Uncertain hopes

Northern Nevada HOPES is a nonprofit Reno health center created in 1997 for “medically under-served populations.” HOPES is an acronym for HIV Outpatient Program Education and Services. While it originally dealt principally with sexually transmitted diseases and similar maladies, Dr. Trudy Larson—one of its founders—said this week, “It now provides total primary care for adults and children. It’s quite remarkable. It’s a full-fledged community health center.”

In its two decades of service, HOPES has gone from an ability to handle 800 cases to 10,000. And it is now turning away 80 cases a day. The limitations on its ability to handle more cases is mainly the size of its physical facilities. Its building was constructed for expansion, and in the next two or three weeks, work will be completed on an expansion that will allow it to handle 18,000, which should serve it until 2020.

But that’s not the only challenges it has faced. In 2009, the Medicaid provisions of the Affordable Care Act allowed HOPES to widen its assistance to more patients.

“It has had a huge impact on our patients, allowing them to get the care they need,” Larson said. “It also provides reasonably priced insurance for the patients who are outside the Medicaid salary cap. And it was very difficult before ACA to get our imaging and lab testing done—a scan or MRI—or specialty care that might be necessary.”

But the ACA is unlike other federal laws. Normally, in the past, when a law was enacted, even over fierce opposition such as Social Security, the 1964 Civil Rights Act or Medicare, the debate ended with enactment. The majority’s final decision was accepted, and the nation got on with implementing the measure.

But many Republicans in Congress have never taken that final step, and there have been repeated attempts to repeal the ACA. Failing that, Republicans more recently switched to a strategy of trying to get rid of individual components of the ACA until it is “hollowed out.”

For example, in October 2017, Donald Trump ordered that payments be halted for cost-sharing subsidies that reimburse insurers for reducing deductibles and out-of-pocket costs. Republicans argued that although Congress had approved the subsidies, it had never appropriated the funds for them. About six million lower-income policy holders were affected. The change threw “insurance marketplaces into a tizzy and possibly result[ed] in higher prices and less coverage for many,” health care journalist Trudy Lieberman wrote. As it happened, Trump could do nothing about insurance companies having to meet the cost of the subsidies, so they raised rates.

There have been about a half dozen such changes. The administration even cut back on advertising that explains the program to consumers, which resulted in a drop in sign-ups, meaning fewer people with insurance, which drives up health care costs.

For HOPES and many other health care programs, the chronic uncertainty is unnerving.

“I think what we see with the ACA and with Medicaid, the expansion of Medicaid, is that we find the uncertainty challenging as we try to think strategically about the future and expansion,” said CEO Sharon Chamberlain. “Having a very clear picture of what is going to unfold could help us have a better opportunity to insure that we are sustainable in whatever business models that we have.”

Navigating politics

It’s not just HOPES that is experiencing this uncertainty. Health care organizations of all kinds feel it. HOPES marketing coordinator Mary Ingvoldstad has been a U.S. Senate aide dealing with health issues and was previously associated with Immunize Nevada and Renown Health, giving her a wide view of the health care system.

“The uncertainty around the ACA has added stress to the whole health care system,” she said.

The costs in tension and finances of coping with frequent changes is anyone’s guess.

For HOPES, which in part treats patients with stigmatized maladies, it exacerbates an already difficult mission.

And just to tie things together neatly, at the moment, there is an election campaign going on in which the ACA’s fate may well be determined. For many health care programs like HOPES, it’s like walking through a political minefield. Such programs try to maintain good relations with congressmembers on both sides of the aisle, but the campaign does not make that easy.

Last year, U.S. Sen. Catherine Cortez Masto, a Democrat, toured HOPES. Afterward she put out a statement: “HOPES has been essential to Nevadans who rely on their services and we must ensure that it continues to get the support it needs. Unfortunately, community health centers like HOPES risk losing their funding, and 400,000 Nevadans could lose their health coverage because Republicans are recklessly threatening to repeal the Affordable Care Act. We must work together to improve the ACA—not put the health and well being of Nevadans at risk.”

Ingvoldstad told us HOPES is non-partisan and has a good working relationship with Republicans Dean Heller and Mark Amodei, who also represent it in Congress.

Chamberlain said, “We’ve spoken with and have good relationships with all our congressional delegates, and we have heard that there is support for continued ACA and Medicaid expansion.”

In Nevada, state Republicans—including Gov. Brian Sandoval—opposed enactment of the ACA. When it was approved anyway and survived court tests, Sandoval said grudgingly, “Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court. As such, I am forced to accept it as today’s reality, and I have decided to expand Nevada’s Medicaid coverage.”

Sandoval also decided the state would have its own exchange rather than having Nevadans deal with federally managed exchanges to obtain coverage. His eventually cooperative attitude has stood in contrast with many other Republicans. To this day, only 12 states have state-run exchanges, officials of other states being unwilling to participate in ACA even to that extent.