Through a wave of mergers and acquisitions, coupled with downsizing or closing of financially-stressed hospitals, health systems are scrambling to re-position themselves in a changing marketplace that includes new Affordable Care Act incentives and penalties. Some hospitals and health systems are joining with physician practices and even insurance companies in integrated provider/payer arrangements that could improve care coordination, but also wield significant market and political power or—in the case of some religiously-affiliated systems—impede access to certain kinds of care. These dramatic changes will have lasting repercussions for consumers, especially those low-income patients who are dependent on local safety-net hospitals.

Yet most of these sweeping health industry changes are proceeding with little or no assessment of the likely impact on consumers and very little opportunity for community engagement in hospital regulatory oversight processes, some of which have been significantly weakened in recent years. Let’s take a look at the current state of play.

Recent Hospital Consolidation Trends

According to Modern Healthcare, the number of hospital mergers and acquisitions climbed by more than 18 percent to 109 in 2012, the third straight year of increasing hospital consolidation. These figures are double the annual average seen before health care reform and the 2008 recession. The volume of hospital mergers and acquisitions is expected to remain elevated as stand-alone hospitals join larger health systems seeking financial stability. According to the American Hospital Association, 436 hospitals gave up their independent status between 1999 and 2011.  One hospital industry consulting firm predicts that another 1,000 hospitals could seek out mergers in the next several years.

Growth of For-Profit and Catholic-Sponsored Hospitals and Health Systems

Research conducted by ACLU and the MergerWatch Project of Community Catalyst last year found that the number of for-profit hospitals jumped dramatically by 46 percent between 2001 and 2011, and the number of Catholic-sponsored hospitals increased by 16 percent, while the number of other non-profit and government-run hospitals decreased.

The study also found that for-profit and Catholic-sponsored systems dominated the 2011 roster of the 25 largest health systems in the nation.

There can be benefits for independent hospitals that merge with or are acquired by large health systems, such as greater access to capital for improvements to aging facilities, savings through joint purchasing and administration, and a financial “cushion” to help survive through hard times. But, there are also perils for hospitals and their patients. The shifting of local control to out-of-town system managers can mean a hospital is less responsive to community needs. Acquisition by a for-profit system can mean much greater attention to the bottom line, and sometimes, inappropriate practices such as demanding deposits from uninsured patients. Concerns remain that costs at for-profit hospitals could exceed those at non-profit hospitals.

In cases involving religiously-affiliated hospitals, issues of community access to care can arise. For example, secular hospitals that join a Catholic health system must cope with ethical and religious directives that can cause the elimination of key reproductive and end-of-life health services, including contraception, sterilization, infertility treatments, the treatment of pregnancy emergencies, “safer sex” counseling and the honoring of end-of-life wishes that contradict Catholic teaching.

Hospital consolidation can also lead to domination of local health marketplaces by one system, which then has greater ability to demand higher prices from insurers. New Yorker health care writer Atul Gawande demonstrated in a 2009 article that variation in health care costs between communities was relative to the amount of for-profit care in each area. In Massachusetts, the newly established Health Policy Commission and the Attorney General have been tasked to review whether a for-profit system’s proposed acquisition of two hospitals can both enhance quality of care and improve costs in what is becoming an increasingly consolidated market.

Decline of Publicly-Owned Hospitals

The ACLU/MergerWatch study found that government-owned hospitals, which traditionally perform far more uncompensated care than for-profit or other non-profit systems, have dropped 31 percent between 2001 and 2011. Heavily dependent on Medicaid funding and state or local funds, publicly-owned hospitals face an uncertain future as they struggle with declining reimbursements and the financial penalties attached to the quality-improvement initiatives offered in the Affordable Care Act.

Public hospitals in states that have yet to expand Medicaid to cover all adults earning up to 138 percent of the federal poverty level are especially vulnerable. These safety-net hospitals will likely face cutbacks in per-patient payments by Medicare and Medicaid without a corresponding increase in the number of insured patients among the low-income populations they serve.

Migration of non-acute care out of hospital settings

At the same time, health care experts expect ACA incentives to accelerate the pre-existing trend of moving non-acute medical care from hospitals to outpatient clinics, urgent care centers or short-stay surgi-centers. In some cases, these outpatient settings are affiliated with hospitals and can help reduce patient reliance on emergency departments. However, many of the new medical facilities that are unaffiliated with hospitals are located in places where they compete against each other for well-insured patients, potentially leaving behind the underinsured or uninsured in chronically underserved communities. Moreover, for-profit urgent care centers usually are under no obligation to provide charity care.

Weakened state regulatory review

These changes come at a time when many states do not have the authority to review hospital transactions or have weakened regulatory oversight which reviews the impact these deals may have on community need. Currently, 36 states have some sort of Certificate of Need program in place, with varying degrees of consumer protection. At least 24 states have enacted legislation regarding non-profit hospital conversion to for-profit entities, also with varying degrees of consumer protection. While some state and federal policymakers have begun jumping into the fray, a robust consumer advocacy response to the changing health industry landscape is clearly needed.

For more information about the report, please email MergerWatch staff directly at info@mergerwatch.org 

Sheila Reynertson and Lois Uttley, MergerWatch 

First, congratulate yourselves and each other

After a horrific start in much of the country, with not only the federal marketplace but also many states as well failing to perform, the first ACA open enrollment period finished on a strong note. Enrollment surpassed the Congressional Budget Office’s (CBO) original estimate of 7 million in state and federal marketplaces. Millions more have been covered by Medicaid, in plans sold outside the marketplaces and perhaps, although we don’t have the data yet, in new take-up of employer-sponsored insurance.

While the "tech surge" that brought Healthcare.gov back from the brink got a lot of ink, the robust enrollment results could never have been achieved without the herculean efforts of all kinds of assisters, both paid and volunteer, who spread the word and helped people navigate the often balky enrollment process. They are the unsung health care heroes of the hour.

Then take a deep breath…

It will take some time to sort out just how many people have gained coverage as of March 31. And even when we learn the enrollment numbers through March, that will not be a final number, and I don't mean just because of the extension granted to those who started the process but were unable to complete it by March 31. Although Marketplace open enrollment is over except for those who are already in line, the enrollment process itself never really comes to an end.

…And get back to work

Enrollment (like a diamond) is forever. This is especially true for the lowest income households because Medicaid enrollment is continuously open year round. In addition, many people who have changes in life circumstances will still be able to enroll in the marketplaces. Graduating high school and college students probably represent the biggest wave of people with qualifying life changes, and efforts to help them enroll need to ramp up in just a few short weeks.

Beyond the need to keep up the enrollment efforts, there is still a lot of room to improve the enrollment process so that year two open enrollment, only half as long as year one, can be even more successful. Ensuring adequate funding for assisters of various kinds should be at the top of the to-do list, but it is not just a money issue. Improvements are still needed in the website and the call center, and it will be important to do a better job next time of distributing assistance resources. For example, a recent survey by Enroll America found that African Americans and Latinos were 43 percent more likely than whites to rely on in-person assistance to help with enrollment. If we want to make sure that the ACA fulfills its potential to reduce racial and ethnic health disparities, we have to make sure that there is adequate assistance in communities that need it most.

The battle for hearts and minds continues

I’m sure now that President Obama has declared that the debate over the ACA is over, all of the critics among the politicians and punditry will find something else to do with their time. Unfortunately, the truth is that while the facts on the ground have grown ever more favorable, there has been no let-up in the anti-ACA rhetoric, nor will there be in the near future. Although the ACA is not a candidate for any office and will not appear on any ballot, it will be attacked mercilessly (and largely speciously) throughout the election season. 

In order to set the stage for a second successful enrollment period, supporters need to push back against the exaggerations and outright falsehoods that will fly even more thickly during campaigns than they have up until now and just keep lifting up the benefits of the law by putting a human face on it. Fortunately, thanks to the hard work of so many who engaged in the work of helping people enroll—simple in concept but difficult in practice—those benefits should be clearer than ever.

Navigators, assisters, and certified application counselors are the unbiased people who are there helping consumers understand what the Affordable Care Act means for them and the new insurance options available to them through the law. We want to elevate their voices to share the experience of enrolling people and asked enrollment specialists to share their experiences with us in their own words. You can learn more about our work on Outreach and Enrollment here.

For me, working as a Navigator has been nothing short of a whirlwind adventure. I have participated in close to 100 outreach and enrollment events and have had contact with more than 1,500 consumers throughout a five county area in Kansas. When I began this position for the Salina Family Healthcare Center & Smoky Hill Family Medicine Residency Program, I was unsure of what to expect. What I have found is that regardless of people’s political or personal views, they are often pleasantly surprised to see how the Affordable Care Act has already helped them or will help them.

I have also discovered that many consumers are still unaware of the general provisions of the ACA. For example, I have explained to individuals that their pre-existing conditions can no longer be excluded from coverage and have informed parents that their children can remain on their policies through the age of 26. The reactions and responses I receive to these facts are usually positive. Often, I can sense that previously-established barriers that had been formed due to political views or misinformation are brought down.

I feel fortunate to say that I have had many success stories during my time as a Navigator. A few experiences hold a special place in my heart. I worked with a woman who had traveled more than two hours to receive in-person assistance. I helped her enroll in a plan that covered her medical needs and fit within her budget. She told me she had not seen a doctor in more than 20 years and broke down in tears upon realizing she could now afford to see one. I also received a call from a consumer who wanted to tell me how much the work I was doing meant to her and the community. She was crying as she told me that under her new health plan, she could now afford her prescriptions that were previously too expensive.

Initially, one of the challenges I faced was working with consumers who, for various reasons, were unable to obtain coverage by the date they needed or desired. Communication and technical errors between the Marketplace website and the insurance company’s website slowed the application process for some consumers. However, in all of these situations I was able to assist consumers with making phone calls and taking other necessary steps to help them complete their enrollment.

An even greater challenge I face now is that Kansas has not expanded Medicaid. I work with consumers every day who fall into the Medicaid “coverage gap,” which means their incomes are too low to qualify for financial assistance through the Marketplace, but too high to qualify for Medicaid. As a result, many residents do not have access to the care they deserve.

While Kansas does have a Medicaid program, it only covers individuals who make $7,421 or less per year. To qualify for financial assistance through the Marketplace, however, an individual must make at least $11,490 a year. Because the authors of the ACA intended for every state to expand their Medicaid program, but the Supreme Court made this expansion optional, people making below a certain amount cannot receive financial help through the Marketplace.  

A particularly difficult experience has been working with single parents who are not offered coverage through their employer. I have found that parents working low-wage jobs often have income levels too high to qualify for our state’s Medicaid program without the expansion, but too low to qualify for financial assistance. To qualify for financial assistance in my state, a single parent with three kids would have to work 40 hours a week for at least $11.33 an hour. Unfortunately, not many jobs in my area pay that high of an hourly rate. This puts many families in my area in the coverage gap.

The Medicaid coverage gap leaves a significant population in my state without access to needed health care coverage. As a result many Kansans will have limited access to health care, and particularly the specialized services they may need. In my work as a Navigator, I am witnessing the hard truth that many individuals and families will still be unable to obtain health coverage, even though the Affordable Care Act planned to cover them.

-- Christina Bachman 

At the beginning of March, we were thrilled to report that the bi-partisan way had been paved for New Hampshire to expand its Medicaid program. With Senate approval of Senate Bill 413 in hand, the House passed the Medicaid expansion bill on March 25, by a margin of 202-132. Finally, on March 27, Governor Maggie Hassan signed the bill into law. As a result, about 50,000 low-income adults in New Hampshire will have access to health coverage through Medicaid.

Members of the advocacy community played key roles in helping New Hampshire get to yes on the question of accepting federal funds to offer Medicaid coverage to more of its residents. In particular, we would love to give a big shout out to our friends at New Hampshire Voices for Health, as well as all the other advocates in New Hampshire, for their hard work throughout this debate. By encouraging a variety of low-wage workers—such as hair dressers, restaurant employees, and child care providers—to share their stories about the importance of Medicaid to them, advocates helped policymakers to see how much their friends and neighbors would benefit from the expansion. We have been proud to support and partner with them through Community Catalyst’s ACA Implementation Fund and the New England Alliance for Children’s Health.

There is still much to do to ensure Medicaid expansion works for the people of New Hampshire. For most of the newly eligible, coverage should begin on July 1. In the meantime, advocates and policymakers will undertake a waiver application process to get approval of some aspects of the expansion plan from the Centers for Medicare and Medicaid Services. But as New Hampshire embarks on these next steps, we congratulate them on the progress they have made toward realizing the full potential of the Affordable Care Act to increase coverage and access to care for everyone in the Granite State. 

Navigators, assisters, and certified application counselors are the unbiased people who are there helping consumers understand what the Affordable Care Act means for them and the new insurance options available to them through the law. We want to elevate their voices to share the experience of enrolling people and asked enrollment specialists to share their experiences with us in their own words. You can learn more about our work on Outreach and Enrollment here.

I am the director of the Insure Central Texas program at Foundation Communities, a non-profit that offers health plan enrollment and tax preparation assistance to low-income individuals at five locations around Austin, Texas. Our free tax preparation program is well-established, preparing more than 18,000 tax returns each year for individuals and families earning less than $50,000 a year. By offering health plan enrollment and tax preparation assistance at the same locations, we have been able to talk to people about the Affordable Care Act who would otherwise have never considered it.

As clients walk in to have their taxes prepared, a volunteer or staff person with Insure Central Texas asks people if they have health insurance. While we have their attention, we quickly explain that there is no penalty this year but “you may be penalized on your tax return when you file next year if you don’t have health insurance this year.” We explain further that we don’t want people to be surprised by the penalty next year and are available to discuss options. In my first day of screening tax clients at one location, three people I spoke with in the first hour were uninsured and had not considered health insurance. For all three, I used the “See Plans before I Apply” feature on HealthCare.gov, which is a display page that lists available plans based on the person’s age, income and location. By using this feature, I could show that the cost of insurance with the subsidies was much less than they assumed and could be less than the penalty. Two had assumed the penalty would be less and had planned to pay the penalty. One was planning to purchase insurance later in the year, when they thought they could afford it, and did not understand the deadline for open enrollment. After seeing the premiums, all three decided to enroll in health insurance.  

Since the tax sites opened in mid-January, we have seen these stories repeat over and over. Last week, Mr. C, a 39-year-old who works part time, had his taxes prepared by one of our long-time dedicated tax volunteers, Eleanor, who also volunteers as a certified application counselor. When Mr. C told Eleanor his job did not offer benefits, she encouraged him to return and apply for health insurance through the Health Insurance Marketplace. He did not think he could afford health insurance with his part-time wages, but he followed Eleanor’s advice to come back and get the facts. When Mr. C returned, Eleanor was at the site assisting with health insurance enrollment and she was again paired with Mr. C. That day, he enrolled in a silver plan that costs him $3 a month and, with cost-sharing reductions, has a $500 deductible and $750 maximum out-of-pocket expenses. He also qualified for a premium tax credit of $202 a month, and so his yearly premiums will cost less than the penalty for being uninsured. He said, "Everyone here is so nice but Eleanor is the best!"

Recently, a couple in their early 60s was at our site to have their taxes prepared. Neither had been insured for 15 years. All it took was someone asking if they had insurance and explaining their options for the couple to feel comfortable enrolling in a health plan they had assumed they could not afford. The affable husband was very blunt, stating it was ignorance that kept them from looking into health insurance. He explained that he had believed all of the negative press surrounding the Affordable Care Act—that the prices of new health plans were prohibitively high. As a result, he and his wife assumed they had no option but to wait until they qualified for Medicare. They are now thrilled to have health insurance they can afford and agreed to share their story on Telemundo to encourage others to enroll.

My experience at Insure Central Texas has taught me that connecting with people at tax time has been an effective form of outreach. Without a doubt, it has allowed us to reach people who would otherwise have not enrolled. 

-- Elizabeth Colvin, Insure Central Texas