Rising costs, limited access and uncertainty surrounding the future of Medicaid and the Affordable Care Act are driving factors concerning health care — the top issue identified by readers of The Daily Item heading into the midterm election Nov. 6.

Of 343 respondents in a weeklong online survey at dailyitem.com, 264, or 77 percent, said health care was the “most important” issue. Health care kicks off a weeklong series, 5 Issues in 5 Days, that will also examine concerns surrounding immigration, the economy and jobs, gun policy and senior issues.

The local results reflect returns in a statewide poll by Altarum and a national poll by the Kaiser Family Foundation, each of which closed with health care topping all other issues.

Millions of Americans gained access to health care with the introduction of the Affordable Care Act, but insurance premiums remain expensive and there’s been confusion for registrants who found it difficult to keep plans and doctors they preferred.

Republican leaders long pledged to repeal “Obamacare” but midterm elections brought about new campaign pledges: protecting the legal precedent that bars insurers from denying coverage to people with pre-existing conditions. Democrats seized on recent comments by Senate Majority Leader Mitch McConnell, a Republican, implying “entitlement” programs like Medicaid, Medicare and Social Security could be cut to reduce the nation’s deficit.

Robin Stelly, a statewide organizer with Pennsylvania Health Action Network, said there’s one commonality across all demographics political and social: anxiety.

“People are worried about costs, costs of premiums, costs of care, deductibles,” Stelly said. “They all agree they want something done about it.”

Those who purchased insurance through the HealthCare.gov Marketplace and those covered by traditional Medicaid and others added through Medicaid’s expansion fear a decision in Washington could cost them health coverage altogether, Stelly said.

A poll of 960 Pennsylvania adults by Altarum, a nonprofit research and consulting group, found half were burdened by medical bills this year and one-third struggled to pay the debt. The poll found 4 in 5 worried about affording health care in the future, and 4 in 5 across party lines were dissatisfied with the current health system.

The Kaiser poll found that Republican voters rank health care behind immigration and the economy and jobs, but it tops the list for Democrats and independents. Health care costs unite voters nationally, the poll found, and in the end, the issue ranked tops among all issues as a whole.

Federal policy changes to short-term limited-duration insurance plans concern the Pennsylvania Insurance Department, according to Alison Beam, chief of staff.

Such plans were intended to be a bridge for those between jobs or who missed open enrollment periods. They were limited to three months and were non-renewable, Beam said. New federal rules effective Oct. 2 allow people to stay on such plans for up to three years — one initial year with two renewals.

Short-term plans are cheaper because the coverage is far less comprehensive than major medical coverage. The risk is what’s not covered and ensuing out-of-pocket costs as a result. Beam said the department is concerned that some insurers don’t fully explain the potential risks and coverage limits. Licenses for eight insurers were revoked for misrepresenting such plans, Beam said.

“People are characterizing it as an alternative to major medical without going into depth on its shortcomings,” Beam said. “This is not a product intended to replace major medical.”

Beam likened short-term plans to Swiss cheese — it’s shaped like a block of cheese but filled with holes.

Though the ACA protects those with pre-existing conditions who buy major medical coverage, such protections aren’t in place for short-term health insurance, Beam said.

Maternity care, emergency care, prescription drugs and hospitalization are among many essential health benefits for which coverage on a short-term plan isn’t mandatory.

Dr. Greg Burke is a Geisinger internist and the health system’s chief patient experience officer. Among the biggest issues expressed by patients is accessibility and stability. They worry about being able to set timely appointments and about remaining patients of doctors with whom they’ve developed trusting relationships, he said.

Patients in rural areas struggle with a lack of options. Burke said some months Geisinger hires 50 to 60 clinicians. However, there are portions of the state where there simply aren’t enough physicians and specialists. One potential solution, he said, is telemedicine.

“Drug costs and affordability is becoming increasingly a top priority. Sometimes patients come and say, ‘I can’t afford it.’ Those prescriptions can’t be filled,” Burke said of people making health care decision based on out-of-pocket costs.

The complexity of marijuana laws in the U.S. raises the issue of employee use of medical marijuana, according to Nichole Frye, director of operations, The Workcenter at UPMC Susquehanna Sunbury.

Medical marijuana is legal in Pennsylvania and other states, but overriding federal laws continue to prohibit marijuana use medicinally and recreationally. Certified doctors recommend patients to use the drug, but it’s not considered a prescription like what’s written for access to painkillers or antibiotics.

Employers of heavy equipment operators, truck drivers and the like are concerned about the potential impairment of employees using medical marijuana, Frye said, and there is no standardized guide for impairment as there is for alcohol. It complicates policy-making for employers, she said.

Impairment depends on the type of medical marijuana a patient may use. According to the National Institute on Drug Abuse, the main properties currently used for medical purposes are THC and CBD. THC produces psychoactive effects, the feeling of being "high." It's used to boost appetite and reduce nausea and also as a pain reliever. CBD, however, lacks the THC, doesn't produce a "high" and isn't popular for recreational use. Its use includes reducing pain and inflammation and controlling epileptic seizures.

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