Sen. Joni Ernst told a crowd of constituents at a recent town hall meeting her “commitment to rural America is very strong” because she lives in rural Iowa.
Josh Dahle challenged that statement, explaining to Ernst how the Affordable Care Act benefited a rural hospital where he used to work, and how her votes to repeal the ACA were, in fact, not good for rural America.
Rather than make a humanitarian argument for the ACA — that all Americans should have health insurance — Dahle said he has reframed the discussion around economics when talking to Republicans about the benefits of the ACA.
“This is something that I’ve been a pretty strong advocate for,” said Dahle, 28, a former human resources professional at Stewart Memorial Community Hospital in northwest Iowa. “When those votes were going through Congress, she voted for several different provisions to repeal the [ACA]. I was calling her office just about everyday to voice my concerns, and then informing people I knew and some of the groups that I was involved with, on some of the messaging about the economic impact the rural hospitals have on rural communities.”
In Lake City, where Dahle lived and worked, the hospital is Calhoun County’s largest employer, providing jobs for about 300 people in a city of less than 1,500.
“A large percentage of people worked for the hospital,” Dahle, who now lives in Des Moines, told Starting Line. “Not only those people, but the jobs that depend on the economic activity from that hospital,” like downtown businesses, home values and the school system.
The economics of the hospital have “huge, huge ripple effects that nobody is really talking about,” he said.
Stewart Memorial Community Hospital, and others like it that depend on government reimbursements for health care services, benefitted financially from the ACA’s expansion of Medicaid.
Hospitals in rural America typically have a higher percentage of Medicaid patients than urban or suburban areas. Prior to the ACA, people who were uninsured but still required health care services resulted in a financial loss to health care providers. But under the ACA’s Medicaid expansion, more people were eligible for Medicaid, thus creating more opportunities for hospitals and clinics to be reimbursed for services they provided to the poor and disabled.
“With the Medicaid expansion that Iowa participated in, that meant less medical debt write-offs, more people were able to be covered under those [government] programs, so the government reimbursed the services so the hospital had to write off less bad debt,” Dahle explained.
He referenced findings from an independent foundation researching health care policy, the Commonwealth Fund, that analyzed how repealing the ACA would effect the finances of rural hospitals.
As part of its findings, the Commonwealth Fund concluded in its 2017 report: “Estimated savings across all hospitals in Medicaid expansion states totaled $6.2 billion. The largest reductions in uncompensated care were found for hospitals in expansion states that care for the highest proportion of low-income and uninsured patients. Legislation that scales back or eliminates Medicaid expansion is likely to expose these safety-net hospitals to large cost increases.”
At the Aug. 17 town hall in Polk County, Ernst defended her 2017 votes to repeal former president Barack Obama’s ACA, telling the crowd it “expanded access to health insurance” but did not succeed in bringing down the cost of health care.
“What happens is, yes, we have access to health insurance, but what did it do to address the root cause of the issue, which is the actual cost of health care?” said Ernst, up for re-election for the first time in 2020. “So, my commitment to rural America and to the metro areas, is to actually address the issues associated with the cost of health care.”
Instead of building on the ACA — 2019 enrollment was estimated at 8.5 million, not including those insured through the Medicaid expansion — Ernst said she was “working on reducing the cost of prescription drugs” and, at the time of the ACA repeal votes, advocated for an alternative system with an “invisible risk pool.”
According to Ernst, the plan worked “quite successfully in Maine” and “protected people with preexisting conditions.”
As described in an article by the Association of Health Care Journalists, so-called “invisible risk pools” help drive down premiums because insurance companies receive financial assistance from the government if they insure someone with a preexisting condition or significant health risks. Rather than waiting to provide payment until a patient incurs a high medical bill, the payments are doled out to insurers ahead of time, as a way of incentivizing coverage of expensive patients.
“I have family members with preexisting conditions,” Ernst said. “Two members of my family are juvenile diabetics. They have lived on insulin shots their entire lives, and I would never want to take away their health insurance. The ACA, some may support it, but I think there are better ways of doing business.”
In addition to cutting the ACA’s advertising budget and shortening the open enrollment window, President Donald Trump and Republicans in Congress have supported a reduction in cost-sharing payments to insurers that help keep premiums affordable.
“Her answer about rising premiums was so disingenuous,” Dahle said. Republicans “purposely limited funds for the reinsurance programs and the cost-sharing programs that were meant to help insurers establish better” insurance pools, “so her actions directly led to higher premiums.”
By Elizabeth Meyer