Dr. Bruce Siegel worries that efforts to repeal and replace the Affordable Care Act will not only leave millions of Americans uninsured, but also severely hamper efforts to advance population health. The president of America's Essential Hospitals, a trade group representing nearly 300 safety-net providers, is also concerned about what kind of trades Senate leaders may have to make to get a bill passed. Siegel visited with Modern Healthcare's editorial team in late June, a week before an initial vote on the Senate bill was delayed. The following is an edited transcript.
Modern Healthcare: You've expressed major concerns with the approach House and Senate leaders are taking with their healthcare bills. Are they listening? Do you get the sense that provider groups are being heard?
Dr. Bruce Siegel: There are hints of traction and we are hearing some senators raise concerns. Frankly, we are surprised we aren't hearing more. Senate Majority Leader Mitch McConnell is a very smart strategist. I don't agree with the policy, but I understand the politics of what he's trying to do.
We are concerned that there will be tradeoffs to try to get votes, like, "We'll put money into opioid prevention, just let us rollback Medicaid expansion."
That is a deal that could get offered, and we are concerned that we'll lose sight of the big picture.
A question for me would be: Is Sen. Jeff Flake going to vote to have 400,000 Arizonians lose health coverage? I hope not. I hope he won't vote to take $2.5 billion a year out of the Arizona economy. These are significant impacts, and we are going to work hard to educate senators about exactly what is at stake here.
MH: What would a trade-off for the opioid crisis look like?
Siegel: I'm speculating, but there's a lot of talk about that now. I am all for putting resources into opioid prevention. Let's be clear about that, but taking 22 million people who are at higher risk of addiction, mental health, all those things, and removing them from the insurance system is not a recipe for combating opioids. That coverage needs to be a basic threshold, otherwise those people can't be assured that they'll have some access to the mental health or addiction services they need. I'm concerned that we'll be penny-wise and pound-foolish to think we're going to solve the opioid crisis with some targeted funding, but really have kicked the foundation of coverage out from under these people.
MH: Even some kind of funding package might not go toward such things as medication-assisted treatment. Do you have a long-term strategy to try and combat the opioid epidemic?
Siegel: First, the resources need to be there, and the coverage needs to be there.
From our point of view, our job is to figure out models out there that really work and spread them in our membership. We're going to spend time over the next six to nine months both in terms of educational sessions and meetings to get that information out there because there are a lot of bright spots around opioid treatment and prevention. That technology transfer isn't happening as fast as it should happen nationally, and I think we're not alone as an association that is worried about that.
MH: What efforts are the association and its members making in terms of population health?
Siegel: There's a lot of confusion in the area of population health and a lot of different language being used loosely, and that's to be expected. We are focusing on the social determinants of health. Many times, talk around population health is about better care management, ACO models and the like; we're all for that, but our focus is going to be very much on social determinants because that's a space where we can make a difference.
When we surveyed our members, we have found strong interest in a couple of areas very specifically. Housing is one of them, food deserts, and then-this is a little harder to define-changing behaviors. Housing and food insecurity come up again and again. And when I talk about housing, some people look at it as supportive housing for those at risk, but a lot of people are just looking at it for housing, period. We cannot have a healthy community if people don't have safe, secure housing.
We have places like Bon Secours in Baltimore using tax credits to build low-income housing. They have done things like the Gibbons Commons development, which brings together housing, retail, job training and outpatient care. It's really quite impressive.
That is a wonderful thing, but a lot of our hospitals are also asking us, "Where do I just start? That's a great vision, but I am just beginning." Some of the things we're going to try to do over the coming months is to help our hospitals identify where can they begin. How do they begin to set some priorities out of their community health needs assessment or somewhere else? They need to have some sort of way forward.
MH: What's it like in the boardrooms for your hospitals? Have they started to come along with that way of thinking?
Siegel: Some have. Many have not. I see some boards that are quite motivated to do this, and often because there's board leadership, and they are invested in this. Sometimes it is driven by a conversation that goes like this from a hospital in Massachusetts: "We care for a large, low-income community in this population who are on Medicaid who have many social and economic challenges. Massachusetts is moving to a Medicaid ACO model. We are going to be increasingly at risk for the care of these patients, and we want to do a good job. If we can't begin to impact the social determinants, we will fail. We will fail clinically. We will fail financially. If this community continues to use the emergency room at the rates it uses it, if it has readmissions at the rate it has, then under what Massachusetts is now rolling out, we will fail."
MH: How are population efforts and community benefit affected by a healthcare financing policy change that retrenches funding. Does that change your members' trajectory in moving forward with those kinds of initiatives, or do they find a way to do it anyway?
Siegel: I think that they will find a way to do it, but it will be a lot harder. The Congressional Budget Office says 23 million people lose coverage, at least from the House bill. We know millions more people didn't get coverage who should have because not every state expanded Medicaid. So 10% of Americans won't have insurance who could have had insurance otherwise. All the work we're doing around either identifying their opiate problem in a primary-care visit or getting them a prescription or food from the food pantry, all those things that depend on them being in some sort of organized system of care goes away and they're back dependent on an emergency department, or just out of luck.
It's going to be very hard to move the ball on population health if you take tens of millions of people and just cut them out of the system. The impacts on equity, the impacts on value will be significant. You start rolling back the expansion funding to these states, you've begun a terrible, distracting debate for years to come over how each state finances healthcare. You begin a debate over whether it even does finance care for these people or it just pulls back.
When all the bandwidth of your state Medicaid director and your state health commissioner and your governor and your legislature is trying to figure out if and how to replace billions in lost federal funding, there is going to be a lot less energy that goes into really moving on population health.
We'll work on it. It's essential to our mission, and I think hospital leaders realize that they can't change the trajectory of health in their community without working on this, but let's be real, there's going to be a battle royal over Medicaid—we're already in one—and that's going to suck a lot of energy out of the room.