As another ACA repeal looms in the near future — after ACHA and BCRA — the Graham-Cassidy-Heller-Johnson (Graham-Cassidy) legislation makes me think back to a patient I took care of a few months ago.
Months into my third-year rotations, I was offered a women’s health selective that took me to a more rural part of North Carolina. The free clinic in this area primarily served as a comprehensive women’s health provider. The women we saw at this clinic were mostly young, had small children, came from low-income backgrounds and used the clinic as a primary care home for their health care needs. With a team of nurses, physicians, as well as a nutritionist and social worker, this was a one-stop shop for many by providing STI testing, cancer screening, HPV vaccinations and contraceptive counseling.
My patient was 19, working a minimum wage job while going to a local college. She had many preexisting conditions, some a manifestation of her lifestyle and others simply bad luck. On top of these preexisting conditions, she was married, had one child and pregnant with another. She desperately wanted an IUD. She refused to talk about birth control options with her husband because she was afraid of what he might say.
Looking over her chart and speaking with her throughout this visit, it was clear that many of her current health issues could have been avoided with the right preventive services. Risk-reduction through these services could have led to different outcomes in her health narrative.
Graham-Cassidy moves the scale over in the wrong direction. It will harm the most vulnerable patients we care for. It is the opposite of “first do no harm.” And here’s how the newest repeal without an appropriate replacement plan wants to do it.
In North Carolina, where this patient lives, the Kaiser Family Foundation estimates that in 2016 Medicaid paid for 54% of births. Nationwide, the numbers are similar — half of all U.S. births are Medicaid funded. The counterargument typically seems to be, “Stop having children you can’t pay for and afford.” Sure, that’s easy to say, but what about this patient, who was fearful of telling her partner, who provided most of the household income for her and her children. Without him, she couldn’t afford oral contraceptive. Hence, we made numerous phone calls on her behalf to see if we could jump through hoops and prior authorizations to get her an IUD for a lower cost or for free.
Graham-Cassidy’s proposed Medicaid cuts would disproportionality affect pregnant women and women of reproductive age. Starting in 2020, Graham-Cassidy proposed to cap the federal government’s contribution on Medicaid and contribution would not increase based on need, but on economics. This is similar to the ACHA’s proposed per capita cap.
In addition, Graham-Cassidy would get rid of pre-existing conditions, an idea that has largely stayed unpopular in the public through these repeal-and-replace efforts. What is truly concerning is that the bill doesn’t delineate how states would provide coverage to people with pre-existing conditions. States would have the individual option of undercutting protections for whatever conditions they deemed were not covered.
Insurers would legally be able to deny coverage for selected health needs including maternity care, mental health services, prescription drugs and substance abuse treatment. Prevention and risk-reduction are tenets of health care. The Affordable Care Act established the Prevention and Public Health Fund, as the first-ever mandatory funded focus on public health and prevention. Graham-Cassidy would gut that program, continuing America on its rocky path to sick-care.
Graham-Cassidy also plans to defund Planned Parenthood over the single issue of abortion. Like the clinic I worked in, Planned Parenthood is a comprehensive, affordable reproductive health provider for women. Due to federal regulations, Planned Parenthood does not use federal money for abortions as it stands. It does, however, provide services to women who would otherwise not seek care at all. We risk people making the choice to not seek out care at earlier stages of a problem that is easier to manage and will cost less health care dollars.
While health care in our country is such a complicated amalgam, it is prudent that our lawmakers listen to people on the front lines — the clinical providers, researchers and administrators who work within this system on a daily basis. It says something that the American Medical Association, American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the National Association of Medicaid Directors, direct insurers, medical students and individual health care providers are all vehemently opposing this bill. As future health care providers, medical trainees will have to bear the burden of what our laws dictate about what we can do for our patients. It’s already apparent that much of direct patient care as it is practiced is widely influenced by the national stage.
Graham-Cassidy is the latest, but it is probably not the last. There is not a shred of evidence that this is an appropriate replacement for the ACA.
It is with great privilege, ignorance and a lack of judgment that a replacement plan would be ushered through without due diligence for the sake of political gain. We all share the very human burden of sickness and illness. We are all patients at one time or another. The patient I worked with above could be anyone in any state in this country. She is not an anomaly or political prop. And we owe it to her and all our patients to oppose Graham-Cassidy and any future ACA replacement that does not put preventive medicine at the forefront. Sick care is not the future of a sustainable health care system.