Funding now expired, Georgia health care providers see impact

Steve Miracle stands in the parking lot of the Georgia Mountains Health clinic in Blue Ridge. on September 28 2017. Georgia Mountains Health provides health care at seven location including two in Blue Ridge, and about half of its patients have no insurance. The clinics are largely funded by a federal program established by President Lyndon B. Johnson as part of the War on Poverty. (Photo by Rebecca Breyer / special to the AJC)

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Steve Miracle stands in the parking lot of the Georgia Mountains Health clinic in Blue Ridge. on September 28 2017. Georgia Mountains Health provides health care at seven location including two in Blue Ridge, and about half of its patients have no insurance. The clinics are largely funded by a federal program established by President Lyndon B. Johnson as part of the War on Poverty. (Photo by Rebecca Breyer / special to the AJC)

In Washington this past week, lawmakers abandoned another all-out attempt to repeal Obamacare and then headed home to take stock.

Meanwhile in Georgia, a clinic network funded by regular federal grants halted replacement of badly needed dental chairs and stopped work on a planned contract to recruit a pediatrician.

A Houston County couple watched their health insurance crumble. The Georgia commissioner of community health drew up contingency plans.

All of that is happening here now because Congress — absorbed over the past few months in undoing the Affordable Care Act — has not approved funding for other long-standing, bipartisan health care programs that affect millions of patients and faced Sept. 30 expiration or crucial deadlines.

Those dates passed this past week.

The patients, insurers and caregivers affected are now seeing the consequences: in budgets that plan for drought and insurance premiums that assume fiscal turmoil. In the most recent blow, some Georgia customers of the Obamacare exchange learned their premiums will jump by more than half, with a large part of that purely due to federal uncertainty.

On many programs, lobbyists for health care providers are frantically pressing Congress about the now-lapsed authorizations, but leaders don’t appear to see it as an emergency. There’s some money left in the bank and checks may not start bouncing until the end of the calendar year.

“We have tried to get the attention of our elected officials and it’s just not on their radar,” Kevin Miracle said in desperation earlier this week. Miracle is the CEO of Georgia Mountains Health, part of a “community health center” program set up under President Lyndon Johnson’s War on Poverty. “You can see this ‘It’s not urgent til it’s urgent,’ ” he said. “But it has impact.”

Miracle said he had seen funding battles push uncomfortably close to the deadline before, leaving only months to spare. But nothing like this.

“This fiscal cliff thing,” he said, “we haven’t faced it in the way we’re facing it this time.”

A start

Health officials worry about a handful of programs with deadlines just passed.

  • Community Health Center subsidies such as Miracle's fund 35 centers in Georgia with about $86 million a year, perhaps 70 percent of which was cut. Nationally, the program is facing a $3.6 billion cut, and that cut will be distributed among the states.
  • Subsidies for rural hospitals, called "rural extenders," have expired to the tune of at least $11.7 million in this state this coming year. The small facilities say that represents a large portion of their bottom lines.
  • Subsidies for hospitals that treat a disproportionate share of indigent patients, such as Grady Memorial Hospital, are cut by $49 million in Georgia for the coming year. The figure depends on changing variables but is to expand to approximately $149 million by 2025.
  • Subsidies for working-class kids, called the Children's Health Insurance Program nationally and PeachCare in Georgia, face cuts of $427 million in Georgia this year.
  • In addition, some companies offering policies on the Obamacare exchange market said they raised rates and pulled back coverage because of uncertainty about federal subsidies for lower-income customers.

The impact of the inaction is already felt deeply not only in businesses but in state government, where officials don’t know what to plan for.

Renee Unterman, R-Buford, the chairwoman of the state’s Senate Health and Human Services Committee, said she was on the phone daily with lobbyists and fellow state officials about the millions of dollars state health care providers and patients potentially stand to lose.

“Every single day that’s all we think about,” she said. “Because if the state has to cough up the money, it’s not a little bit of money. It’s millions and millions of dollars.”

Georgia Department of Community Health Commissioner Frank Berry said his department has made preparations to take up the gaps in care wherever it can.

“We’re looking at all options,” Berry said. But he knows there are limits.

“It’s a real concern,” he added. “If we lose potentially millions — hundreds of millions — of dollars of federal funds, it will have an impact on Georgia.”

Gov. Nathan Deal’s chief of staff, Chris Riley, said the governor “is confident that Congress will meet its obligations and reauthorize the CHIP program and not place hundreds of thousands of Georgians in jeopardy.” He did not address the other lapsed programs.

Some, but not all, of the federal programs are expected to be taken up starting in a U.S. House hearing in the coming week.

Lobbyists and congressional staffers, who asked not to be identified in order to speak freely, said in interviews this week that the GOP’s various attempts to scrap the 2010 Obamacare law sucked away much of the energy and attention on Capitol Hill in recent months, making it hard to advance any other health care policies.

That extended even to the bipartisan ones, such as CHIP. It expired Sept. 30.

CHIP is the headline program to be considered for renewal in a negotiation hearing the coming week, along with community health centers such as Miracle’s and “other important public health priorities,” according to the hearing announcement.

U.S. Senate Finance Chairman Orrin Hatch, R-Utah, also said the programs were a priority. “We just have to find the time to do it,” he said.

“It should be done by the end of the month. But if not, they still have enough money to keep going,” he said of the CHIP program. Hatch negotiated a compromise to extend the program for five years with his Democratic counterpart last month, only to see it moved to the back burner as the chamber tried one last time to repeal Obamacare.

The inaction so far on CHIP may not make an impact on Georgia for several more months. The state’s PeachCare Program is estimated to have the longest runway to bankruptcy of the endangered programs, likely running out of cash in the spring.

Lawrenceville Republican Congressman Rob Woodall described his party’s health care strategy in terms of most pressing deadlines. The GOP’s filibuster-proof bill to repeal Obamacare had a hard deadline of Sept. 30, compared with other health care programs’ squishier ones.

“There’s no debate going on in the (House) Energy and Commerce Committee about whether or not CHIP or (funding for community health centers) continues,” Woodall said. “Of course they’re going to continue.”

“But with all the items lined up in the queue, if the dollars don’t actually run out for another quarter … I can understand (how) they have a little less urgency than those things that are happening today,” Woodall added.

Spend the money, hope for reimbursement

There’s been no announcement about some other programs.

Hospitals that treat a disproportionate share of the poor are particularly concerned. They benefit from a federal program called DSH, or Disproportionate Share Hospital grants. A long-planned funding cut is scheduled to go into place Sunday, and there's been no mention on Capitol Hill about staving off the cuts as they have three times before.

The omission of DSH is somewhat mysterious, since there appears to be little opposition to saving the program, particularly since many rural hospitals and GOP states that did not expand Medicaid rely on it. Lingering anger at the hospital industry for rejecting the GOP’s Obamacare replacement plans — several of which included language warding off the DSH cuts — is playing a role, one lobbyist said.

Others pointed to difficulties finding potential spending cuts, $2 billion worth, to offset the cost of maintaining the current level of DSH payments.

In any case, congressional aides said that DSH largely should not be a worry until the end of the year, since that’s when states will submit their expenses to the federal government to be reimbursed; it is only after Dec. 31 that the true impacts of not having reauthorized the program on time will be felt, they said. So, should Congress decide to stop the impending DSH cuts before then, hospitals will be able to be reimbursed as usual.

DSH advocates scrambled into the weekend to get language reauthorizing the program onto the relevant House committee’s agenda in the coming week. If they failed, they worried they would not have another chance until December.

Separately, U.S. Sen. Johnny Isakson of Georgia said he was working to attach DSH money onto other legislation moving through the Senate so that “it doesn’t hurt our hospitals.”

Meanwhile, more than 220 members of the House — representing more than half the chamber — wrote Thursday to leaders of both parties urging that the House act swiftly to delay the DSH cuts for at least two years or until a more permanent solution can be found.

"Our nation's hospitals cannot sustain losses of this magnitude," the lawmakers wrote. "Institutions will be forced to shutter, leaving our constituents without a safety net."

Five Georgia lawmakers — Democrats John Lewis, Hank Johnson, David Scott and Sanford Bishop, and Evans Republican Rick Allen — signed onto the letter.

Allen told The Atlanta Journal-Constitution that he signed because of the rural hospitals in his district. They also face cuts from “rural extenders,” grant programs for small rural hospitals.

“I won’t let Washington forget about the rural communities that are the heart of my district,” Allen said. He called them “a lifeline” and added, “they deserve better.”

“The ambiguity is devastating”

Action now is somewhat late for many customers of Georgia’s Obamacare health insurance exchange market. Congress and the White House have cast uncertainty month to month over whether to pay certain “cost-sharing subsidies” that the government pays monthly to help the market work. So much uncertainty, that at least one insurance company has raised its rates and pulled back its coverage area, saying it did so as a result.

Washington got no savings in return for the turmoil; it has still paid the subsidies every month so far. In the case of the biggest company, Blue Cross Blue Shield of Georgia, the Georgia Department of Insurance and Blue Cross made clear that the massive rate hikes for next year averaging 57.5 percent were specifically due in part to the uncertainty, and that they will take place even if things continue as they are now, with the White House paying the subsidies regularly but under a cloud of uncertainty.

Lower rates may take their place at Blue Cross only if Congress appropriates the subsidy money by law, the insurance officials said.

Chris Johnson and his wife in Houston County already have a $774-a-month premium to Blue Cross. The hikes announced Wednesday would make Johnson’s family premiums “what, $1,300?” he laughed, bitterly. They started out years ago at an affordable $300-some a month, Johnson said. His deductible is now $13,000 annually.

Republican U.S. Sen. Lamar Alexander of Tennessee convened a bipartisan committee a couple of weeks ago to give that certainty to the subsidies and stabilize the insurance market. But in the face of the furor over the Obamacare repeal bill, Republicans walked away. This past week Alexander went back to work on it.

But some rates are still going to stay higher than they would have been before all the uncertainty, according to insurance company filings. Even if Alexander leads his colleagues to a deal and they deliver an appropriation with certainty for the subsidies, Blue Cross’ rates will see an average price increase of 40.6 percent. Blue Cross said this summer that that rate baked in the uncertainty thus far.

Johnson won’t exactly say he’s disappointed it got to this point. “I guess the thing is I don’t expect anything of them whatsoever,” he said. “They have completely fulfilled my expectation.”

He just can’t believe the federal strategy is this bad.

“This is a game to them,” Johnson said. “They have decent health care. They don’t have a human face on this issue. It’s all dollars and politics and power.”

On the state level, the Legislature might be able to replace some of the federal money, but at great cost, Unterman said.

“The fiscal part of it has huge implications,” she said. “Because then it bleeds over literally into education. The money is going to come from somewhere. Do you take it from public safety? Do you take it from roads? Do you take it from natural resources? Health care is a priority.”

Unterman asks one thing of Washington: “To have a plan of action.”

“To be definitive,” she said. “We’re either going to help you, or we’re not going to help you. The ambiguity is devastating.”

Staff writer Greg Bluestein contributed to this article.