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Killing Medicaid Expansion Kills Patients

by Ethan Forsgren, medical student at the University of Iowa Carver College of Medicine, and Melissa Palma, MD, recent graduate of the University of Iowa Carver College of Medicine


Although he doesn’t know it, my patient Daryl will soon be at risk of dying due to lack of health insurance. Dressed in a Cyclones sweater and a Hawkeyes baseball hat (one for each grandchild, he tells me), Daryl is a jovial man in his mid-seventies who loves the daily crossword puzzle and bragging about his wife’s rhubarb cobbler.

Daryl and I discuss the pain from his crippling hand numbness in neurology clinic, where I am a medical student at the University of Iowa. These symptoms have worsened from steering wheel vibrations while driving, on average, three hours round trip to see specialists in Iowa City following a farm accident.

His warm smile fades for a moment as he recounts his wife, Sally, who lives in the dementia wing of a nursing home. Fully dependent on staff for all of her activities of daily living, she still remembers her prize-winning recipes, but not his name.

The House-approved American Health Care Act of 2017 (AHCA) and the proposed Senate Better Care Reconciliation Act (BCRA) would approve cuts to Medicaid that hurt Iowans. These changes could cause rural hospitals to close down, shutting out patients like Daryl and Sally from lifesaving care close to home.

Since 2016, over 150,000 patients have gained health insurance from the Affordable Care Act. We call on Sen. Grassley and Sen. Ernst to oppose the BRCA, and any reductions in Medicaid expansion.

The proposed bill strips Iowans of coverage for mental health, preventive care, maternity care and Medicaid expansion through the Iowa Health and Wellness Plan. These changes will devastate patients in Iowa and across the nation. To our future patients, we will soon have to say, “I’m sorry, I can’t help you.”

The cuts to Medicaid would hurt rural Iowa the most. Under the Senate bill, states can allow insurers to charge older people more than five times what younger people pay. Former Governor Vilsack remarked,”Rural America has an older population. It has less access today to medical care. It’s pretty much dependent on Medicaid. And, this is going to hurt rural hospitals, and make it hard for them to stay into business.”

Over 538,000 Iowans, 17% of the state population, rely on Medicaid for health care. Patients like Daryl would no longer be able to afford seeing doctors. Without adequate Medicaid reimbursement, BCRA would have a devastating impact. It would deprive stable employment from the 8.8% of Iowans employed by hospitals in Iowa, to the tune of 25.5 billion dollars.

There are 168 rural clinics and 82 critical access hospitals in rural Iowa with over 2,000 hospital beds. As a rural state with a growing elderly population, Iowa needs to expand access to health services, not decimate it.                                               

Killing Medicaid expansion kills Iowans. Nearly 240,000 men, women and children are at risk of losing coverage if the Senate health bill passes. Based on estimates published in the Annals of Internal Medicine, for every additional 830 adults who gain health insurance, we stop one preventable death. The BRCA restrictions will lead to unnecessary deaths of hundreds of Iowans and tens of thousands of Americans nationwide.

To be sure, there must be a solution for the rising costs of health care in this country. But it should not come by stripping hardworking Iowans, their children and our rural communities from crucial access to health care.

The medical community is united against this health care bill because we cannot turn our backs on our patients. The American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Diabetes Association, the AARP, and the American Public Health Association, have all come out against the AHCA and the current Senate bill.

The American Association of Medical Colleges implores that a health care bill out of the Senate should at least maintain current levels of health care coverage. It should not weaken Medicaid. It should happen as part of a deliberate and transparent process.

Unfortunately, this bill doesn’t meet any of these criteria. It doesn’t put patients first, and by sending more patients to the emergency room in places like teaching hospitals, it could even destabilize the health care system. We urge our representatives to learn and understand how this legislation will affect constituents.

As medical students and trainees, we see firsthand the fears of people faced with impossible decisions. Together we took an oath, “First, do no harm,” and together we must stand against this health care bill to ensure it never has the chance to harm our patients.

We call on our fellow citizens to protect the people of Iowa to contact Sen. Grassley (202-224-3744) and Sen. Ernst (202-224-3254) to oppose any bill to phase out Medicaid expansion at the expense of our rural, elderly and most vulnerable citizens. The lives of cobbler-eating grandfathers with neuropathy, nursing home residents, and patients all across Iowa are at stake.

Editor’s note: An abbreviated version of this editorial appeared in The Daily Iowan.

Melissa Palma, MD Melissa Palma, MD (2 Posts)

Resident Physician Contributing Writer

Greater Lawrence Family Medicine Residency


Melissa Palma is an aesculapian advocate and resident at the Greater Lawrence Family Medicine Residency in Lawrence, MA. Her writing reflects on the privileges and responsibilities we have as physicians to advance health equity for our patients and our communities. When not in the hospital, you can find her studying or reading non-fiction while nursing a taro boba tea.