Norra MacReady

June 13, 2017

SAN DIEGO — If the American Health Care Act of 2017 — passed by the House of Representatives in May as a replacement for the Affordable Care Act and currently wending its way through the Senate — is ultimately passed, there will be disastrous consequences for many people with diabetes, according to a presentation by experts here at the American Diabetes Association (ADA) 2017 Scientific Sessions.

When this new bill was approved by the House in May, "everybody in Washington was stunned. No one thought it would happen," Marc M Boutin, JD, the chief executive officer of the National Health Council — an advocacy organization which represents 133 million people with chronic conditions and their caregivers — told ADA meeting attendees.

But even after it passed, many observers assumed the new bill would not survive in the Senate. But now, after some tweaking and political deal making, there is a good chance that the Senate may pass the bill before the 4th of July, he explained.

In a packed session on "The Fate of the Affordable Care Act," Mr Boutin described some of the changes in the new law and how they may affect the diabetes patient population.

 "We find ourselves in a new world — there's a new balance of power," he told ADA attendees.

These changes could mean huge disruptions for patients: "We've got to represent our populations and speak up, because for some reason in this debate, the impact on real people is being lost. We're talking about the 23 million people who got expanded access to care [with the Affordable Care Act], and that can mean life or death for many of them."

Speaking to the potential impact of this change specifically on patients with diabetes was Alvin C Powers, MD, director of the division of diabetes and endocrinology, Vanderbilt University School of Medicine, Nashville, Tennessee, who is also president, medicine and science, of the American Diabetes Association.

Dr Powers warned that out-of-pocket costs for patients with diabetes could skyrocket, meaning a return to patients doing without medications and delaying care, and huge gains in preventive screening made during the years of the ACA could be undone.

Repeal and Reduce…

While the Affordable Care Act is by no means perfect, with affordability still a challenge for many people, there is no question that it has improved access to health services for millions of people, including many with chronic conditions such as diabetes, Mr Boutin said in his talk.

The current President and Congress have two major goals for a replacement healthcare bill: to lower costs, and to allow states more flexibility in determining what should be covered by Medicaid or private insurers. And in fact, a flexible approach can have some real benefits, as long as it is balanced by patient protections, he said.

The new law also would most likely eliminate the individual mandate. "We can probably live without that," he explained. "The evidence suggests that most of the people who entered the [insurance] marketplace did so because they received subsidies," rather than the requirements of the mandate.

Other cost-cutting measures, however, are much more concerning.

"The reductions in Medicaid coverage and spending are incredible."

In addition, the subsidies many people now receive to help them pay for their insurance premiums would essentially be eliminated.

"This is critical to the patient community, because the subsidies are what brought most of them into the healthcare marketplace," Mr Boutin pointed out.

Thanks to the subsidies provided by the Affordable Care Act, approximately 20 million people had access to healthcare for the first time. Without the subsidies, "you largely eliminate that affordability."

American Health Care Act Violates Fundamental Principle of Insurance

Of equal consternation to those with chronic conditions is a change in the "critical" accommodations for older or sicker people: under the American Health Care Act, those patients would have to pay more.

This violates one of the fundamental principles of insurance, which is to spread risk across a broad swath of the population, Mr Boutin explained. "By charging more to people who are older or have chronic health conditions, you eliminate that risk spread, and you dramatically increase costs."

In keeping with the mantra of more flexibility, the new law would also allow states to let insurers reduce coverage of certain essential health benefits, such as maternity services and emergency care.

This could send out-of-pocket costs skyrocketing, he warned.

This would present "a huge challenge" to patients because it would violate certain core principles that underlie the Affordable Care Act, such as nondiscrimination against people with preexisting conditions and not imposing annual or lifetime limits on coverage and out-of-pocket costs.

"All of that will be eliminated if states do away with essential health benefit coverage."

Impact on People With Diabetes

Stepping up to speak about the impact of any changes on people with diabetes specifically, Dr Powers said at least one study has shown that in states that expanded Medicaid coverage, there was a 23% increase in the number of newly diagnosed cases of diabetes, compared with states that did not accept the increased Medicaid funding provided by the Affordable Care Act.

"This strongly suggests that expansion of preventive screening services led to identifying diabetes in people who didn't know they had it. More important, it identified them at a younger age and at lower levels of HbA1c."

What is more, Dr Powers stressed, is that in states that opted out of Medicaid expansion, there was evidence that people with diabetes were delaying care or doing without their medications.

He echoed the concern that repeal or reform of the Affordable Care Act might return diabetic patients to an era of higher premiums and limited services.

Picture Not Entirely Bleak; Work to Make Sure Patient Voices Heard

Mr Boutin had some words of comfort, though, explaining that the picture is not entirely bleak, thanks in part to certain political realities.

For example, many states with Republican governors chose to participate in the expansion of Medicaid because it was funded mostly by federal money. Senators from those states may be reluctant to vote in favor of a bill that requires them to turn down hundreds of millions of dollars that provide their constituents with better access to care.

To further soften the political consequences, the Senate may also stipulate that changes such as reduced Medicaid funding not go into effect until 2024, so they will be less prominent in voters' minds when these senators are up for reelection.

Nevertheless, if it passes, the new law could have real consequences for patients, and "that creates a lot of anxiety for the patient advocacy community," said Mr Boutin.

"We are working hard to convince the Senate not to go down that pathway. We've got to make sure the patients are represented in this discussion," he concluded.

Neither Mr Boutin nor Dr Powers disclosed any relevant financial relationships.

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American Diabetes Association 2017 Scientific Sessions. The Fate of the Affordable Care Act; June 10, 2017; San Diego, California.

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