These mostly unedited excerpts are taken from this podcast. This spreadsheet offers live tracking of the bill.
ACA changes
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limit the annual open enrollment period that people can sign up for coverage. Instead of ending mid-January, that would end in mid-December.
- 40% of people who use Obamacare, this 10 million Americans, they actually selected their plans after December 15th.
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requires people to provide additional verification of their income before they can sign up for coverage
- verification then would have to happen against information with the IRS, the Social Security Administration, state Medicaid databases, and the Department of Homeland Security.
- they try to match your income to known databases, let's say the IRS, but if it doesn't match, they would come back to you and say we need more verification. And that process could take a while, particularly with the kind of layoffs we've been seeing in the federal government. And with the shortened open enrollment period, you could find yourself trapped in this verification process and not being able to verify your income until the deadline has already passed.
- prevent people from auto renewing their coverage. So for those of us who have insurance through our employer, every year, it just gets automatically renewed. We don't have to go through a process to re-up our health insurance. That would no longer happen with Obamacare.
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the bill would eliminate coverage for many lawfully present immigrants who can currently sign up for Obamacare.
- They wouldn't be eligible for Medicaid, they wouldn't be eligible for the ACA, they would be forced to be uninsured.
Medicaid changes
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a work requirement, so that people would have to be working or qualify for certain exemptions or do community service
- 92% of Medicaid enrollees are either already working or would qualify for an exemption, like being a parent of a dependent child or being ill, having substance use, being in school.
- have to report it potentially as frequently as every month…in states like Arkansas and Georgia that have had work requirements, many people lost coverage, not because they weren't working, but because they couldn't navigate the process to prove that they were working.
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Limits Disproportionate Share Hospital Payments (DSHs): these are payments made by the government, by Medicaid, to hospitals that serve a larger than usual proportion of low income or uninsured or Medicaid patients to help them keep going
- because fewer people would be covered, hospitals would get paid less, they would have fewer paying patients. In fact, they would end up with more uninsured patients who couldn't pay their bills.
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another provision that allows states to direct money to hospitals would be capped. There are taxes that hospitals and nursing homes pay to help fund the state share of the Medicaid program. 70% of children in CD4 are Medicaid patients.
- Medicaid represents about one fifth of all hospital care provided in the country. In fact, over four in 10 births. So hospitals are quite dependent on Medicaid payment for low-income patients
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for folks who need long-term care: they have to have limits on how much equity they have in their homes. Medicare, which covers all seniors, does not cover long-term care. It does not cover nursing home care that's covered in Medicaid, or people pay out of their own pockets. Very few people can actually afford a long stay in a nursing home.
- In order to qualify for Medicaid and get long-term/nursing home care, people spend down their assets and there are some limits on how much of the value of your home you can retain as you spend down to qualify for Medicaid. And this bill lowers that limit somewhat.
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Republicans have been framing the changes to Medicaid and the Affordable Care Act as trying to eliminate fraud, waste and abuse. The reality is, there certainly is fraud in these programs. There's fraud everywhere. There's fraud in private insurance as well.
- Fraud is mainly perpetrated by health care providers. So a durable medical equipment provider that is billing for wheelchairs that they're not actually providing to patients.
- There's really nothing in this bill that addresses that kind of fraud. This is a spin effort to try to frame cuts that will result in more people being uninsured as eliminating fraud, waste and abuse.
- This is very different from past budget reconciliation bills that have been done in the past, which had a mixture of cuts and expansions in programs. The BBB only has cuts.
- It cuts Medicaid and the ACA substantially and Medicare to some extent, in order to help pay for tax cuts.
Medicare
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a lot of it involves people who are eligible for both Medicare and Medicaid. Medicare doesn't cover everything, so low-income people often sign up for Medicaid as well.
- So for example, you would only have to renew your coverage once a year under the assumption that once you're elderly, you stay elderly. Once you're disabled, you typically stay disabled. And then once you're low income, when you're elderly, you typically stay low income. This bill would remove that requirement, that you only have to renew your coverage every year. The Congressional Budget Office has estimated that 1.3 million people would lose Medicaid coverage.
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The bill would restrict Medicare eligibility to Citizens, Green card holders, certain immigrants from Cuba. And people residing under the Compact of Free Association.
- Essentially people who would no longer be eligible would be folks on TPA or temporary protective status, refugees and asylum seekers. Or people granted asylum in the United States.
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if the bill is enacted, you say in its current form, and Congress takes no further action, the increase in the deficit would trigger mandatory cuts. And those cuts could be approximately $500 billion to Medicare. From 2026 to 2034.
- these cuts to health care, which are substantial, a trillion dollars in cuts to health care, which would be the biggest rollback in federal support for health coverage ever. Even those trillion dollars in health care cuts don't pay for the tax cuts fully, so the deficit would increase substantially.
- when the House started drafting this bill, they gave instructions to various committees, including the House Energy and Commerce Committee, which has jurisdiction over Medicaid to find $800 billion in cuts. And so when you do that, it's a recognition. You're going to have to find something within your committee. To help pay for this bill. But members haven't been as forthright about it…they'll talk more about, we need to root out waste, fraud and abuse in Medicaid. That's why we're doing this. We're trying to protect Medicaid for the most vulnerable. But they won't say this needs to happen so that we can pay for the tax cuts. They talk about those things separately. They say, we need to extend these tax cuts and also, we need to make changes to Medicaid, but they don't tie the two together.