Health care ruling will impact Mother Lode

Retired Soulsbyville School teacher Donna Underwood, 65, of Sonora, meets with HICAP volunteer counselor Rita Vigil to discuss decisions about her Medicare plan. Alex MacLean/Union Democrat, copyright 2012

Advocates say rural counties directly benefit from several provisions in the law including insurance reforms, changes to the way Medicare doctors get reimbursed and investments in prevention and public health. 

Also, they say changes in Medicare have made medication and preventive-care services more affordable for the area’s aging population.

Since Obama signed the Affordable Care Act into law in 2010, it has generated heated debate. Detractors say the mandate requiring individuals to purchase health insurance is unconstitutional, while proponents argue the requirement is essential to reducing costs associated with people trying to get covered only after becoming sick.

The Obama Administration has stated one of the major goals of the law is to reduce the number of uninsured people who have little choice but to revert to emergency rooms as their primary source of care.

Rising cost of health care

Hospitals are required to provide services to anyone needing emergency health care treatment under the Emergency Medical Treatment and Active Labor Act passed by Congress in 1986, which has created increasing cost pressures on hospitals as the number of uninsured Americans has grown over the past several decades. 

The annual cost of uncompensated care among registered community hospitals has risen from $3.9 billion in 1980 to $39.1 billion in 2009, according to a 2010 report from the American Hospital Association based on data collected from yearly surveys.

The number of uninsured residents in Tuolumne County is estimated at 7,426, or 17 percent of the population, and the estimated number in Calaveras County is 5,826, or 16 percent, according to the most recent County Health Rankings and Roadmaps report, which is an annual study conducted by the University of Wisconsin Population Health Institute and Robert Wood Johnson Foundation that tracks public health statistics nationwide.

Sonora Regional Medical Center, which is part of Adventist Health, a not-for-profit, faith-based health system operating in multiple states, supports the individual mandate “as a vehicle to expand healthcare coverage and reduce the number of uninsured,” said Bruce Chan, the hospital’s director of business planning and marketing.

“We are committed to creating a system that reduces the overall cost of health care and building a healthier state and community,” he said.

Making insurance 
more affordable

Tuolumne County Public Health Officer Dr. Todd Stolp said the insurance reforms were one of the most impactful aspects of the law on rural populations. Some of those reforms include allowing people under 26 to stay on their parents’ health plans and prohibiting insurance companies from denying coverage to people with pre-existing illnesses.

“We get a lot of calls at the Health Department from people with pre-existing health risks who can’t get coverage,” Stolp said.

Beginning in 2014, the Affordable Care Act would also place limits on the amount that individuals and families would have to contribute toward insurance policies.

The Kaiser Family Foundation, a nonprofit and nonpartisan group that focuses on health-related issues, conducted an analysis of census data that found 17 percent of working-age adults in the Central Sierra who earned up to four times the poverty level in 2010 would be eligible for federal assistance under the Affordable Care Act in 2014.

Subsidies on insurance premiums would be provided to individuals and families earning between 133 to 400 percent of the poverty level. Premiums would be fully-covered for those making below 133 percent of the poverty level, which is about $11,000 for an individual and $22,000 for a family of four.

Aid for rural communities

Another provision of the Affordable Care Act specifically targets expanding the health care workforce in rural and underserved communities.

“This is important because urban Medicare reimbursement is generally higher,” Stolp said. “So we’ve seen a number of health care providers leaving rural areas.”

Primary care doctors would be paid no less than 100 percent of Medicare payment reimbursements and other incentives would be offered to doctors choosing to serve in rural and underserved areas under the Affordable Care Act.

Other provisions Stolp cited as significant for local residents included big investments in disease prevention programs and public health education.

Tuolumne County and 11 other small counties in the state recently received grants to develop programs that address public health issues. The county’s grant was for $237,000, with $50,000 of that going to Sonora to develop a plan for expanding the Dragoon Gulch Trail under its proposed “Get Up, Get Going, Get Healthy — Sonora” program.

“We are due to get $225,000 for the next five years, but depending on what happens Thursday, we might not end up getting all five years,” he said.

Other projects funded through the grant will include hiring a consultant to assess elements of the county’s general plan and evaluate health impacts, as well as other planning projects in partnership with various community agencies to promote healthy and active lifestyles, Stolp said.

Calaveras County was also one of the 12 communities awarded a five-year grant under the program, which is administered by the Public Health Institute.

Dr. Dean Kelaita, the county’s public health officer, said the money will be focused on promoting anti-smoking ordinances, addressing the problem of obesity, creating chronic-disease prevention programs and increasing physical activity in the community.

Some of the planned projects include educational campaigns to limit children’s access to sugar sweetened substance that are attributed to the epidemic of childhood obesity and mobilizing community health workers who will teach classes on self-managing chronic diseases by eating healthy and exercising, according to Kelaita.

“Once the money runs out, we want to have set up activities that are self-perpetuating,” he said.

Changes to Medicare

The Area 12 Agency on Aging’s Health Insurance Counseling and Advocacy Program helps seniors and other people in Tuolumne, Calaveras, Mariposa, Amador and Alpine counties with decisions about health plan coverage.

HICAP Program Manager Debbie Shally said a number of clients in the program have already been taking advantage of benefits provided under the Affordable Care Act, including increased access to medications and preventative services. 

Some Medicare prescription drug plans have a coverage gap, meaning after a patient has spent a certain amount of money in the plan for covered drugs then that patient is forced to pay the full price of medications.

Beginning in 2012, the Affordable Care Act provided funding to subsidize 50 percent of the cost of brand-name drugs and 86 percent of the cost of generics to Medicare recipients who had reached their coverage gap.

The law also provides Medicare recipients with an introductory primary care doctor visit and annual wellness visits in an effort to prevent illnesses or detect them in early stages before they become more costly to treat.

Shally said those discounts and doctor visits could go away depending on what the Supreme Court decides.

“It’s nerve-racking because we don’t know what’s going to happen,” she said. “But we will be there for clients to help them make any transition, if there is a transition.”

HICAP remains politically neutral on the subject, and Stolp said he wasn’t about to make any predictions either.

Stolp pointed out that the conversation about health care reform in the U.S. has been going on for decades, and will likely continue no matter what the Supreme Court decides on Thursday.

“Regardless of where we go, we need to sit down and talk about the next revision,” he said.