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HILLSVILLE — About 100 people turned out to Ninth District Rep. Rick Boucher's town hall meeting on healthcare reform in Hillsville on Saturday, and attendees heard the congressman's concerns about the public insurance option and his assurances that no federal funds will go toward treating illegal aliens or providing abortions.
Audience members mostly listened to Boucher (D-Abingdon) respectfully — unlike widespread television broadcasts of disruptive yelling and chanting crowds at other legislators' town hall meetings over the summer — but several speakers repeated fears about illegal aliens and abortions.
Some audience members appeared to not accept the Ninth District representative's consistent answers on those hot button topics.
At the outset of the nearly three-hour meeting held in the Carroll County High School auditorium Saturday morning, Boucher explained that he did not come to Hillsville to support or oppose any of the five bills on healthcare reform circulating in Congress, but to get input from constituents and present an opportunity for discussion.
"Citizens have significant concerns, hopes for and certainly views to express," he said.
However, he shared with the audience his personal feelings over the viability of the "public option," or the federal government getting into the business of providing health insurance for the millions of people who cannot afford to purchase their own from private companies.
The public option system would likely be set up similar to federal programs like Medicaid and Medicare, Boucher said from the stage. Medicare and Medicaid do not reimburse hospitals for the entire cost of providing care to the program's beneficiaries.
The congressman put the number for reimbursement by these federal programs at about 80 percent of the actual cost, so hospitals lose money on each of their Medicaid and Medicare patients. That's a problem for small rural hospitals, like the ones in Southwestern Virginia, because they are financially fragile.
Rural hospitals depend on the number of patients with private insurance to stay financially stable, Boucher continued. But more people taking the public option — on payment schedules expected to be similar to Medicare and Medicaid, if that became available through the reform — could reduce the revenue that goes to the hospitals even more, further financially weakening those institutions.
Boucher said he voted against the proposal that the House Energy and Commerce Committee put forward, which would give citizens more time to read up on the bills and provide input. "I thought we were rushing the process."
In the end, he hoped the extra time could be used to develop legislation that had broad public and bipartisan support.
As he's talked to people, including healthcare professionals, in the interim, Boucher has heard one continuing refrain — that the financial health of rural hospitals could be at risk if the reforms aren't handled right.
The question of how healthcare reform will affect healthcare delivery in rural areas is a practical consideration, not a political or a philosophical one. Boucher pointed out that two hospitals in Southwestern Virginia had closed temporarily to highlight the shaky ground that some institutions find themselves on already.
Reforms are necessary, because the current practices are clearly not sustainable, Boucher said. Costs of insurance to citizens are increasing more than three times the growth of disposable income.
As costs rise, fewer people can afford healthcare insurance, which is why about 36 million don't have any insurance at all, he said. Most people who don't have health insurance are working but don't have insurance offered through their company and they don't make enough to buy private insurance on their own.
If it keeps going this way, then only the privileged will be able to afford insurance.
Those without insurance who have health issues will hold off on seeking treatment until the problem becomes critical, Boucher said. Then they present themselves at a hospital's emergency room and receive the highest priced basic medical care services available.
"It's a very expensive way to get basic health care," he said.
Because of these patients' lack of insurance, the hospitals can't recover these costs, so the healthcare provider increases prices for everyone to get the needed revenue to continue operations. Boucher said this causes the typical American family to pay $100 a month extra for healthcare services.
With healthcare reform, the average family could save that much in healthcare expenses right away.
Insurance companies denying policies for people with pre-existing medical conditions means that some are trapped in their jobs, because if they left that place they couldn't get a new insurance policy, he said. Healthcare reform will seek to end the practice of denying people coverage based on pre-existing conditions.
There's also a need to promote preventative care, which leads to better health results at a lower cost.
People who want to keep their health insurance should be able to under healthcare reform, Boucher said. And Medicaid and Medicare recipients should get at least the same level of coverage they get now, if not more.
The congressman expects switching from paper to electronic records, another reform aim, would lead to better accuracy in treatment and fewer duplicated tests, because all healthcare providers would have access to the same records.
Boucher brought along three healthcare professionals to provide additional perspectives.
Lindy White, CEO of Smyth County Community Hospital, provided her insight as an administrator of a 47-bed non-profit facility.
She recognized that the current healthcare situation is not sustainable, with 18 percent of the United States gross domestic product going to pay for healthcare, she said. People don't have the same access to healthcare, and wellness and prevention needs to be emphasized more.
She agreed with the need for electronic records to better coordinate care in hospitals and reduce waste.
Patients have benefitted from the miraculous development of diagnostic technology that allows providers to understand their health problems more quickly, start treatment sooner and get better outcomes, White said. Those with chronic care needs, those with congestive hearth failure or pneumonia need improvement so patients can be treated and sent home quicker, reducing the costs.
Facilities that do well in tackling patient care and controlling costs should be rewarded under the reforms for their good work, she said.
Health care providers need to study those institutions that do a better job of managing costs and implement the best management practices at hospitals, she said.
But White said that the health care system is complex and cannot be fixed overnight, so she hoped that legislators would make less sweeping and more practical reforms over time.
As Boucher said, hospital administrators are worried about the financial impact of the public option and reduce reimbursements.
The problem is already growing with the former rate of 6.5 percent of Smyth County's patients being uninsured — and that number has doubled recently.
White supports tort reforms to bring the costs of malpractice insurance down for healthcare providers.
Reform should follow the same philosophy as the hospital practices when providing medication for a patient, she said. Just like hospitals need to give the right medication, in the right dosage at the right time, the federal government needs to be sure that its reforms take the right form and right dosage at the right time, and she wondered if, during the current recession, it is the correct timing to go ahead with these measures.
"We got to take it slow, steady, conservative, accurate pace," she concluded.
Galax-based physician Jim Nuckolls noted that the healthcare system is so piecemeal, it's hard to remain consistent.
Doctors could take the blame for ordering too many tests or charging too much, he said. But even if the doctors didn't charge for their services, there still would be the issue of patients being able to afford treatments and medication.
The physicians could prescribe a medication and then have to raid their own drug supply hoping to find enough samples to provide a patient, so they could afford the help they need.
Insurance is a complex issue — Nuckolls said his clinic had to deal with 411 different insurance companies and they all had different diagnostic tests they cover over different periods of time and different medications, too.
He agreed with the need for both electronic records and better treatment for chronic ailments.
The fact that Carilion went to electronic records back in the 1990s in its 72 offices and six hospitals allowed better management of 25,000 diabetic patients in the system. Through the records, he said Carilion could monitor which patients were doing well and, as a result, which doctors were treating patients correctly.
Sharing those results helped the doctors who weren't doing as well improve their patient care, Nuckolls recalled. It reminded him of the saying, "Don't call him a cowboy until you see him ride."
The electronic records let doctors collaborate and share and it's better for patient safety. Nuckolls noted that, with 60,000 medications out there, doctors just aren't smart enough to know which medications, when taken together, cause adverse reactions.
C.M. Mitchell, director of pharmacy at Twin County Regional Hospital and mayor of Galax, points out that electronic records would improve efficiency, specifically in billing.
After patients get discharged, it takes 23 people to go through that person's chart to ultimately figure out the bill, he said. Electronic records would be helpful in reducing such inefficiencies.
Goals of reform include expanding coverage, focusing on wellness and providing quality care, he said.
There is an incentive for communities to provide health care with a focus on wellness. "If we can have a healthier community, maybe we don't have as many people with chronic conditions."
Communities with healthier people could be an economic development tool by providing businesses with more productive workers, Mitchell said. "It's vitally important we continue to build healthy communities."
When Boucher opened the floor to speakers from the audience, more than a dozen people quickly approached his aides in the aisles with the microphones.
Those speakers and their concerns included:
• Maggie Anderson, who spoke about her support of removing from federal law the exemption of health insurance companies from anti-trust provisions and her hope that taking that action would increase competition. She also mentioned insurance cooperatives' success in providing competition to the private companies.
Boucher agreed that removing that exemption is important because, in many states, effective competition does not exist, with only one or two healthcare plans being available.
The House Judicial Committee is soon to debate the repeal of this exemption, and he thinks it's time for that to happen.
The thought that the public option is needed as a way of encouraging competition remains in the minds of some, but Boucher knows a few with different ideas about how to make that happen.
He has been listening to a proposal from Tom Carper of Delaware, who wants to allow the states to decide whether they want to provide a public health insurance option.
That would allow it to become a function of states and their constituencies to decide policy, rather than having Washington impose something on the entire nation.
Insurance cooperatives in Washington state and Minneapolis, non-profits controlled by citizens who participate in them, have seen successes in controlling costs and providing competition.
The role of the federal government in co-ops, as Boucher sees it, is only to provide loans for them to start up.
• A man who did not identify himself said he supports the tort reform provision of the legislation and suggested allowing insurance companies to sell policies across state lines to provide competition among insurance providers.
Boucher noted that he has provided his federal colleagues with Virginia medical malpractice legislation as a potential model, which he helped write years ago as a state representative.
When drafted, it capped malpractice awards at a million dollars, though the congressman believes that's been increased to $2 million now. He's been slow to come to the conclusion that the federal government needs to enact a similar cap, because he's a states' rights advocate.
But now, he believes that there are too many cases of "runaway awards" in courts that have nothing to do with the facts presented in the cases.
That drives up malpractice costs and, therefore, the costs for all patients, he said.
His worry about allowing competition between states for health insurance is that it would spark "a race to the bottom," with companies seeking out the state that imposes the least stringent standards in providing insurance.
• Two speakers in a row, Mike Vaughn and Carroll Hill, expressed their worry about the federal government implementing a healthcare program that costs about a trillion dollars, given current spending deficits.
Boucher agreed that federal government spending is already at a ridiculous level.
"I will not vote for healthcare reform that will add to the federal deficit," he said to applause.
• Tony Olivera indicated that elected officials in Washington are not acting with transparency when committees with representatives like Senator Max Baucus are going behind closed doors to fill in details of their proposals.
Boucher answered that different pieces of legislation pertaining to healthcare reform have emerged from the public process of writing the bills.
The process of merging the bills is merely a mechanical one, and he said that nothing that wasn't put in the proposal during the open process would appear in the final combined version of the legislation.
• Virginia Del. Bill Carrico (R-Grayson County) said he understands the cost of doing nothing in regards to healthcare reform is $150 billion, but that pales in comparison to the cost of more than $800 billion to go ahead with the changes.
If the federal government rushes to change the system, then the cost would be great and the result will also put personal liberties at risk, Carrico said.
But Boucher recalled that healthcare costs have already grown quite expensive and are continuing to rise, greatly increasing the number of people who can't afford to have health insurance.
Failure to act means that more people will lose insurance, and as a result, the costs will go up for everybody else until only the wealthy can afford insurance, Boucher said. Considering those facts, the congressman believes that the cost of doing nothing is far greater than enacting the reforms.
• George Haydt noted that the country loses 40,000 people annually due to lack of medical care, a cost that needs to be considered in the equation, too.
He went on to share that his son-in-law makes $15 an hour at a small company that provides health insurance.
Coverage is affordable for him, but not for his wife, who has a pre-existing condition. Haydt said that's already led to their family declaring bankruptcy due to her medical issues and he expects they'd have to declare bankruptcy again if she has more problems.
Haydt also said he's enrolled in a medication program where the costs will soon rise 400 percent to $3,000 in a year, while at the same time the CEOs of top insurance companies are making a combined $1.48 billion in compensation a year.
Haydt believes that the federal representatives have the intelligence to make changes to the law so his daughter will not have to go bankrupt if something happens.
"Insurance companies don't need help, they're doing fine," he concluded.
• Jeff Holderfield wanted to know if Boucher would go on record if he would vote on a public option or not.
At this point, Boucher said he wants to consider the impact that all options would have on delivery of healthcare in Southwest Virginia, and right now he believes that the public option would have a negative effect.
• Paula Carrico expressed her opinion that once healthcare reform passes, the American Civil Liberties Union would immediately bring a lawsuit that illegal immigrants must be provided with federal coverage — and she expects the U.S. Supreme Court would hand down a ruling that agrees with that position.
Boucher answered that illegal aliens have no constitutional standing to demand coverage from the United States government.
("That's not true," blurted an audience member, one of the few times when the audience's reaction overrode its quiet composure.)
It's true that some states have decided to provide illegal aliens with some benefits, but that's been a voluntary decision, Boucher said.
Carrico had also raised questions about the delays for treatment that relatives who live in Spain have experienced in their healthcare system.
That's because Spain has a single-payer system and it's completely government-run, Boucher said. Nothing like that is being considered in the healthcare reform process here.
• More than one citizen asked Boucher if he would oppose federal dollars paying for abortion.
Yes, Boucher said. That is already prohibited under federal law.
After one audience member brought up the insurance benefits that federal representatives get, Boucher explained that the goal of healthcare reform is to make sure that the general public can enjoy the same kinds of coverage that all federal employees do.
Boucher's benefits come from Anthem Blue Cross/Blue Shield, he said. Congressmen have deductibles and co-pays just like everybody else.
What's different is that federal employees get real choices and they can't be denied on the basis of pre-existing medical conditions.
Reform, if approved, would create exchanges where citizens can study their choices, benefits and costs with good information, Boucher said. The goal is to let individuals have the same insurance options that federal employees have access to, Boucher said.
• William Roberts of Elk Creek said he believes that federal legislators can deal with the concerns involving reimbursement rates for rural hospitals by writing an amendment to address that.
• Dennis Neely pointed at the recently created "donut hole" as proof the federal government should stay out of health care reform.
Boucher explained that the man was referring to loopholes in the Medicare Part D prescription coverage that creates sizable gaps for medications that the individuals have to pay for themselves.
But another goal of health care reform is to do away with the so-called donut hole, he added.
• Scott Webster believes that there would be sufficient competition if only the federal government would allow the 1,300 insurance companies to compete against each other across state lines.
• Gina Isom asked if her small business would have to provide its workers with insurance.
No, Boucher said, small businesses would be excluded from such requirements. But he expects there would be government subsidies available to help businesses meet requirements of new legislation.