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Columbus Community Hospital has managed to thrive during the ups and downs that came with the Affordable Care Act, but other rural hospitals haven't been so lucky.

COLUMBUS — Several Republican lawmakers, including President-elect Donald Trump, ran for office on the platform of repealing the Affordable Care Act.

But what the health care legislation, also known as Obamacare, would be replaced with is still up in the air. That has health care advocates, hospitals and care providers concerned.

“Nebraskans deserve to know what our health care is going to look like before making a huge change in our system,” said James Goddard, an attorney for Nebraska Appleseed. “The Affordable Care Act should not be repealed without a plan in place to continue the gains made.”

The Nebraska Department of Health and Human Services reported last week that 85,282 Nebraskans signed up for health insurance coverage in 2017 through the Marketplace created by the Affordable Care Act. Of that figure, 43,336 were from rural areas, including Columbus.

In Platte County, 1,487 people signed up for health insurance through the ACA, according to Nebraska Appleseed.

What, if anything, would happen to those consumers depends on which parts of the ACA lawmakers decide to keep in place.

“There's some good provisions in the Affordable Care Act and there's some bad ones,” said Mike Hansen, president and CEO of Columbus Community Hospital. “Some have worked and some haven't worked.”

The good provisions, Hansen said, were those that increased access to care as insurers could no longer reject someone based on pre-existing conditions or drop their coverage when they became sick. Caps were also set for how much insurers can charge older patients.

The expansion of health insurance coverage reduced the amount of bad debt, which is unlikely to be paid, that providers had to take on.

Rebecca Rayman, executive director of East Central District Health Department, said the local Good Neighbor Health Center benefited from having more patients with insurance.

“That meant we had more income and were able to expand some of our services to serve more people,” Rayman said in an email.

While many Nebraskans found health insurance through the Marketplace, Hansen said the broader plan didn’t pan out. The Marketplace was supposed to allow insurers to compete, driving down premiums and deductibles.

“Well, obviously that didn't happen,” Hansen said.

Nebraska’s Marketplace started with fewer than a handful of insurers, some of which later dropped out. With less competition and more unhealthy people signing up, insurers had little incentive to keep prices low.

“In effect, the insurance companies have transferred their risk to their members, which in turn transfers risk to us,” said Hansen. “Because if somebody has a $5,000 deductible, the chances of them paying the deductible are pretty slim. Most people can't afford $5,000 right out of their pocket.”

One of the trade-offs hospitals made with the ACA is receive less reimbursement for treating Medicare and Medicaid patients. For Medicaid patients, Hansen said CCH receives about 60 percent of the cost of care.

In exchange, hospitals were going to have more patients, usually the poorest and least likely to be able to pay a hospital bill, covered under Medicaid expansion. But only 31 states expanded Medicaid — Nebraska wasn't among them — so that money didn’t come to the state's health care providers.

“It was a lot of money left on the table that Nebraska taxpayers are sending to Washington, D.C., and not getting back,” Hansen said.

In a recent "Weekend Edition" segment on NPR, Maggie Elehwany of the National Rural Health Association said 80 rural hospitals have closed since 2010 in part because those states did not expand Medicaid.

“If this rate continues, in less than 10 years' time we're going to have 25 percent of rural hospitals close within less than a decade,” Elehwany told NPR’s Scott Simon.

In spite of the negative trends for rural hospitals, Hansen said CCH is doing well.

“We're kind of a misnomer because we've done so well,” he said.

Part of the hospital’s success is because a majority of its patients have private insurance. Hansen said only 40 percent of CCH patients are on Medicare and 7 percent on Medicaid.

“We're also very lucky to have ECDHD, who also provides care to those who can't afford it,” he said. “We have that benefit here where a lot of places don't have that.”

Rayman said that while the ACA is not perfect, she hopes lawmakers will keep some of its provisions.

“Arguably, the ACA has flaws, but even with those flaws people are still seeking out insurance,” she said. “I hope and believe that our lawmakers will consider these individuals when working out a solution for our health care system.”

Hansen said he hopes the provisions that helped consumers access care will stay in place.

“Originally, they had talked about repealing everything,” he said. “Well, I think they wised up and realized that, hey, there are some good provisions of the Affordable Care Act.”

Rayman and Hansen said there are some fundamental issues with the health care system that need to be addressed.

“I suspect, no matter what, there will continue to be uninsured and underinsured,” said Rayman.

“We as Americans have to answer one question: Is health care an entitlement or a benefit?” said Hansen. “If it’s an entitlement, then we need to define what that entitlement is and the government needs to provide that level of entitlement. Beyond that, if you want additional services then you pay for it yourself or through your insurance.”

“We've never answered that question,” he said.

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