The 2018 midterm elections will decide the fate of numerous healthcare-related ballot measures as well as which leaders will shape health policy in the coming years.
Issues to watch: Medicaid expansion in 4 states, a healthcare bond initiative in California, and the debate over preexisting condition protections.
Candidates to watch: Wisconsin Gov. Scott Walker, former Gov. Phil Bredesen, former HHS Secretary Donna Shalala, and others.
Healthcare has been an overarching issue for voters in the 2018 midterm election cycle, with many focusing on the future of the Affordable Care Act when it comes to national health policy but also taking stock of state and local ballot initiatives as well.
Several traditionally Republican states will decide whether to expand Medicaid under the ACA; staffing requirements for nurses are a hot-button topic in Massachusetts; and a major children’s hospital bond is on the table in California.
Beyond the issues are the candidates, including many Republican leaders on Capitol Hill in tight races to defend their seats after voting to repeal and replace the ACA. At the state level, Republican governors and their attorneys general are having their healthcare records put to the test as Democrats make protecting preexisting conditions and rejecting Medicaid work requirements key parts of the campaign.
Here are the key issues and candidates healthcare leaders will be watching as results begin rolling in Tuesday evening, with voters determining the direction of healthcare policymaking for years to come.
MEDICAID EXPANSION IN 4 RED STATES
One year after voters approved Medicaid expansion in Maine, the first state to do so through a ballot initiative, four other states have the opportunity to join the Pine Tree State.
Montana: The push to extend Medicaid expansion in Montana before the legislative sunset at the end of the year is tied to another issue: a tobacco tax hike. The ballot measure, already the most expensive in Montana’s history, would levy an additional $2-per-pack tax on cigarettes to fund the Medicaid expansion which covers 100,000 persons.
Nebraska: Initiative 427 in traditionally conservative Nebraska, could extend Medicaid coverage to another 90,000 people. The legislation has been oft-discussed around the Cornhusker State, earning the endorsement of the Omaha World-Herald editorial board.
Idaho: Medicaid expansion has been one of the most talked about political items in Idaho throughout 2018. Nearly 62,000 Idahoans would be added to the program by Medicaid expansion, some rural hospitals have heralded the move as a financial lifeline, and outgoing Gov. Bruce Otter, a Republican, blessed the proposal last week.
Utah: Similar to Montana’s proposal, Utah’s opportunity to expand Medicaid in 2018 would be funded by a 0.15% increase to the state’s sales tax, excluding groceries. The measure could add about 150,000 people to Medicaid if approved by voters, who back the measure by nearly 60%, according to a recent Salt Lake Tribune/Hinckley Institute poll.
4 MORE BALLOT INITIATIVES
In addition to the four states considering whether to expand Medicaid, there are four others considering ballot initiatives that could significantly affect the business of healthcare.
Massachusetts mulls nurse staffing ratios. Question 1 would implement nurse-to-patient staffing ratios in hospitals and other healthcare settings, as Jennifer Thew, RN, wrote for HealthLeaders. The initiative has backing from the Massachusetts Nurses Association.
Nurses have been divided, however, on the question, and public polling prior to Election Day suggested a majority of voters would reject the measure, which hospital executives have actively opposed. The hospital industry reportedly had help from a major Democratic consulting firm.
California could float bonds for children’s hospitals. Proposition 4 would authorize $1.5 billion in bonds to fund capital improvement projects at California’s 13 children’s hospitals, as Ana B. Ibarra reported for Kaiser Health News. With interest, the measure would cost taxpayers $80 million per year for 35 years, a total of $2.9 billion, according to the state’s Legislative Analyst’s Office.
Proponents say children’s hospitals would be unable to afford needed upgrades without public assistance; opponents say the measure represents a fiscally unsound pattern. (California voters approved a $750 million bond in 2004 and a $980 million bond in 2008.)
Nevada nixing sales tax for medical equipment? Question 4 would amend the Nevada Constitution to require the state legislature to exempt certain durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax. The proposal, which passed a first time in 2016, would become law if it passes again.
Bennett Medical Services President Doug Bennett has been a key proponent of the measure, arguing that it would bring Nevada in line with other states, but opponents contend the measure is vaguely worded, as the Reno Gazette Journal reported.
Oklahoma weighs Walmart-backed optometry pitch. Question 793 would add a section to the Oklahoma Constitution giving optometrists and opticians the right to practice in retail mercantile establishments.
Walmart gave nearly $1 million in the third quarter alone to back a committee pushing for the measure. Those opposing the measure consist primarily of individual optometrists, as NewsOK.com reported.
INCUMBENTS, PLAINTIFFS, PREEXISTING CONDITIONS
It’s been more than two months since Republican attorneys general for 20 states asked a federal judge to impose a preliminary injunction blocking further enforcement of the Affordable Care Act, including its coverage protections for people with preexisting conditions. Some see the judge as likely to rule in favor of these plaintiffs, though an appeal of that decision is certain.
Amid the waiting game for the judge’s ruling, healthcare policymaking—especially as it pertains to preexisting conditions—rose to the top of voter consciousness in the midterms. That explains why some plaintiffs in the ACA challenge have claimed to support preexisting condition protections, despite pushing to overturn them.
The lawsuit and its implications mean healthcare leaders should be watching races in the 20 plaintiff states in the Texas v. Azar lawsuit: Alabama, Arizona, Arkansas, Florida, Georgia, Indiana, Kansas, Louisiana, Maine Gov. Paul LePage, Mississippi Gov. Phil Bryant, Missouri, Nebraska, North Dakota, South Dakota, South Carolina, Tennessee, Texas, Utah, West Virginia, and Wisconsin. Thirteen of those plaintiff states have active elections involving their state attorneys general, and several have races for governor in which the ACA challenge has been an issue, including these noteworthy states:
- Texas: Attorney General Ken Paxton, a Republican representing the lead plaintiff in the lawsuit, is facing a challenge from Justin Nelson, a Democrat, and the race seemed to be competitive, as The Texas Tribune reported. Gov. Greg Abbott was expected to win against Democratic challenger Lupe Valdez.
- Florida: Attorney General Pam Bondi, a Republican, is term-limited, so she’s not running for reelection. Ashley Moody, a Republican, and Sean Shaw, a Democrat, are facing off for Bondi’s position. Moody expressed support for Florida’s participation in the ACA challenge, while Shaw said he would pull the state out, calling the case a “partisan stunt,” as the Tampa Bay Times reported. Bondi has campaigned, meanwhile, for Republican gubernatorial candidate Ron DeSantis, who’s facing off with Democrat Andrew Gillum. Gillum said he would back a state law to protect people with preexisting conditions, while DeSantis said he would step in if federal action removed the ACA’s preexisting condition protections, as the Miami Herald reported. Gillum and DeSantis are vying to succeed term-limited Gov. Rick Scott, a Republican who’s running for U.S. Senate.
- Wisconson: Attorney General Brad Schimel, a Republican, is facing a challenge from Josh Kaul, a Democrat who has slammed Schimel’s participation in the ACA challenge, as The Capital Times reported. Gov. Scott Walker, a Republican, said he supports preexisting condition protections, despite authorizing his state’s participation in the lawsuit. Democratic challenger Tony Evers accused Walker of “talking out of both sides of his mouth,” as the Milwaukee Journal Sentinel reported.
PROPONENTS OF MEDICAID WORK REQUIREMENTS
Five states have received approvals from the Centers for Medicare and Medicaid Services to institute Medicaid work requirements: Kentucky, Indiana, Wisconsin, New Hampshire, and Arkansas. (Only four have active approvals, however, since a federal judge blocked Kentucky’s last summer.)
Three incumbent governors who pushed for work requirements are running for reelection:
New Hampshire: After receiving approval for New Hampshire’s Medicaid work requirements, Republican Gov. Chris Sununu said the government is committed to helping Granite Staters enter the workforce, adding that it is critical to the “economy as a whole.” Despite spearheading a controversial topic in a politically centrist state, Sununu has not trailed against his Democratic opponent Molly Kelly in any poll throughout the midterm elections.
Arkansas: Similarly, Arkansas Gov. Asa Hutchinson, is running in a race where he has held a sizable lead over his Democratic challenger Jared Henderson. Since enacting the work requirements over the summer, the state has conducted two waves where it dropped more than 8,000 enrollees.
Wisconsin: The most vulnerable Republican governor of a state with approved Medicaid work requirements is Wisconsin Gov. Scott Walker, who has been neck and neck with Democratic nominee Tony Evers. While the Badger state only received approval for its Medicaid work requirements last week, healthcare has been a central issue of the campaign as Walker, a longtime opponent of the ACA, works to address premium costs in the state and defend his record on preexisting conditions.
Indiana and Kentucky: Indiana Gov. Eric Holcomb and Kentucky Gov. Matt Bevin are not on the ballot this year.
When HealthLeaders issued its first list in April of the healthcare leaders running for public office during the primaries, there were more than 60 candidates with relevant healthcare backgrounds out on the campaign trail.
Now, for the general election, that list has nearly been halved, with 35 candidates still remaining.
This collection of healthcare leaders includes registered nurses, former insurance company executives, physicians, and former government health policy leaders.
U.S. Senate: Running for the Senate are Florida Gov. Rick Scott, former Tennessee Gov. Phil Bredesen, former Celgene CEO Bob Hugin, and State Sen. Leah Vukmir.
U.S. House: Among those aiming to join the House are Lauren Underwood, RN, former HHS Secretary Donna Shalala, and Dr. Kim Schrier.
The potential health and economic consequences of a trend associated with states that have turned down Medicaid expansion.
Hospitals are often thought of as the hubs of our health care system. But hospital closings are rising, particularly in some communities.
“Options are dwindling for many rural families, and remote communities are hardest hit,” said Katy Kozhimannil, an associate professor and health researcher at the University of Minnesota.
Beyond the potential health consequences for the people living nearby, hospital closings can exact an economic toll, and are associated with some states’ decisions not to expand Medicaid as part of the Affordable Care Act.
Since 2010, nearly 90 rural hospitals have shut their doors. By one estimate, hundreds of other rural hospitals are at risk of doing so.
In its June report to Congress, the Medicare Payment Advisory Commission found that of the 67 rural hospitals that closed since 2013, about one-third were more than 20 miles from the next closest hospital.
A study published last year in Health Affairs by researchers from the University of Minnesota found that over half of rural counties now lack obstetric services. Another study, published in Health Services Research, showed that such closures increase the distance pregnant women must travel for delivery.
And another published earlier this year in JAMA found that higher-risk, preterm births are more likely in counties without obstetric units. (Some hospitals close obstetric units without closing the entire hospital.)
Ms. Kozhimannil, a co-author of all three studies, said, “What’s left are maternity care deserts in some of the most vulnerable communities, putting pregnant women and their babies at risk.”
In July, after The New York Times wrote about the struggles of rural hospitals, some doctors responded by noting that rising malpractice premiums had made it, as one put it, “economically infeasible nowadays to practice obstetrics in rural areas.”
Many other types of specialists tend to cluster around hospitals. When a hospital leaves a community, so can many of those specialists. Care for mental health and substance use are among those most likely to be in short supply after rural hospital closures.
The closure of trauma centers has also accelerated since 2001, and disproportionately in rural areas, according to a study in Health Affairs. The resulting increased travel time for trauma cases heightens the risk of adverse outcomes, including death.
Another study found that greater travel time to hospitals is associated with higher mortality rates for coronary artery bypass graft patients.
In many communities, hospitals are among the largest employers. They also draw other businesses to an area, including those within health care and others that support it (like laundry and food services, or construction).
A study in Health Services Research found that when a community loses its only hospital, per capita income falls by about 4 percent, and the unemployment increases by 1.6 percentage points.
Not all closures are problematic. Some are in areas with sufficient hospital capacity. Moreover, in many cases hospitals that close offer relatively poorer quality care than nearby ones that remain open. This forces patients into higher-quality facilities and may offset negative effects associated with the additional distance they must travel.
Perhaps for these reasons, one study published in Health Affairs found no effect of hospital closures on mortality for Medicare patients. Because it focused on older patients, the study may have missed adverse effects on those younger than 65. Nevertheless, the study found that hospital closings were associated with reduced readmission rates, which is regarded as a sign of increased quality. So it seems consolidating services at larger hospitals can sometimes help, not harm, patients.
“There are real trade-offs between consolidating expertise at larger centers versus maintaining access in local communities,” said Karen Joynt Maddox, a cardiologist and health researcher with the Washington University School of Medicine in St. Louis and an author of the study. “The problem is that we don’t have a systematic approach to determine which services are critical to provide locally, and which are best kept at referral centers.”
Many factors can underlie the financial decision to close a hospital. Rural populations are shrinking, and the trend of hospital mergers and acquisitions can contribute to closures as services are consolidated.
Another factor: Over the long term, we are using less hospital care as more services are shifted to outpatient settings and as inpatient care is performed more rapidly. In 1960, an average appendectomy required over six days in the hospital; today one to two days is the norm.
Part of the story is political: the decision by many red states not to take advantage of federal funding to expand Medicaid as part of the Affordable Care Act. Some states cited fiscal concerns for their decisions, but ideological opposition to Obamacare was another factor.
In rural areas, lower incomes and higher rates of uninsured people contribute to higher levels of uncompensated hospital care — meaning many people are unable to pay their hospital bills. Uncompensated care became less of a problem in hospitals in states that expanded Medicaid.
In a Commonwealth Fund Issue Brief, researchers from Northwestern Kellogg School of Management found that hospitals in Medicaid expansion states saved $6.2 billion in uncompensated care, with the largest reductions in states with the highest proportion of low-income and uninsured patients. Consistent with these findings, the vast majority of recent hospital closings have been in states that have not expanded Medicaid.
In every year since 2011, more hospitals have closed than opened. In 2016, for example, 21 hospitals closed, 15 of them in rural communities. This month, another rural hospital in Kansas announced it was closing, and next week people in Kansas, and in some other states, will vote in elections that could decide whether Medicaid is expanded.
Richard Lindrooth, a professor at the University of Colorado School of Public Health, led a study in Health Affairs on the relationship between Medicaid expansion and hospitals’ financial health. Hospitals in nonexpansion states took a financial hit and were far more likely to close. In the continuing battle within some states about whether or not to expand Medicaid, “hospitals’ futures hang in the balance,” he said.
- Hospitals across the U.S. are being battered by financial headwinds, and rural hospitals are vulnerable because they don’t have capital or diversified services to fall back on when the going gets rough. Between 2013 and 2017, 64 rural hospitals closed due to financial distress and changing healthcare dynamics, more than twice the number in the previous five years, a new Government Accountability Office analysis shows.
- Rural hospital closures disproportionately occurred in the South, among for-profit hospitals and among organizations with a Medicare-dependent hospital payment designation.
- One potential lifeline was Medicaid expansion. According to GAO, just 17% of rural hospital closures occurred in states that had expanded Medicaid as of April 2018.
Declining inpatient admissions and reimbursement cuts have taken a toll on rural hospitals. Since 2010, 86 rural hospitals have closed, and 44% of those remaining are operating at a loss — up from 40% in 2017.
CMS Administrator Seema Verma released a rural health strategy in May aimed at improving access and quality of care in rural communities. Among its objectives are expanding telemedicine, empowering patients in rural areas to take responsibility for their health and leveraging partnerships to advance rural health goals.
The agency also expanded its Rural Community Hospital Demonstration from 17 to 30 hospitals. The program reimburses hospitals for the actual cost of inpatient services rather than standard Medicare rate, which could be as little as 80% of actual cost.
Such initiatives can be helpful, but if a hospital can’t make ends meet on its Medicare and Medicaid businesses and has only a modicum of privately insured patients, “that’s just not a balance that works financially,” Diane Calmus, government affairs and policy manager at the National Rural Health Association, told Healthcare Dive recently.
In all, 49 rural hospitals closed in the South, or 77% of rural hospital closures from 2013 through 2017, according to GAO. Texas had the most closures with 14, followed by Tennessee with eight and Georgia and Mississippi, each with five. By contrast, there were eight rural hospital closures in the Midwest and four each in the West and Northeast.
GAO also looked at closures by Medicare rural hospital payment designation. Critical access hospitals made up 36% of rural hospital closures, 30% were hospitals receiving Medicare standard inpatient payment, 25% had Medicare-dependent hospital designation and 9% were sole community hospitals.
To aid rural hospitals and ensure access for patients, NRHA has urged CMS to adopt a common sense approach to the “exclusive use” standard and lobbied lawmakers to pass legislation eliminating the 96-hour condition of payment requirement, two policies that are particularly hard on rural providers.
Another bill, the Save Rural Hospitals Act, would reverse reimbursement cuts to rural hospitals, provide other regulatory relief and establish the community outpatient hospital, a new provider type offering 24/7 emergency services plus outpatient and primary care.
Hit especially hard were Massachusetts’ community hospitals, with median operating margins plunging to 0.9 percent.
Acute care hospitals in Massachusetts are turning a profit for the most part, but in many cases those profits are less than robust. The state’s Center for Health Care Information and Analysis found that many are in a financially precarious position.
According to the report, about 65 percent of the commonwealth’s hospitals have operating margins below three percent. Overall, hospitals’ operating margins hovered around 1.6 percent. That’s down from 2.8 percent during the previous fiscal year.
While 49 of 62 hospitals were profitable in the fiscal year ending Sept. 30, many low margins low enough not to be considered financially healthy.
Hit especially hard were Massachusetts’ community hospitals, with median operating margins plunging to 0.9 percent — down two full percentage points from the previous year.
The northeastern part of the state saw the lowest margins geographically, at 1.6 percent, with some facilities operating on negative margins and hemorrhaging cash. North Shore Medical Center in Salem was among the hardest hit, seeing $57.7 million evaporate in fiscal year 2017.
Not all Massachusetts hospitals are feeling those kinds of pressures. Northeast Hospital enjoyed a 9 percent operating margin during the past fiscal year, translating into a $33.1 million surplus.
That the state’s rural hospitals are struggling isn’t surprising, given the national trend. A recent report found that nearly half are operating at negative margins, fueled largely by a high rate of uninsured patients. Eighty rural hospitals closed from 2010 to 2016, and more have shut their doors since.
Aside from the high uninsured rate, a payer mix heavy on Medicare and Medicaid with lower claims reimbursement rates is a contributing factor. More patients are seeking care outside rural areas, which isn’t helping, and many areas see a dearth of employer-sponsored health coverage due to lower employment rates. Many markets are also besieged by a shortage of primary care providers, and tighter payer-negotiated reimbursement rates.
A new congressional proposal would raise the minimum disproportionate share hospital adjustment percentage that DSH hospitals must meet to qualify for the 340B drug discount program, eliminating 340B eligibility for over half the participating hospitals, according to a study by 340B Health.
Under the bill, proposed by Rep. Joe Barton, R-Texas, 573 of the 1,115 DSH hospitals enrolled in the 340B program would no longer be eligible for the drug discounts. Under the current rules, DSH hospitals are eligible for the 340B program if their Medicare DSH adjustment percentage is greater than 11.75 percent. The proposal would raise the qualifying rate to 18 percent.
Here are the 10 states with the most DSH hospitals that would lose 340B eligibility under the proposal:
- California (39)
- Texas (35)
- North Carolina (33)
- Georgia (31)
- Ohio (29)
- Michigan (23)
- New York (21)
- Illinois (19)
- Alabama (19)
- Pennsylvania (18)
Two rural Missouri hospitals recently handed over their operations to a private company that promised to turn them around with a billing practice it calls “a lab outreach program.”
But the approach that company is using is drawing attention from lawmakers and Missouri’s auditor. It is similar to a tactic underway at 20 rural hospitals in Missouri, Kansas, Oklahoma, Florida and California.
Read KHN’s previous coverage of this topic: “Outsiders Swoop In Vowing To Rescue Rural Hospitals Short On Hope — And Money” by California Healthline senior correspondent Barbara Feder Ostrov.