“An Amazing Moment of Profound Uncertainty” The Post Obamacare Future for Chicago’s Sickest Citizens

Dr. Harold Pollack is among the nation’s leading experts on health policy. Along with being the Helen Ross Professor at the University of Chicago’s School of Social Service, he is the co-director of the University’s Crime Lab, a former chair of the University’s Center for Health Administration Studies, and a widely published author specializing in the intersection of healthcare and poverty.

When asked about the future of the Affordable Care Act, President Obama’s signature healthcare reform, he let out an audible groan.

Pollack’s response is far from unique. As the first Republican-led government in a decade enters its third week of legislation, health-care in America faces, in Pollack’s words, an “amazing moment of profound uncertainty.” And for some of Chicago’s most at-risk citizens, this uncertainty could have dire consequences.

The ACA’s protection for individuals with pre-existing conditions, i.e., conditions that put an individual at a higher risk of needing medical care, is among its most popular and successful accomplishments. Its so-called “prohibition of pre-existing conditions exclusion” ensures, in its own words, that “health insurance companies can’t refuse to cover you or charge you more” based on your medical history. While the full effects of this reform are hard to quantify, it has been undeniably monumental. A recent study by the Kaiser Family Foundation found that 27 percent of all Americans have conditions which “would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices.” In Illinois alone, the study estimates that over two million individuals would be without insurance were it not for this protection.

While Donald Trump and his administration have promised to maintain this protection for individuals with pre-existing conditions, many experts fear that their intended reforms for Medicaid and the individual mandate will make that promise impossible to keep. Among those experts is Pollack, who has not shied away from expressing this sentiment since the election. In an interview with the Huffington Post last month, when asked about President-elect Trump’s promise to repeal the ACA’s individual mandate but keep its pre-existing condition protection, he remarked, “If you could do the popular parts without the unpopular parts, people would already have done it.” When asked to clarify his comment, he offered a more measured response. Pointing out that insurance companies need a large pool of healthy individuals to offset the cost of the medically complex, he observed that “to the extent that you could [do without the individual mandate], you would need to make insurance so affordable that people naturally complied,” through “higher subsidies” provided to those buying insurance on the private market. As Republicans have been a vocal critic of the ACA’s subsidies since 2011, Pollack concluded, once again, that “I don’t think there is a way.”  

Barbara Otto, the head of Health and Disability Advocates, a patient advocacy group located in downtown Chicago, shared many of Pollack’s concerns, telling the Gate that she fears House Republicans will repeal the measure and re-introduce high-risk pools as an alternative to cover the medically complex. High-risk pools, which lump together individuals with expensive pre-existing conditions into a single plan, have been supported by Republicans for decades as a method of covering medically complex patients. However, they have also been criticized by numerous health experts as expensive for administrators and enrollees alike and prone to providing poor care. Otto shared this sentiment, affirming that  “the concept of health insurance only works if everybody’s in one pool,” before candidly remarking “I worry that … the unintentional consequence of trying to throw red meat to your base and say you repealed the ACA will be a healthcare ghetto for these people with pre-existing conditions.” Cynthia Cox, associate director at the Kaiser Family Foundation and co-author of their aforementioned study on medical underwriting, similarly told the Gate that she believes the individual mandate is “likely the first thing to go”, and its removal will result in the re-introduction of high-risk pools. She went on to assert that “if these high-risk pools aren’t funded well enough, [there] is no guarantee of access to coverage, especially for low-income people.” Both Otto and Cox have thus far seemed prescient: in a town-hall interview with CNN last Thursday, House Speaker Paul Ryan voiced his support for high-risk pools as a “smarter way of guaranteeing coverage for people with pre-existing conditions.”

In addition to the individual mandate, many experts fear that the Republican Party’s proposed reforms to Medicaid could also harm medically complex patients who receive coverage through the program. Along with potentially repealing the ACA’s Medicaid expansion, which has covered an additional eighteen million individuals nationwide (five hundred thousand in Illinois alone), many House Republicans have pushed for block-granting the Medicaid system. Perhaps none are more fervent than Ryan, who has supported the idea since his 2011 budget proposal and made it a central feature of his recent “Better Way” health-care alternative this past summer. Block granting, or giving states a set dollar amount to provide low-income coverage rather than matching a percentage of their Medicaid expenditures, is praised by its proponents as a way of cutting federal costs and giving states the flexibility to design their own Medicaid programs. However, critics say that such a system is ineffective and harmful to enrollees, pointing to Native American tribal lands, which currently operate under a block grant for Medicaid, as an example of their failure to provide adequate care and resources.  

Pollack expressed vehement opposition to such a system, remarking that it “creates fundamental incentives to constrain resources,” especially as they relate to the medically complex who are “often the main drain” on Medicaid programs. He went on to state that such programs remove accountability, as states are able to defend cuts by telling residents they don’t have enough federal funds, and the federal government is able to blame states for inefficient spending. Otto concurred with this view, remarking that “I don’t want to see states weakened” in their ability to provide low-income coverage. Similarly, Cox fears that under a block grant “states could have an incentive to reduce Medicaid benefits, or … make it difficult for people with complex needs to enroll in the program.”

While the impact of these proposed changes on Illinois is hard to predict, it will likely be substantial. According to the Illinois Department of Public Health’s most recent publicly available data, there are 670,000 Illinois residents with chronic diseases that have required hospital care in the past five years. Perhaps more concerningly, 136,000 of them live in zip codes where the annual median income is below $40,000, with 20,000 living on the South Side of Chicago alone. As chronic diseases which require hospitalization are among the most damaging pre-existing conditions, it is likely that a large number of these individuals would either struggle to find health coverage or be forced into high-risk pools if the proposed Republican reforms took effect. Moreover, according to Illinois’s Health and Family Service’s Medicaid data, there are 123,000 Medicaid enrollees with disabilities in Cook County alone. As Cox observed, these enrollees could face cuts to services and higher costs under a potential block grant system. According to Pollack, all this means that if the proposed reforms took effect, “there really will be poor people and disabled people who are horribly hurt.”

For now, however, the healthcare world is forced to wait and see. As congressional Republicans take their first steps towards an ACA repeal, approving a budget last Thursday that allows them to attack the law without the threat of a Democratic filibuster, experts, insurers, and enrollees alike, watch on with bated breath. For Pollack, all that is clear is that “we are in uncharted waters in every sense of the word.” As he remarked to the Gate at the end of his interview, “I kind of trust President-elect Trump not to take away insurance from millions of people, and I kind of trust Speaker Ryan not to use the nuclear codes. The problem is the wrong person is in charge of both.”

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