Courtney Pladsen next to a doctor's chair.
credit: Justine Coleman

As a Republican Congress and president aim to take down the Affordable Care Act, District officials and health care experts warn that a repeal could leave tens of thousands of residents without health insurance.

Both the House and Senate proposed versions of an ACA repeal that were considered earlier this year included massive reductions in Medicaid spending. The Senate narrowly was able to open debate on the ACA July 25, giving Republicans the opportunity to create legislation to begin ACA repeal.

More than 260,000 people in the District received coverage from Medicaid in fiscal year 2016. Officials have expressed concern that a repeal would threaten the city’s financial stability and put the wellbeing of its most vulnerable populations in jeopardy.

Predicting the Unpredictable

The D.C. Council Committee on Health scheduled a hearing to discuss how the proposed federal health care reforms would affect the District in mid-July. But Senate Majority Leader Mitch McConnell delayed a Senate vote on the bill until after the July 4 recess. The council committee canceled its meeting accordingly. “Right now we’re just in the dark because we don’t know what Congress is going to do,” said Janis Hazel, director of communications for Ward 7 Councilmember Vincent Gray, who chairs the committee on health.

Gray wrote in an email that the committee would reschedule the hearing during D.C. Council’s summer recess if necessary. “My emphasis is to preserve health care coverage regardless of what the Congress does,” Gray said.

“We believe in Washington, D.C. that it’s fundamental to our values that we support people having access to high quality care,” Mayor Muriel Bowser told Bloomberg last week.

The Senate’s most recent replacement plan would have cost the District $2.9 billion over the course of seven years, according to a report compiled by Wayne Turnage, the director of the D.C. Department of Health Care Finance.

Because the Senate has now opened debate, several votes aimed to take apart the ACA will be held in the coming days.

“I want to congratulate the American people because we’re going to give you great health care, and we’re going to get rid of Obamacare which should have been frankly terminated long ago.” Trump said during a press conference July 25 “It’s been a disaster for the American people.”

Several people, including disability activists from National ADAPT and the National Council on Independent Living, interrupted the Senate debate with protests against the potential cuts to Medicaid by chanting “Don’t kill us. Kill the bill.”

Assessing the Cost

Nearly 40 percent of D.C. residents received Medicaid, and more than 11 percent were covered exclusively by the ACA Medicaid expansion in fiscal year 2016, according to a Street Sense analysis of a recent D.C. audit. The federal government funds 95 percent of the expansion and 70 percent of the general Medicaid program, according to a report compiled by Wayne Turnage, the director of the Department of Health Care Finance. The unpassed Senate health care plan included reduction of federal spending on Medicaid expansion programs to 70 percent, in line with the traditional program funding, according to the report.

The Congressional Budget Office reported that the latest Senate bill, the Obamacare Repeal Reconciliation Act, would reduce the federal deficit by $473 billion between 2017 and 2026 but would leave 32 million previously insured Americans without health insurance. The act would repeal the ACA coverage provisions in two years, giving the Senate time to come up with a replacement plan.

Turnage said in the District, he expects 100,000 people will rely on the Medicaid expansion to qualify for insurance next year. Without the federal government funding, the District would take a “big hit” and need to either find additional revenue or reprioritize the city budget to stop people from losing health care.

The cuts would mainly affect single adults without children. About 99 percent of the people that would lose insurance in the District earn far below the federal poverty level, which is set at $12,060 per year for individuals, according to Turnage.

Shortly after Donald Trump won the presidential election, Ward 2 Councilmember Jack Evans requested that D.C. auditors study how a loss of the ACA would impact the District’s finances and residents, according to auditor Kathy Patterson.

In January, the auditors released their research, which stated that the District would lose $563 million in the first fiscal year if the city tried to cover lost federal Medicaid expansion funds and would continue to lose more than $1 billion each year by the 10th fiscal year. More than 100,000 people could lose their health insurance if Medicaid expansion and subsidies for those in D.C. Health Link, the District’s health care marketplace, are eliminated, Patterson said.

If federal funding is greatly reduced, the council and the mayor would be asked to find local dollars to fill the gap.

“The likeliest thing to happen would be that policymakers here in the District would figure out a way to continue to cover as many of our residents as possible,” Patterson said, who thinks all of the repeal bills will include cuts to Medicaid expansion.

The number of people who would lose health care and the timeline depends on how the federal dollars would be withdrawn, according to Patterson.

The Risk for Homeless People

GOP leaders have been pushing to fund Medicaid through state per-capita caps and block grants. Block grants would provide states with a set amount of money to distribute to individuals. Per-capita caps set a spending limit for each individual, which could be problematic if a person develops a medical condition, according to Courtney Pladsen, a family nurse practitioner and the clinical coordinator for the Unity Health Care women’s respite program.

Pladsen is most concerned about the impact of reduced Medicaid spending on those in poverty and with disabilities. Some of her patients are scheduling full physicals and asking for long-acting reversible contraceptives just in case their coverage disappears.

“The people that are the most disproportionately impacted are people who are living in poverty and who are disabled,” Pladsen said.

Infographic Created by Justine Coleman

Infographic Created by Justine Coleman

A lack of housing can intensify people’s health issues and limit their access to care, creating more obstacles to exit homelessness, according to Lara Pukatch, director of the advocacy program at Miriam’s Kitchen. The nonprofit provides breakfast and dinner to homeless guests Monday through Friday and offers on-site medical care during that time, as well as connection to outside service providers.

“When we see proposed cuts to Medicaid that limits access to health care for some of our vulnerable residents, that medical outreach we’re trying to do in the dining room does not reach its full potential,” she said.

One provision of recent GOP plans require people to work in order to obtain Medicaid. MaryBeth Musumeci, an associate director at the Kaiser Family Foundation’s program on Medicaid and the uninsured, said these work requirements could cause some eligible individuals to get lost in the administrative shuffle when filing documents like their exemptions.

“There’s the danger that paperwork can get lost, things can slip through the cracks and people that were eligible could lose coverage,” Musumeci said.

About 59 percent of people that receive Medicaid work and 80 percent are a part of working families, according to a March KFF report.

Jeffery McNeil, a Street Sense vendor who also assistant-manages a local fitness center receives Medicaid from AmeriHealth Caritas, said that he does not think a work requirement for Medicaid would be fair for those unable to work.

“The problem with Medicaid is you get health care but not health coverage,” he said. “Half the doctors don’t want to see you. I can only go to Whitman Walker or Unity Health Care. Thank God I’m not severely sick. That’s when the complications start.”