On the ground in Iowa: The real healthcare story as caucuses loom

CEDAR RAPIDS, Iowa—The spacious waiting room at the Community Health Free Clinic is two-thirds full, and CEO Darlene Schmidt and her team of volunteer and staff providers have a lot of patient problems to solve before noon, when the clinic closes.

Schmidt, a nurse who co-founded this clinic in 2002 in Iowa's second-largest city, scurries from one hallway huddle to another with the doctors, nurses and pharmacy staff.

Even with the Affordable Care Act's private insurance and Medicaid expansions in Iowa—which she calls “an absolute blessing”—she is constantly scheming to get patients access to affordable treatment and prescription drugs. She works closely with the city's two hospitals, Mercy Medical Center and St. Luke's Hospital, and with the Eastern Iowa Health Center, a federally qualified community health center, to arrange services for her patients, most of whom are uninsured, waiting to be insured, or underinsured.

While the clinic was scrambling to fill these gaps, a nonstop procession of presidential candidates trooped through Cedar Rapids this month trying to win over voters ahead of the Feb. 1 Iowa caucuses, the first-in-the-nation primary contest. But there has been a big disconnect between this city's—and the nation's—complex healthcare realities and the candidates' rhetoric.

The Republican hopefuls who came here, including Florida Sen. Marco Rubio, mentioned healthcare just long enough to call for repeal of the ACA. In contrast, the Democrats, including Hillary Clinton and her husband, Bill, warned that electing a Republican president would kill affordable healthcare. Hillary Clinton promised to “fix” the ACA with measures to make care and drugs more affordable, while attacking the government single-payer proposal by her rival, Vermont Sen. Bernie Sanders, who has surged in the polls here.

The Republicans “have no clue what they'll replace the Affordable Care Act with,” said former President Clinton, campaigning for his wife at a local museum. “Do we need to do more work on it? Yeah. But should we scrap it? No.”

Republicans are less specific because “right now, healthcare is more of a symbolic issue—being against Obamacare and riling up the base,” said Douglas Gross, a Des Moines attorney who headed Republican Mitt Romney's Iowa presidential campaign in 2008. “One of the lessons they learned from Romney is don't offer your own plan because it may come back to bite you. But in the general election, you'll have to have a credible alternative to Obamacare if you want to repeal it.”

Political observers say healthcare won't be the top issue for most Iowa caucusgoers when they gather to pick their respective party nominees. But sharply clashing views about Obamacare are helping shape the climate, conversations with healthcare providers and voters in Cedar Rapids suggest.

Providers say more detailed discussion of healthcare issues is badly needed, including how to fill the ACA coverage gaps, reduce drug costs and boost access to mental health services. One healthcare leader shrugged off the politicians' lightweight healthcare talk. “We'll hear interesting conversations when the primaries are over,” predicted Tim Charles, CEO of MercyCare Service Corp., which operates the independent Mercy Medical Center.

Other healthcare executives are more anxious about the repeal pledges. “There are pieces of the ACA that we know aren't perfect, and we'd like to see some modifications,” said Sabra Rosener, vice president of government relations at UnityPoint Health, which operates St. Luke's and 16 other hospitals in Iowa, Illinois and Wisconsin. “But full-scale repeal? We have made so many changes in how we deliver care and our IT system, I don't know how it would even be possible to unroll it and not have complete chaos.”

One healthcare issue that has gained political traction in Iowa is Republican Gov. Terry Branstad's push to rapidly move 560,000 Medicaid beneficiaries, including those with severe disabilities, into private managed-care plans. The Obama administration recently delayed that controversial conversion from Jan. 1 to March 1. Branstad promises the new program will improve care and save money, though many say Iowa already has one of the best-run Medicaid programs in the country.

Many providers, including Mercy Medical Center, have not yet signed contracts with any of the three contracting Medicaid plans. Beneficiaries have had a hard time getting information on what providers are in the plan networks. “It's just been a mess,” said Democratic state Sen. Rob Hogg of Cedar Rapids, who's seeking to challenge Republican U.S. Sen. Chuck Grassley in the November election. The plans did not respond to requests for comment by deadline.

Hillary Clinton has sought to make the governor's Medicaid privatization a campaign issue, warning that it could mean a cut in services. “She's using the issue quite effectively with the Democratic base to drive a wedge,” said Republican attorney Gross.

Iowa, which voted for Obama in 2008 and 2012, has a mixed ACA track record. Branstad pushed through a customized Medicaid expansion with beneficiary premium contributions, which started in 2014. The state's uninsured rate, which was a relatively low 9.7% in 2013, dropped to 5% in the first half of 2013, according to Gallup. Both Cedar Rapids hospitals say the ACA coverage expansions have improved their bottom lines by reducing uncompensated-care costs.

But nearly 200,000 Iowans remain uninsured, with 47% eligible for Medicaid and 16% eligible for exchange subsidies, according to the Kaiser Family Foundation. One factor that may have limited the law's impact was the decision by Wellmark Blue Cross and Blue Shield, the state's dominant individual-market insurer, not to participate in the federally run insurance exchange during its first three years, though Wellmark has agreed to sell on the exchange in 2017. Another issue is that the state let insurers keep selling plans that don't comply with the ACA, though that ends this coming fall.

Then there was the financial collapse in late 2014 of CoOpportunity Health, an ACA-funded not-for-profit insurer, which forced thousands of Iowans to switch plans. More recently, average premiums for Iowa exchange plans for 2016 jumped by double-digit percentages. All this strengthened the arguments of Obamacare opponents that the reformed market is unsustainable.

At the Community Health Free Clinic, Schmidt and her team deal with the ACA's imperfections every day. They often have to help insured patients with their high deductibles and other cost-sharing and finagle to get Medicaid patients into private providers for tests, specialty care and procedures. On the day Modern Healthcare visited the clinic, Schmidt authorized an $80 payment to cover a patient's copay so she could see a rheumatologist.

For uninsured patients, the goal is to get them signed up for an ACA exchange plan or Medicaid. The clinic's enrollment counselors helped Jack Fligor of nearby Hiawatha apply for Medicaid last month. While he waits for an eligibility decision, he's visiting the clinic to pick up insulin for his diabetes, with no charge. “If I won the lottery, I'd donate a ton of money to this place,” he said.

But other patients fall into the law's cracks. Dr. David Rater, a retired cardiologist who volunteers every Wednesday at the clinic, walks into Schmidt's office to discuss how to arrange surgery for a young Sudanese woman with a possible malignancy on her neck. She's a legal immigrant but has to wait five years to qualify for Medicaid. Schmidt will have to pull strings at the hospitals to get the woman in for an operation. Rater says he wishes the U.S. had a national health system like Canada's that guarantees care for everyone.

A constant challenge is that the hospitals and doctors' offices in town are putting Medicaid patients on waiting lists. At the Eastern Iowa Health Center, which can't turn anyone away, CEO Joe Lock said his percentage of patients on Medicaid has soared to nearly 80% because private providers are capping the number of new Medicaid patients they'll take.

UnityPoint's primary-care clinic in Cedar Rapids gets up to 20 calls a day from Medicaid beneficiaries seeking appointments. Dr. Clete Younger said two of the doctors there are “completely full” while he and another doctor are accepting new Medicaid patients only on a limited basis.

Locals have different reactions to the ACA's imperfections and to the visiting candidates' rhetoric about Obamacare. Shelley Sullens, a bed-and-breakfast operator who lost her insurance two years ago when her husband was laid off, hates the law. She and her husband bought an exchange plan with a subsidy in 2014. But she thought the premium was too high and didn't like taking government help. They switched to a faith-based, healthcare cost-sharing plan.

Sullens says she's glad to be out of Obamacare because her premium dollars are no longer being used to pay for abortions or “prison inmates' sex-change operations.” She plans to attend a GOP caucus, though she doesn't yet know which candidate she will support, and the ACA will play a role in her thinking.

In contrast, Roger Henley, a retired corporate purchasing director who volunteers at the free clinic as a Medicaid enrollment counselor, said the law helped many people he sees who lost jobs, work at low-wage jobs without insurance, or have a serious medical condition and can't work. And it's helped him personally.

Though he's on Medicare, his wife, who is younger, previously couldn't get insurance because of a serious medical condition and had to go into the state's high-risk pool, where the coverage was expensive and not very good. Under the ACA, she was able to buy comprehensive, high-quality private coverage. “That's made a huge difference, and it's made a difference for me politically,” he said. “The ACA isn't perfect, but it's a real good start.”

Some of the grass-roots hostility toward the ACA is being stoked by employers, said Tom Hoffmann, executive vice president of Benefit Solutions, an employee-benefits consulting firm in Cedar Rapids. “Employers are using strident rhetoric and telling their employees, 'Your premiums are going up because of Obamacare, which you voted for in the last election,' ” he said.

Schmidt, who keeps a picture of Mother Teresa on her office wall, supports the law because it has helped her patients establish a medical home for managing their chronic conditions. It's also reduced her clinic's annual patient volume from 15,000 to 7,000. To her chagrin, some of her patients say they hate Obamacare and refuse to sign up for coverage, and then they seek free care at her clinic. “It's frustrating to get a few of those patients, but it's not our place to judge,” she said.

She declines to discuss how the outcome of the presidential election could affect healthcare, saying she never talks politics because it could alienate her more conservative medical volunteers. She did, however, attend that week's Hillary Clinton speech and praised the candidate's warmth and knowledge on the issues.

Schmidt is interrupted by a colleague seeking help in obtaining a depression medication for a patient who's scheduled for surgery in a few days and got bumped off Medicaid. Returning to the election question, she wonders how her community could deal with all the healthcare access problems if the ACA were repealed. Still, she says, no matter who's elected, “There will always be a need for a free clinic, because the poor will always be with us.”