The Meridian Free Clinic exclusively serves those without insurance in East Mississippi and West Alabama. Already at capacity, longer waits would be in store if more people go without insurance.

Whether loathed or embraced, the Affordable Care Act, commonly know as Obamacare, is facing inevitable repeal under President Donald Trump’s administration and a Republican Congress.

That makes for a murky future for healthcare access in Mississippi, including the Meridian area’s two largest employers, Anderson Regional Health System and Rush Health Systems, was well as independent healthcare professionals and consumers. 

“What’s next? I don’t think anybody knows the answer to that question,” said Anderson President and CEO John G. Anderson. “It’s a game of wait and see.”

The ACA encountered numerous obstacles in Mississippi, including a lack of support from Gov. Phil Bryant and a failed federal marketplace application, the only state to fail. That failed application meant the state received only a fraction of the funding needed to promote and create the marketplace in Mississippi.

Despite the pushback, however, the uninsured rate in Mississippi fell 30 percent, or 161,000, since the ACA became law in 2010, according to a six-year report by the United States Department of Health and Human Services.

The law also prevented insurers from denying coverage for pre-existing conditions, such as diabetes or cancer, and allowed children to stay on their parents’ insurance until the age of 26, both provisions that Trump previously said he’d keep in his revision of the ACA. The law also resulted in costly premiums, however, and placed a burden on hospitals to improve community wellness.

Demand at free clinic

For the estimated 360,000 still uninsured in Mississippi, facilities like the Meridian Free Clinic exclusively serve those without insurance. But, because of the low number of providers, patients have to wait three to four weeks to see a physician or primary care doctor.

“We already have more patients than we can handle with the number of providers that we have,” said Brenda Hiatt, co-founder and board president of the clinic.

Hiatt said the two-year-old clinic serves counties that touch Lauderdale County and serves around 200 patients a month. Because the number of patients already strains the clinic’s resources, patients outside of the area must seek other clinics in Tupelo, Hattiesburg and Jackson, for healthcare.

“There are several great things about the Affordable Care Act,” said Dr. Lee Valentine, D.O. and the medical director of the clinic. “There’s (also) a lot wrong with the Affordable Care Act.”

Valentine and Hiatt both stressed the need for more doctors and other providers in the area and the clinic, which would face greater demand if people lost coverage when changes are implemented.

“Whether representatives repeal or change the act there’s still going to be a need,” Valentine said. “They’re going to need the free clinic.”

The clinic’s six physicians (including some of Valentine’s residents), six nurse practitioners and numerous nurses provide non-urgent care, labs and, by appointment only, x-ray and ultrasounds by working with Anderson and Rush.

“But we always encourage others to volunteer,” Hiatt said, noting that the clinic asks providers to volunteer for even one four-hour shift a month. “It would really hammer down our waiting list.”

Impact on hospitals

Hospitals could have had their own difficulties with the ACA, facing penalties for readmissions and new costs for healthcare.

But a report, commissioned by the American Hospital Association and Federation of American Hospitals in late 2016 said hospitals could lose $165.8 billion if the ACA repeal looks anything like the Republican-sponsored ACA House bill from last year.

“Losses of this magnitude cannot be sustained and will adversely impact patients’ access to care, decimate hospitals’ and health systems’ ability to provide services, weaken local economies that hospitals help sustain and grow, and result in massive job losses. As you know, hospitals are often the largest employer in many communities, and more than half of a hospital’s budget is devoted to supporting the salaries and benefits of caregivers who provide 24/7 coverage, which cannot be replaced,” wrote Rick Pollack, AHA President and CEO, and Chip Kahn, FAH President and CEO, in a press release.

As part of the ACA, federal aid for uncompensated care – or the uninsured – tapered off. Newly ACA-insured patients never came to replace the reimbursements the hospital used to receive for giving care to the uninsured. In the AHA and FAH report, hospitals asked Congress to consider bringing reimbursements back.

One part of the ACA, bundle payments, have especially hurt hospitals. Under a bundle payment, hospitals choose a period of time as an episode of care, either 30, 60 or 90 days. The 90 days payout is bigger but also carries a greater risk.

For example, if someone breaks a hip, the hospital chooses a period of care, covering time spent in the hospital and outpatient care. The hospital chooses to cover someone for 90 days. If that patient, discharged on day 65, suffers another injury in the days remaining, that treatment must also be covered from the money used in the first 90-day payment.

“It penalizes the provider,” Anderson said. “That’s one aspect I hope is strongly looked at.”

Medicaid question

A few years ago, Mississippi lawmakers voted against expanding Medicaid, meaning that many able-bodied, working poor under the age of 65 have no options for coverage. This class of people composes one-third of those uninsured in Mississippi. A 2015 White House news release estimated that 139,000 people would gain coverage if Medicaid had been expanded.

“It would catch a lot of our patients in they expanded Medicaid,” Hiatt said. “We have people who are working full time, whose employers don’t offer insurance, who simply don’t make enough. Some retired early and are not yet eligible for Medicare.”

To qualify for the free clinic, patients must make less than 200 percent of the Federal Poverty Guidelines, or $23,540 for a family of one and $48,500 for a family of four per year. Patients can be as young as 19, but usually range from 26-year-olds, just off their parents’ insurance, to those too young for Medicare.

Others have disabilities and need care for the 24 months they must wait during the application process for Medicaid. 

Uninsured cost hospitals 

Hospitals lose when it comes to caring for the uninsured. By law, hospitals must treat any person who comes into their emergency departments. Anderson estimated that the hospital had provided around $27 million in uncompensated care.

The hospital also may lose money to patients with insurance under the ACA, simply because their insurance payments are rescinded if the patient falls behind in monthly payments.

Not all of the ACA has been bad. There has been a special emphasis through the ACA of improving population health –encouraging patients to stay out of the hospital, to follow physician’s directions and to take their medication as directed. This “care coordination” links patients leaving the hospital to their primary care doctors for follow-up appointments and continued education.

One way to reduce healthcare costs – on both the individual and the community – would be to encourage everyone to visit a primary care doctor regularly.

“We want to help reduce the non-emergency use of emergency rooms,” Valentine said, explaining that these primary care visits can catch patients who are pre-diabetic before they have a diabetic coma and need to use an emergency room.

“I’m a strong advocate of primary care, of continual monitoring care and working with a physician,” Valentine said. “That’s what’s going to reduce healthcare costs.”

Anderson agreed that more patients needed to utilize primary care providers before using the emergency room as a last resort. But whatever decisions are made about the ACA in the upcoming weeks, Anderson said the surrounding community would feel the effects.

“If something happens to the hospital system then it has a tremendous rippling effect on the Meridian/Lauderdale area,” Anderson said. “The medical community here is as impressive as any that I’ve ever seen. You don’t want to lose that.”