Bobby Redwood, MD, MPH
Wisconsin emergency physicians should be leery of the U.S. Senate’s latest version of The Better Care Reconciliation Act (BCRA). Stripping away the loaded messaging from the special interest groups and the political baggage that haunts the Affordable Care Act (ACA), what the Senate has proposed is a bill that will deliver a triple blow to emergency medicine in Wisconsin. Stated simply, passing the BCRA will have a negative impact on our patients, our profession, and our physician workforce.
Painful Cuts for Patients: With the BCRA, our patients are definitely being forced to take their medicine (and there is no spoonful of sugar to help it all go down). Tax credits for out-of-pocket expenses will be phased out by 2019, insurers can charge older patients up to five times as much as younger patients, and annual/lifetime limits on individual coverage are coming back. Furthermore, patients will again have the option to buy what Kaiser Health News calls “junk insurance” (low cost, minimal coverage plans that were eliminated under the ACA). Oh, and guess what, the BCRA eliminates the individual mandate, so all those invincible young patients coming in with mental health crises, overdoses, and traumatic injuries will no longer be obligated to have insurance, but EMTALA will still require emergency physicians to provide their uncompensated care. The congressional budget office sums up this can of worms quite nicely, estimating that the BCRA will eliminate insurance coverage for more than 20 million people over the next decade and Wisconsin’s hit would be 394,100 newly uninsured patients.
Painful Cuts for Emergency Department Revenue: Since Wisconsin has a thriving, diverse payer mix; the best course for our state would be to reform the ACA, rather than repeal it, so that even more Wisconsinites can have access to private insurance plans. Wisconsin is already worst in the nation in terms of Medicaid reimbursement*, compensating emergency physicians just $37.77 for a level 5 visit (compared to Medicare’s $169.14 for a level 5 visit). The changes proposed by the BCRA will distribute federal Medicaid funds to the states based on a capped, per-capita or block grant basis. Our state government has already shown us how much they value our work…what will happen to emergency department and emergency physician compensation under the (presumed) cuts of a block grant system?
Painful New Realities for Practicing Emergency Physicians: For the 99% of us who are not policy wonks, how will the BCRA affect our daily workflow in the emergency department? For starters, an greater underinsured population will equate to more challenges securing inpatient psychiatric beds, so expect those mental health boarding times to increase. Blocking federal payments to Planned Parenthood will decrease young women’s access to contraception, HPV vaccines, cervical cancer screening, and prenatal care; so expect more pelvic exams, more abnormal findings on pelvic exams, and more pregnancy complications. Some of those patients who were briefly insured under the ACA, but have since lost coverage, will be turning to the ED to manage their recently discovered chronic health conditions and lets not forget the return of lifetime limits on individual coverage. “I’m sorry Mrs. Smith, you reached your coverage limit with your last cardiac stent, how about this DNR paperwork instead?” If the BCRA passes, I sincerely hope you compensation is not tied to patient satisfaction, because we are going to be seeing a lot of unhappy individuals under this substandard attempt at health insurance reform.
National ACEP has already weighed in, warning that “the BCRA would allow insurance companies to offer skimpy plans that offer no essential benefits coverage to consumers” and that “the consequences for emergency patients could be devastating.” I agree and would add that the consequences for Wisconsin will be particularly jarring for our state’s patients, profession, and physician workforce. Tammy Baldwin is a vocal opponent of the BCRA, but Ron Johnson is still on the fence.
Tell Ron Johnson to vote "NO" on the BCRA:
*WACEP is working hard to improve this dismal statistic.