Answering My Girlfriend's Questions About Losing Her Obamacare

My girlfriend gets her medical coverage through the California's Medi-Cal, our state's Medicaid program. She wouldn't have qualified for Medicaid before federal spending increased under the Affordable Care Act, also known as Obamacare.

She's one of the millions of people who has insurance thanks to the ACA, and she's also in the group most likely to lose coverage if the Senate Republicans' Better Care Reconciliation Act, revealed Thursday, actually passes.

Ever since Donald Trump won the election, my girlfriend has been asking me increasingly anxious questions. Mostly, all I've told her was, "You're going to be fine," and, "Everything's gonna be OK." What else do you say to someone as she grows increasingly worried that the government is about to swoop in and take away something she needs but can't afford?

On Thursday, however, there was no denying it anymore: The Senate has a bill, it will pass unless three or more Republican senators vote against it, and though a few conservatives have made noise about how they don't like it, that doesn't mean it won't ultimately become law. When my girlfriend saw that, she emailed me a bunch of questions.

I've already answered her first question: "Why did you lie to me?" Her second, "What made you think I wasn't going to be affected by this?" really has no answer—I guess I just hoped.

The rest of her questions were much more answerable (or at least less heartbreaking for me to answer). A modified version of her question list makes for a pretty good primer on what's going to happen to any given American who gets their coverage from Medicaid.

"Starting in 2021, federal funding for Medicaid expansion dates would start to phase down," said Matthew Fiedler, a fellow with the Brookings Institute's Center for Health Policy who served on Barack Obama's Council of Economic Advisers.

By 2024, the expansion is meant to be completely gone. Losing the expansion means the federal government returns California to it's normal Medicaid match rate, which is 50 percent, meaning (in very simplified terms) California picks up half the bill, and the federal government pays for the rest. (There won't be much of a change if you live in one of the 19 states that said no to the Medicaid expansion.)

This is based an analysis of the House version of the bill from the Congressional Budget Office (CBO). "When it analyzed the House bill, CBO's conclusion was that that would lead most states that would have a Medicaid expansion under current law to not have a Medicaid expansion, and I would expect a similar outcome under the Senate bill," Fiedler said.

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You'll probably get a letter.

There's no switch that Republican congressional leaders Paul Ryan and Mitch McConnell will turn on after the final passage of the bill that rips away all these people's healthcare at once. Instead, the states have to slowly rein in coverage, meaning they'll slowly change eligibility requirements.

According to Fiedler, that means losing your coverage will come in the form of an increase in paperwork. "This bill would require states to redetermine people's eligibility for Medicaid on a somewhat more frequent basis than they're required to under current law," he told me.

I was there when my girlfriend got a letter from the state informing her she was covered by Medi-Cal. If she loses coverage because of the bill, she'll most likely just get another letter informing her that she's no longer eligible.

No one can say for sure yet.

The CBO's take is that with the House bill will cause about 23 million more people to not have coverage in a decade's time, but they're not all necessarily the same people who didn't have coverage before the Affordable Care Act.

"There's also a broader [spending] cap in this bill," Fiedler told me. What that means is if the Republicans get their way, states will receive a set amount of money per Medicaid recipient—a limit that in practice will amount to hundreds of billions of dollars in cuts nationwide.

There's some wiggle room, however, for a state to design how exactly to inflict this inevitable pain on Medicaid recipients. "They'll have to make some pretty hard decisions," Fiedler said. "They'll either have to find some additional money elsewhere in their budget, kick people off the program, or they'll have to make the services they cover less generous."

If I were a state official concocting a policy for this, I would definitely target the young and healthy. Mostly because they don't need as much help, but also—and this is me being a cynical state official—because they don't vote as much.

You might get lucky, yeah.

According to the CBO, some states will probably at least try to make up for this budget gap. But Fielder pointed out that the cost to the states would "somewhere between triple and quintuple."

Here in California, there's a bill working its way through our state legislature that would bypass all that. It's a single-player plan, and it already passed in our state senate, but it still has to get through the assembly. New York is considering something similar.

Yes, it could. In fact, bad coverage might be a way to keep more people covered when the money stops coming.

Fielder again: "[States] could decide that one of the ways they're going to try to reduce the financial burden of maintaining the expansion coverage is to cut the rates they're going to pay providers, or drop certain services from the benefit package, or require people to pay more in cost-sharing or premiums, which they can do under certain conditions—so that would be one approach."

Maybe.

The idea is that fewer doctors will accept Medicaid as the plans get crappier for the patients. To put it in terms millennials will understand, it's the Dr. Hibbert who will who will shy away, leaving just the Dr. Nicks for the Medicaid crowd. Fielder called this concept "somewhat overblown." But, he told me, if states cut the rates they pay to doctors too much, then there might be what he called "access issues."

"The data suggest it's probably not a huge problem under current law, on average," Fielder said. Although he added that glitches like this are conceivable, even if they're unforeseen problems that have nothing to do with the quality of doctors, because fiscal pressure is just generally not good for government programs. But for what it's worth, a lack of doctors was also a somewhat dubious claim Paul Ryan made about the Affordable Care Act.

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