Paul Hensler is certainly not alone in saying public health officials are "living in a time of incredible uncertainty."
As the CEO of Kern Medical Center, a county hospital in Bakersfield, Calif., Hensler says his top concern is not having to meet the raft of funded and unfunded federal mandates, or figuring out how make his institution financially sustainable during recessionary times. Rather, it's not knowing what the future holds – particular with regard to a pair of imminent, intertwined decisions: the forthcoming Supreme Court ruling on the Patient Protection and Affordable Care Act, and the November elections.
Government Health IT spoke with Hensler about that uncertainty, the potential for public hospitals such as Kern to gear up for Medicaid expansion only to be de-funded while still having to to take on just as many new patients, and how health insurance exchanges could be the back door into a single-payer system.
Q: As a public health center, what are your chief concerns right now?
A: The major concern is, first, what will the Supreme Court decide on health reform, and then, a few months later, what happens in the November election? With all the possible permutations of what the Supreme Court decides combined with which way the House, Senate, and White House go, we’re living in a time of incredible uncertainty about what’s going to happen to the healthcare system six months from now. That’s probably foremost in our mind.
Q: What about the Supreme Court case and the upcoming elections concerns you most?
A: Primarily the uncertainty. We can pretty much adapt to just about anything that happens, but when you don’t know what is going to happen, that is a whole lot more difficult – and the changes could be profound. We’ve gone down the road of planning that most of our uninsured patients will become insured. We need to be more competitive and have better patient satisfaction. We’ve been working hard to increase first-available appointments in our clinics, to be more accessible. If it turns out that we don’t get universal coverage, then we’ve built a more expensive system to take care of patients that still aren’t insured.
Q: It sounds as if, should the Supreme Court strike down the individual mandate, the Medicaid expansion provision or the entire ACA, you would still have a very similar situation, only without federal funding?
A: It depends on the scenario, but several possible scenarios look like that. In our geographical area, we’re heavy agriculture, a lot of our patients are not documented. Of course they’re not included under health reform, so even if it goes through as planned, they’re taking away a lot of the funds we receive for disproportionate share hospitals, safety net care pool funds, and things like that, under the assumption that everyone will be insured so it’s not necessary anymore. But we could very well end up losing all the funds for the uninsured and at the same time have uninsured.
[Podcast: The uncertain future of health insurance exchanges.]
Then off on the other extreme, one of my worries on the foreseeable horizon is personnel. The health care workers are aging and the population is aging so we’re going to end up with more patients for fewer healthcare workers. Then dumping a whole lot of previously uninsured people on the system who want to use their new insurance card, and even now there are fewer residency slots for graduating physicians than there are medical school graduates each year. So the whole health education and training is out of kilter with the demand.
Read the rest of our interview with Kern CEO Paul Hensler on the next page.
Q: The other aspect you touched on was the elections in November – Presidential, House and Senate. Presumably, if Obama is reelected, not a lot would change, but if Romney is elected he has been campaigning that he would offer states a waiver out of the health reform law on day one, and repeal thereafter.
A: Well, I think it’s one of those things that sounds like it’s easy to wave a magic pen at. The reality of it is that Medicaid, the state program, is so integrally interlinked with health reform that I don’t know if that’s even really an option. The Medicaid system is half funded by the federal government, so if a state decides it’s going its own way, it would have to come up with the other half. And I don’t think many – if any – states could realistically do that. There are parts of it like the health insurance exchange that some states have decided not to implement. Frankly, I think in the long run they’re short-changing their own citizens, but that’s their choice.
[Political Malpractice: They all chant 'ACA repeal' but what could a GOP president actually do?]
Q: The argument against a health insurance exchange, of course, tends to be more about federal overreach than whether standing up an HIX is best for citizens.
A: I think there are a lot of people out there with really simplistic answers to a phenomenally complex situation. And they don’t even know what they don’t know, which is dangerous, so you just hope at some point cooler heads prevail. I often hear really insane things coming out of people’s mouths and they have constituency groups behind them. So I guess crazy things could happen.
Q: And the Obama administration has done a poor job of explaining the benefits of health reform to the American public in a way that anyone not directly involved with healthcare can possibly understand.
A: Those of us who are directly involved don’t fully understand! [chuckling] And Nancy Pelosi admitted that they figured, "Let’s just get this bill passed, and then we’ll have time to read it." It’s nearly 3,000 pages of gobbledygook and every month we’ll get something from somebody about a new thing they found buried in the bill that is either good or bad for us. But I think that Congress and the President at the time decided they had a limited window of opportunity and they were just going to cram something through and then fix it later. That’s kind of where we are and I don’t think they expected the incredible opposition to come up from the other side of the aisle. And I don’t think they anticipated the Tea Party going off on the, "We just don’t want the federal government poking in our lives" routine. And the individual mandate, there’s a lot to that – should the federal government be able to tell you what you must buy? I can see points on both sides of that issue.
Q: Which makes it particularly interesting that states such as California and Vermont have proposed the move toward a statewide single-payer system, while others are so opposed.
A: I really think that the insurance exchange is a back door to single-payer. What I see happening over time, the way health reform is planned now, is the penalty payment for employers not offering health insurance is much lower than the cost of offering insurance. So I’m not surprised that small and mid-size companies are openly talking about just paying the penalty and not offering insurance. What’s really surprising is every now and then we hear from really large employers that are thinking the same thing. So, if a significant number of employers just decide to pay the fine, and that fine goes to funding the exchanges, pretty soon the only insurer left in the state will be the exchange. And we will have gone through the back door to a single-payer system.
Q: Much to many people’s chagrin, I suppose?
A: My only chagrin about it – it may very well be the right thing to do – but I don’t like it when policy is implemented in the middle of the night, or on a sneak attack. That’s something that should be up-front.
For more of our primaries coverage, visit Political Malpractice: Healthcare in the 2012 Election.
