Stark Consequences for Low-Income Patients in New York if Affordable Care Act is Repealed, Says Panel

Congressional staffer, Greater New York Hospital Association president, and healthcare leaders from NYU Langone and NYC Health+Hospitals share perspectives

Wednesday, April 19 2017

With uncertainty surrounding the fate of the Affordable Care Act, the Department of Population Health hosted a panel on April 12, about how repeal of the landmark healthcare law would impact vulnerable populations in New York City.

While acknowledging flaws in the 2010 legislation, the panel agreed that repeal could cause low income and other New Yorkers who benefited from the ACA’s expansion of Medicaid coverage and subsidies for purchasing insurance to lose benefits, or insurance coverage altogether.

The panel was moderated by Joseph J. Lhota, senior vice president, vice dean, and chief of staff at NYU Langone Medical Center and included Nicole Cohen, senior caucus policy advisor for U.S. Representative Joe Crowley, a Democrat from New York and Chairman of the House Democratic Caucus; Larry K. McReynolds, executive director of the Family Health Centers at NYU Langone; Kenneth E. Raske, president of the Greater New York Hospital Association (GNYHA); and Andrew B. Wallach, MD, clinical director of Ambulatory Care and chief of General Internal Medicine at NYC Health + Hospitals/Bellevue.

From left: Joseph Lhota, Nicole Cohen, Larry McReynolds, Andrew Wallach, Kenneth Raske
From left: Joseph Lhota, Nicole Cohen, Larry McReynolds, Andrew Wallach, Kenneth Raske

The event is part of a “Controversies in Population Health” series directed by Mark Schwartz, MD, professor in the Departments of Population Health and Medicine, who said that the future of the ACA is an important issue for the NYU Langone community: “Many of our faculty, staff, housestaff, and students are anxious about maintaining access to high quality health care for the populations we serve in New York City given the health policy changes being considered in Washington.”

Weighing the Consequences
Panelists said an ACA repeal with a replacement similar to the Republicans’ American Health Care Act could have several impacts on low-income patients and healthcare systems:

  • Loss of Coverage: “The level of coverage expansion [under the ACA] has been extraordinary,” said Raske, who participated in drafting the law. “Around 2.7 million New Yorkers got covered through Medicaid and health insurance. That’s 2.7 million families that can sleep well at night.”
    Millions of kids on Medicaid nationwide could lose insurance if there were cuts, which would affect their health and, by extension, school attendance and general well-being, said McReynolds. The Family Health Centers at NYU Langone include 22 clinics based in public schools, which provide primary care to students in underserved areas.
  • Focus on Prevention and Outpatient Care Could Lose Steam: Loss of insurance coverage can affect how early patients seek care. NYC Health+Hospitals has seen a six-percent drop in visits to its emergency department at the same time its percentage of uninsured adults declined from 34 to 30 percent, according to Dr. Wallach. “More and more people are coming in early. We’re able to shift our focus to preventative care, taking care of patients, keeping them healthy, keeping them out of the hospital,” he said. 
    Moderator Joseph Lhota addresses the audience
    Moderator Joseph J. Lhota addresses the audience

    Having insurance coverage and free preventive coverage has meant a “cultural shift” for many patients said McReynolds. “A lot of people thought, ‘Well, I don't need to go to the doctor because I’m not sick.’ It took a long time to teach people that you go to the doctor when you’re well.”  

    But this shift to preventive care could lapse, panelists said, if ACA repeal led to less funding and fewer incentives for healthcare systems to focus on preventive, primary care based in communities.

    In New York State, the ACA made possible the Delivery System Reform Incentive Payment Program, which aims to reduce avoidable hospital use by paying healthcare systems and community-based organizations to achieve predefined population health goals. As a result, systems like the Family Health Centers at NYU Langone have been able to focus more on community, rather than institution-based care, said McReynolds.

  • Budgetary Shortfalls: If the federal government-supported Medicaid expansion was cut back, as it would have been if the Republican American Health Care Act passed, “We would face worsening budget deficits while at the same time having to provide care for a larger cohort of patients,” said Dr. Wallach. A large volume of safety net hospitals’ patients come from Medicaid, the program created in 1965 for low-income Americans who can’t afford healthcare. Repeal would thus pose significant financial problems for the healthcare systems that serve these patients, said panelists. Cuts to Medicaid would also hit states, which, because of their own financial stresses, would be hard-pressed to make up for the loss of federal support.


Is Healthcare a Right?
Lhota kicked off the panel by revisiting the national debate over healthcare reform, which began in the early 20th century. Battles over healthcare, from the Truman to the Nixon to the Clinton administrations, have centered on whether or not healthcare is a right.

President Barack Obama believed the answer was yes, but he decided to let Congress do the job of drafting the ACA, which is now associated with his name—Obamacare.

“What people don’t realize is there is no single thing called Obamacare,” said Cohen. “It’s not like Medicare where there’s one single program or policy for everyone. If anything, Obamacare is the concept of having insurance.”

The two major achievements of the ACA were making it easier for people to buy health insurance if they did not get it through their job and setting standards on insurance, such as requiring maternity care coverage, Cohen added.

“I look at the ACA as being both aspirational, and, as President Obama said, it is not a perfect law, it is an imperfect law,” said Lhota.

The Future of the ACA

If the ACA is repealed, some of the changes brought on by the law will continue, such as the move to electronic health records, and investment in ambulatory care, speakers said.

“A lot of people in Congress have realized it is hard to replace,” said Cohen. “The reason why the ACA turned out the way it did is the pieces fit together a certain way,” she added.

For doctors and medical students who want to advocate a position on the ACA’s future, Cohen urged them to contact their representatives: “Policymakers really do appreciate hearing the lived experiences of patients and of providers.”

--Elaine Meyer