affect even those who aren’t on Medicaid.

LRH is required to treat everyone regardless of ability to pay, and if patients who previously had Medicaid lose that coverage, the hospital must spread the costs to everyone else. Thompson said Medicaid funding goes into a pool of money the LRH system relies upon to function.

Florida has been reducing its contribution to Medicaid in recent years, Thompson said, including an $8 million cut in the recently passed budget.

“Our hospital is under a huge burden right now because of what the state has done,” she said. “We don’t have Medicaid floors; once you come into our hospital, every person has to be treated exactly the same. ... So if you take $8 million away from the bucket of money, well, the nurse-to-patient ratio could change here, not just for Medicaid (patients).”

LRH’s emergency department sees about 215,000 patients a year. That makes it the busiest single-site emergency department in the country, according to government statistics.

Negative effects?

Though Lakeland Regional Health is a non-profit system, the executives said it faces the same financial pressures as for-profit centers. Hospitals are considered financially healthy if they have operating margins of at least 4 percent, Spake said, and LRH is “right at that line.”

Among other benefits, he said, having a healthy margin allows LRH to upgrade medical equipment as technology improves.

And if the Republican plans were to take effect?

“I think what you would see is just a very gradual degrading of that, to the point there’s an inability to reinvest in the hospital. And so with the degrading of your operating income, you would have a degradation of your quality as well,” Spake said.

Any decrease in levels of health-insurance coverage would mean less preventive care for people who can’t afford it, Thompson said. Without preventive care, she said, minor health issues or manageable chronic conditions such as diabetes can yield medical emergencies.

And it’s much more expensive to treat urgent conditions than to manage minor or chronic ones, Thompson said.

“If anything, you will have more uninsured people that will seek care in the emergency department,” she said. “It makes no cognitive sense. Even when I sit with Republican leaders and connect these dots, they agree it makes no sense but (say), ‘We have to repeal Obamacare,’ and you say, ‘Why?’ What trend are they watching?”

Gardam said that dynamic also applies to people with mental illness or substance-abuse problems. He said he worries the Republican plans will reduce access to treatment for those conditions.

“We already know what’s going to happen,” Gardam said. “We know the emergency rooms are going to be filled. We know law enforcement is going to be even more busy than they already are helping us deal with substance-abuse problems.”

Rising care costs?

The Republican plans would increase health-care costs for Americans in the 50-to-64 age group. Obamacare includes provisions intended to limit variations in premium costs among people of different ages, setting a 3-to-1 ratio between costs for young, low-risk adults and older enrollees.

The Republican House and Senate plans would change that ratio to 5-to-1, meaning insurance rates would go up for older Americans not yet eligible for Medicaid. The likely result, Spake said, is that many in that age bracket would forego basic and preventive care, leading to more urgent problems that cost more to treat.

He gave the example of someone skipping colonoscopies, which are generally recommended starting at age 50. Instead of having a polyp removed in the early stages, a patient might wind up with stage-three colon cancer and require much more extensive treatment.

“Without that access, they don’t get those services and they come into our emergency department,” Spake said. “We’re treating a sicker person who needs an enormous amount of services and then also needs an enormous amount of follow-up care.”

And when hospital patients can’t afford to pay their bills, the costs are passed along to all patients, he said. In general, he said, lack of coverage for one population group creates “a very large snowball of cost shifting,” as health-care becomes more expensive for everyone.

Gardam said the Republican plans could also change policies on types of coverage required for the government-run plans. Under Obamacare, policies sold to individuals and small groups must include such 10 “essential health benefits,” including pediatric care, maternity care, hospitalization, preventive services and mental-health and addiction treatment.

The Senate bill would eliminate those mandates, allowing states to decide what coverage insurers must offer, according to media reports.

“Within the behavioral health field, for most of our clients it’s about consistency of therapy, consistency of medication,” Gardam said. “That provides care and stability in people’s lives so they can function. Anything that affects that could be very disruptive to those patients and their families and the community.”

Awaiting details

Hospitals in Bartow and Winter Haven are part of BayCare Medical Group. Keri Eisenbeis, BayCare’s director of government relations and community outreach, provided this statement:

“BayCare is very concerned about the potential impact of the Senate health reform legislation on the communities we serve. As currently written, the bill weakens health coverage for low-income Floridians, reduces Medicaid funding, and makes essential health benefits optional for states. We hope the Senate will consider the impact of these issues on our state and address them before moving forward.”

Spokespeople from Lake Wales Medical Center and Heart of Florida Regional Medical Center in Haines City referred The Ledger to the Florida Hospital Association. The organization did not respond to a message left Thursday.

A spokeswoman for Watson Clinic in Lakeland did not respond to interview requests.

Tri-County Human Services, a nonprofit organization based in Lakeland, provides treatment for mental illness and addiction in Polk, Hardee and Highlands counties. CEO Bob Rihn said he isn’t sure what effect the Republican plans would have on the organization.

“Essentially, it’s difficult to determine the impact at the levels we’re providing services because the details have not been rolled out,” Rihn said.

A large percentage of patients Tri-County sees are on Medicaid, Rihn said.

“It’s quite concerning based on what I’m seeing from the national media that the amount of funds that will be impacted is significant,” Rihn said, “but again, without having numbers on how this is specifically related to Florida as it rolls down to us, it becomes a problem in trying to discern how significantly it will impact us.”

The Affordable Care Act created insurance exchanges through which people who don’t receive employer-provided insurance and are not on Medicaid can buy coverage. The Senate plan would retain the government-run program, though subsidies would change.

Rihn said Tri-County sees “very few” patients covered by such plans.

“The whole issue of equal access to mental health and substance abuse vs. (other) health care has been a longstanding issue,” Rihn said. “That was to be addressed over the past several years (under Obamacare), but that hasn’t been addressed effectively.”

Cynthia Ritter, president of the Polk County Advanced Practice Nurses Association, said her organization objects to any policy changes that reduce access to medical care.

“We currently haven’t taken a position on it,” said Ritter, a nurse practitioner at Bond Clinic in Winter Haven. “This has just now obviously come to the forefront, so we haven’t had the opportunity to sit down and brainstorm as group, but I think we all (believe) patients need access to care.”