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Politico
15-07-2025
- Health
- Politico
Choppy waters ahead for health insurers
Presented by With Lauren Gardner and Ruth Reader Driving the Day TRIPLE THREAT — Insurers face a number of pressures that could lead to a jump in out-of-pocket health costs for Americans: cuts to Medicaid, federal policy changes that could hit Obamacare enrollment and medical costs rising faster than expected, Kelly reports. Several health insurers were already on unstable financial footing even before President Donald Trump signed into law the 'big, beautiful bill' — which could lead to millions of people losing coverage. The looming changes now create more uncertainty that could lead to a downturn for the health insurance industry and a jump in premiums for Americans purchasing coverage. 'You have this perfect storm here of very large changes happening all at once,' said Ellen Montz, a managing director with advisory firm Manatt Health and a former CMS official during the Biden administration. 'They're looking at pricing, what is potentially coming down the pike, and we're going to see some very large, both gross and net, premium increases.' Both Centene and Molina Healthcare slashed their yearly financial guidance over the past few weeks amid unexpectedly high medical costs in Medicaid and Obamacare plans. And health insurance giant UnitedHealthcare lowered its guidance in May because of higher-than-anticipated Medicare Advantage costs. 'As we see these cost pressures continue to mount, as we see them go unaddressed and continue to snowball in their effect, the inevitable result is that we will see higher premiums,' said David Merritt, senior vice president of policy and advocacy at the Blue Cross Blue Shield Association. Why it matters: The Congressional Budget Office estimated that an earlier version of the 'big, beautiful bill,' combined with the expiration of the enhanced Obamacare subsidies at the end of this year and new Trump administration Affordable Care Act policies that make it more difficult to enroll, could cause nearly 17 million people to become uninsured. Cushioning the blow: Insurers are pushing Congress and the Trump administration to mitigate some of the fallout, warning lawmakers in competitive districts that their constituents will face widespread coverage disruptions if the policies are implemented. The industry's most pressing concern is the expiration of the enhanced subsidies — which Congress must extend within the next few months to avoid 'very sudden' and 'severe' cost hikes and coverage losses nationwide, said Mike Tuffin, the CEO of health insurance trade group AHIP. So far, few Republican lawmakers have expressed interest in extending the subsidies, which CBO has estimated at $335 billion over 10 years. 'We know over the last 30 years that when people's coverage is disrupted, their access to health care is disrupted, there's an immediate political response, and both parties have seen that in the past, and we want to prevent that,' Tuffin said. What's next: Insurers will start posting their 2025 second-quarter earnings over the next few weeks, which will provide some insight into how they might adjust to rising medical costs. It may also shed light on how they're factoring in looming federal changes to their pricing. First up is Elevance Health, which will report its earnings Thursday. WELCOME TO TUESDAY PULSE. U.S. ice cream makers are pledging to stop using artificial dyes by 2028 — another win for HHS Secretary Robert F. Kennedy Jr.'s Make America Healthy Again initiative. Send your tips, scoops and feedback to khooper@ and sgardner@ and follow along @kelhoops and @sophie_gardnerj. In Congress AUTISM SPEAKS ON THE HILL — Advocates from the group Autism Speaks will head to the Capitol today to urge lawmakers to fund recently reauthorized research and service programs in the wake of the GOP megabill's steep Medicaid cuts. While the group will acknowledge their concerns about how those cuts could impact autism programs in the states, it plans to focus on the annual appropriations process 'since that's the next thing up, and something that we want to try to ensure that we're at least maintaining the levels of funding for those programs,' David Sitcovsky, Autism Speaks' vice president of advocacy, told Lauren. Congress reauthorized the Autism CARES Act in December, which Autism Speaks says is the primary federal funding source for monitoring, research, services and training programs in the autism community. The law's programs are spread across the CDC, the Health Resources and Services Administration and the NIH. The group plans to underscore in their meetings that autism is a lifelong condition — not just a childhood disorder, as often emphasized by Health Secretary Robert F. Kennedy Jr. — for which many people need support as they age. 'It seems like most [of the] conversation about autism has been framed around childhood, and and I think what were really trying to do … is to remind people that [it's a] lifelong issue, and there are many adults who need better understanding and supportive services now,' said Dr. Andy Shih, Autism Speaks' chief science officer. At the Agencies DOC PAY OVERHAUL — The Centers for Medicare and Medicaid Services is proposing a boost in funding to doctors who participate in alternative payment models based on the quality of care delivered instead of individual services, POLITICO's Robert King reports. 'We're making it easier for seniors to access preventive services, incentivizing health care providers to deliver real results, and cracking down on abuse that drives up costs,' CMS Administrator Mehmet Oz said in a statement Monday when the agency released its proposed physician fee schedule that details changes to Medicare pay for 2026. What it means: Doctors participating in the models would receive a 3.83 percent boost to their payments starting in 2026. Doctors not participating in such models would get a 3.62 percent increase. Why it matters: If finalized, the rule would represent a departure from how CMS traditionally reimburses doctors. The agency typically has one rate update that applies to all doctors serving Medicare patients, regardless of whether they participate in an alternative payment model. Both Republican and Democratic administrations have sought to shift Medicare reimbursement away from payments for individual items or services. TECH TROUBLES — The Department of Veterans Affairs told a House panel Monday that it has implemented DOGE-directed cuts to optimize its IT infrastructure. But lawmakers say they want assurances that the agency's past problems with IT modernization won't be its future, Ruth reports. 'For years, this committee has highlighted the wasteful spending, the overbudget projects, poor outcomes that seem to come with all IT projects at the VA,' said Rep. Tom Barrett (R-Mich.), chair of the House Veterans Affairs' Technology Modernization Subcommittee. Since the beginning of the year, the VA's Office of Information and Technology has lost 1,100 employees — mostly from buy-out and early retirement offers — and its 2026 budget has shaved $500 million from its operating funding. Subcommittee ranking member Rep. Nikki Budzinski (D-Ill.) said she's concerned the cuts will undermine the agency's efforts. Eddie Pool, the VA's acting assistant secretary and chief information officer, assured lawmakers that more than three-quarters of the people who left the agency were going to retire soon. Why it matters: Veterans Affairs is in the midst of its latest attempt to update its IT infrastructure, including its electronic medical records system. The agency has been attempting to modernize since 2001 and has failed to do so multiple times, according to the Government Accountability Office. Carol Harris, the GAO's director of IT and cybersecurity, testified that the VA's IT office hasn't adequately taken stock of its workforce. For example, she said, it doesn't have an inventory of employees' current cybersecurity skills and competencies. The agency also hasn't comprehensively identified its current and future human capital needs, Harris added. The GAO has 26 open recommendations for improving the VA's IT and cybersecurity that it said the office still needs to complete. What's next: President Donald Trump recently announced his pick for chief information officer at the VA, Ryan Cote, who served as the Transportation Department's CIO in the first Trump administration. His confirmation hearing hasn't been scheduled yet. Health Costs MEDICAL DEBT RULE TOSSED OUT — A federal judge has overturned a Biden administration rule that would have removed $49 billion in medical debt from the credit reports of 15 million people, POLITICO's Katherine Hapgood reports. U.S. District Judge Sean Jordan of the Eastern District Court in Texas said the Consumer Financial Protection Bureau rule 'exceeds the bureau's statutory authority' and violates the law on permissible purposes of consumer reports. The decision aligns with the Trump administration's stance on the issue. The rule was finalized by then-CFPB Director Rohit Chopra, but the bureau under the Trump administration reversed its position on the rule and joined credit-reporting groups in challenging it. The rule had been set to take effect at the end of July. WHAT WE'RE READING POLITICO's Grace Yarrow and Rachel Shin report on how the White House doesn't plan to crack down on pesticides in farming. STAT's Lev Facher reports on an elite rehab center using GLP-1s to treat a range of addictions.
Yahoo
10-07-2025
- Health
- Yahoo
Pritzker on passing of Trump budget bill: '330,000 Illinoisans will lose their health care'
An estimated 330,000 Illinois residents will be stripped of their Medicaid coverage following the July 4 passage of President Donald Trump's budget bill, Gov. JB Pritzker's Office said in a July 8 press release. "Donald Trump sold out the American people, stripping away their healthcare and raising costs for working families in order to line the pockets of his wealthy friends," Pritzker said in the release. "The widespread health and economic impacts of the largest cut to Medicaid in American history will be devastating for years to come. It will cost people their livelihoods, strain working families, shutter hospitals and slash reproductive healthcare." Here's what we know. The controversial bill, dubbed the "big, beautiful bill" by Trump, proposes major changes to federal programs like Medicaid, the state-federal health program for low-income families and the disabled. The July 8 press release from Pritzker's office cited a statistic from Manatt Health, which claimed the bill would cause about 11% of Illinois' current 3.4 million Medicaid enrollees to lose coverage over the next decade. The governor's office predicted the following impacts as well: Out of pocket expenses are expected to rise for Medicaid enrollees. Premiums for working families with ACA marketplace coverage will rise by 75%, causing them to pay an average of $1,032 more per year in premiums. Nine rural hospitals and 90 nursing homes in Illinois could face closure. 3.4 million Illinoisans are at risk of losing about $52 billion in Medicaid funding. New barriers to coverage will be enacted through work requirements, frequent redeterminations and repealing rules that simplify eligibility and renewal. Prohibiting federal Medicaid matching funds for family planning and other reproductive healthcare services provided by Planned Parenthood will gut reproductive healthcare. The state says it is not in a position to backfill funding for these Medicaid cuts, but says Pritzker will attempt to mitigate impacts through medical relief programs, price reductions for prescription drugs and more. The law will require states to double eligibility checks to twice a year and set up systems to verify recipients' employment or exemption statuses, USA TODAY reported. Health policy experts say these changes will add administrative costs and cut off people who qualify but fall through the cracks. The legislation requires "able-bodied" Medicaid recipients without children 14 or younger to work 80 hours a month or qualify for an exemption. "Able-bodied" is defined in the law as those not medically certified as physically or mentally unfit for employment. The legislation also strips coverage from undocumented immigrants who get Medicaid through state-funded programs. Ken Alltucker, Rachel Barber, Jim Sergent and Janet Loehrke contributed to this article. This article originally appeared on Journal Star: Pritzker responds to passing of 'big, beautiful bill.' Here's what he said
Mint
07-07-2025
- Health
- Mint
How healthcare cuts in the ‘big, beautiful bill' will affect Americans
After the House narrowly passed President Trump's tax-and-spending-cuts bill, he signed it into law on Friday. The passage of President Trump's 'one big, beautiful bill" has left some hospitals, doctors and patient-advocacy groups reeling. Millions of people will lose health-insurance coverage, and struggling hospitals across the country may have to close, lay off staff or shut down some services, they say. States will also face difficult budget choices as federal funds are reduced. 'The magnitude of these reductions—and the number of individuals who will lose health coverage—cannot be simply dismissed as waste, fraud, and abuse," Rick Pollack, president of the American Hospital Association, said after the House narrowly passed the bill. Trump signed the bill into law on Friday, Independence Day. The act slashes over $1 trillion in healthcare spending over the next decade, mostly from Medicaid, the joint federal and state program that provides health insurance to poor Americans. It is the biggest cut to federal healthcare spending—and to Medicaid—in history. The legislation's health provisions, including work requirements for Medicaid recipients, represent a fundamental shift in the federal government's approach to healthcare for its poorest citizens, both Republicans and Democrats have said. 'This is a much more conservative approach to healthcare," said David Mansdoerfer, a former health official in the first Trump administration. 'The big beautiful bill would represent a significant mindset change for federal safety-net programs." There will be nearly 8.7 million fewer people covered by Medicaid over the next decade because of the bill, according to an analysis by Manatt Health, a consulting firm that advises states and healthcare providers on Medicaid policy. Other provisions in the bill, including more-stringent requirements for people to enroll and retain health-insurance plans under the Affordable Care Act, also known as Obamacare, are projected to drive up the number of uninsured, healthcare experts said. Many who study healthcare policy say that people who lose insurance, or people who live in rural areas where doctors and hospitals are closing up shop, often delay preventive care, sometimes costing the system more later. Many of the Medicaid policy changes target the 40 states that expanded eligibility for Medicaid to low-income able-bodied adults. Those enrollees will now have to prove their incomes are below a certain threshold every six months to remain on Medicaid, instead of annually, as well as show that they have spent 80 hours a month working, volunteering or attending school. People in the lowest 10% of income distribution in the U.S. stand to lose noncash government benefits such as Medicaid coverage and food stamps worth nearly $1,600 annually on average, according to an analysis of an earlier version of the bill by the Congressional Budget Office. Hospitals say they are big losers under the new legislation. More uninsured people will mean more uncompensated healthcare costs, they say. And many hospitals now face reductions in some supplemental payments that most states have come to rely on to augment low Medicaid payment rates. Over the next decade, Medicaid payments to hospitals will be reduced by nearly $665 billion, an 18.2% reduction, according to analysis by Manatt. Meanwhile, hospitals' uncompensated care costs are projected to increase by upward of $84 billion in 2034, according to an analysis of the bill by America's Essential Hospitals, which represents some 350 hospitals nationwide. That number takes into account lower Medicaid payments and Medicaid payment shortfalls, as well as costs from caring for the uninsured. 'It is a double-whammy. We're going to have many millions more uninsured individuals showing up needing care," said Beth Feldpush, the group's senior vice president of advocacy and policy. 'But at the same time, hospitals won't be able to backfill financial holes." Medicaid payment rates are notoriously low compared with other types of insurance. States have increasingly boosted these rates in recent years through so-called state-directed payments, which can raise Medicaid payment rates to levels comparable with Medicare or even average commercial insurance rates. The bill clamps down on these payments. States that have expanded their Medicaid programs under Obamacare to include more low-income adults would have state-directed payment rates capped at 100% of Medicare rates; states that haven't adopted expansion would be capped at 110% of Medicare rates. The change will reduce federal spending by $149.4 billion over a decade, according to a CBO analysis. Hospitals in about 30 states will likely see reductions in the state-directed payments they receive once cuts go into effect, according to an analysis by KFF, a health-policy nonprofit. State hospital associations said these payments are lifelines for hospitals, many of which operate at or near a loss. Even before the bill's passage, several hospitals across the country laid off employees, froze hiring and tightened spending, citing the impending cuts to Medicaid as a factor. Providence, one of the country's largest health systems, said last month that it had implemented a restructuring plan that would lead to 600 employees losing their jobs. Other hospitals say they are bracing for the changes to come. Our Lady of the Angels Hospital, a safety-net hospital in Bogalusa, La., said it would have to consider closing its doors, and the University of Kentucky said it might have to pause construction on a new building dedicated to caring for cancer patients if state-directed payment cuts go into effect. The cuts may also eat into the earnings of for-profit hospitals like HCA Healthcare and Tenet Healthcare that have enjoyed lucrative boosts to their bottom lines from state-directed payments. The National Rural Health Association said it was worried that the bill's provisions would significantly hamper healthcare access in rural areas. Senate Republicans added a $50 billion relief fund to the bill at the last minute for rural hospitals, but Sen. Susan Collins (R., Maine), who voted against the bill, said it wouldn't be enough to offset the other changes. For insurers, the biggest impact of the legislation is clear: fewer customers. Though Medicaid is a government program, most enrollees get their benefits through insurers that are paid with state and federal money. 'From a health insurer's perspective, that's a lot of business to lose," says Cynthia Cox, a vice president at KFF, a health-research nonprofit. The industry impact will be heaviest among companies with a focus on Medicaid. Among the largest are Centene, which has nearly 13 million Medicaid enrollees, Elevance Health, UnitedHealth Group, Molina Healthcare and CVS Health's Aetna. 'Revenue and profits will be pressured," said Sarah James, an analyst with Cantor Fitzgerald. A Wellcare location in New York City, part of Centene Corp., one of the largest Medicaid insurers. The cutbacks to Medicaid will come on top of blows to another key insurance market—Obamacare marketplace plans. Federal subsidies that help people pay for Obamacare plans are set to shrink next year, and the new legislation doesn't fill the gap. Along with other Trump administration changes to the rules for Obamacare plans, the reduction in subsidies is projected to reduce the number of people with coverage by another 5.1 million if Congress doesn't extend them. In Obamacare and Medicaid, the shrinking rolls are likely to create another headache for insurers. When people drop out of insurance markets, the healthier ones are often the first to go. That leaves a sicker, more costly pool of customers for insurers, which then seek to get paid more to cover those expenses. They demand higher premiums, either from state Medicaid agencies or from Obamacare customers. Nationally, states will have roughly $1.3 trillion dollars less in federal and state funds to spend on Medicaid over the next decade, according to Manatt. Most of the reductions—93%—will be in states that have expanded Medicaid to cover able-bodied adults. One of the biggest impacts will come from the bill's crackdown on so-called provider taxes, which states levy on hospitals and other healthcare providers to trigger federal matching funds. Most hospitals receive back more than they pay in taxes through higher payment rates via state-directed payments and other mechanisms. Currently, the taxes are capped at 6% of healthcare providers' net patient revenue, but will be reduced to 3.5% in expansion states. In non-expansion states such as Florida and Texas, tax rates will be frozen in place up to the 6% maximum on the date the bill is signed into law. Healthcare workers last month protested the Medicaid cuts proposed in the bill that President Trump signed Friday. The taxes have been criticized as a gimmick that exploits federal taxpayers without requiring states to put any skin in the game. President Obama twice proposed clamping down on provider taxes, including in his 2013 budget, which would have reduced the maximum rate to 3.5%. States use provider taxes to fund state-directed payments to hospitals and other providers. Some, such as North Carolina, have also designed the taxes to fund their Medicaid expansions. On a percentage basis, red and purple expansion states will be hit hardest since many of them tend to rely heavily on provider taxes, says Avi Herring, a Manatt managing director. Montana faces a 21% reduction in state and federal funds; Arizona, Kentucky and Virginia are each looking at reductions of about 18%. The largest blue states, which tend to have more generous Medicaid programs, face far bigger dollar cuts, though they are somewhat smaller proportionally. California is expected to see a 13% reduction. New York's spending will be reduced by nearly 9%. Write to Dominique Mosbergen at Joseph Walker at Liz Essley Whyte at and Josh Ulick at
Los Angeles Times
03-07-2025
- Health
- Los Angeles Times
States brace for reversal of Obamacare coverage gains under Trump's budget bill
Shorter enrollment periods. More paperwork. Higher premiums. The sweeping tax and spending bill pushed by President Trump includes provisions that would not only reshape people's experience with the Affordable Care Act, but also sharply undermine the gains in health insurance coverage associated with it, according to some policy analysts. The moves affect consumers and have particular resonance for the 19 states (plus Washington, D.C.) that run their own ACA exchanges. Many of those states fear that the additional red tape — especially requirements that would end automatic reenrollment — would have an outsize impact on their policyholders. That's because a greater percentage of people in those states use those rollovers versus shopping around each year, which is more commonly done by people in states that use the federal marketplace. 'The federal marketplace always had a message of, 'Come back in and shop,' while the state-based markets, on average, have a message of, 'Hey, here's what you're going to have next year, here's what it will cost; if you like it, you don't have to do anything,'' said Ellen Montz, who oversaw the federal ACA marketplace under the Biden administration as deputy administrator and director at the Center for Consumer Information and Insurance Oversight. She is now a managing director with the Manatt Health consulting group. Millions — perhaps up to half of enrollees in some states — may lose or drop coverage as a result of that and other changes in the legislation combined with a new rule from the Trump administration and the likely expiration at year's end of enhanced premium subsidies put in place during the covid-19 pandemic. Without an extension of those subsidies, which have been an important driver of Obamacare enrollment in recent years, premiums are expected to rise 75% on average next year. That's starting to happen already, based on some early state rate requests for next year, which are hitting double digits. 'We estimate a minimum 30% enrollment loss, and, in the worst-case scenario, a 50% loss,' said Devon Trolley, executive director of Pennie, the ACA marketplace in Pennsylvania, which had 496,661 enrollees this year, a record. Drops of that magnitude nationally, coupled with the expected loss of Medicaid coverage for millions more people under the legislation Trump calls the 'One Big Beautiful Bill,' could undo inroads made in the nation's uninsured rate, which dropped by about half from the time most of the ACA's provisions went into effect in 2014, when it hovered around 14% to 15% of the population, to just over 8%, according to the most recent data. Premiums would rise along with the uninsured rate because older or sicker policyholders are more likely to try to jump enrollment hurdles, while those who rarely use coverage — and are thus less expensive — would not. After a dramatic all-night session, House Republicans passed the bill, meeting the president's July 4 deadline. Trump is expected to sign the measure on Independence Day. It would increase the federal deficit by trillions of dollars and cut spending on a variety of programs, including Medicaid and nutrition assistance, to partly offset the cost of extending tax cuts put in place during the first Trump administration. The administration and its supporters say the GOP-backed changes to the ACA are needed to combat fraud. Democrats and ACA supporters see this effort as the latest in a long history of Republican efforts to weaken or repeal Obamacare. Among other things, the legislation would end several changes put in place by the Biden administration that were credited with making it easier to sign up, such as lengthening the annual open enrollment period and launching a special program for very low-income people that essentially allows them to sign up year-round. In addition, automatic reenrollment, used by more than 10 million people for 2025 ACA coverage, would end in the 2028 sign-up season. Instead, consumers would have to update their information, starting in August each year, before the close of open enrollment, which would end Dec. 15, a month earlier than currently. That's a key change to combat rising enrollment fraud, said Brian Blase, president of the conservative Paragon Health Institute, because it gets at what he calls the Biden era's 'lax verification requirements.' He blames automatic reenrollment, coupled with the availability of zero-premium plans for people with lower incomes that qualify them for large subsidies, for a sharp uptick in complaints from insurers, consumers, and brokers about fraudulent enrollments in 2023 and 2024. Those complaints centered on consumers' being enrolled in an ACA plan, or switched from one to another, without authorization, often by commission-seeking brokers. In testimony to Congress on June 25, Blase wrote that 'this simple step will close a massive loophole and significantly reduce improper enrollment and spending.' States that run their own marketplaces, however, saw few, if any, such problems, which were confined mainly to the 31 states using the federal The state-run marketplaces credit their additional security measures and tighter control over broker access than for the relative lack of problems. 'If you look at California and the other states that have expanded their Medicaid programs, you don't see that kind of fraud problem,' said Jessica Altman, executive director of Covered California, the state's Obamacare marketplace. 'I don't have a single case of a consumer calling Covered California saying, 'I was enrolled without consent.'' Such rollovers are common with other forms of health insurance, such as job-based coverage. 'By requiring everyone to come back in and provide additional information, and the fact that they can't get a tax credit until they take this step, it is essentially making marketplace coverage the most difficult coverage to enroll in,' said Trolley at Pennie, 65% of whose policyholders were automatically reenrolled this year, according to KFF data. Federal data shows about 22% of federal sign-ups in 2024 were automatic-reenrollments, versus 58% in state-based plans. Besides Pennsylvania, the states that saw such sign-ups for more than 60% of enrollees include California, New York, Georgia, New Jersey, and Virginia, according to KFF. States do check income and other eligibility information for all enrollees — including those being automatically renewed, those signing up for the first time, and those enrolling outside the normal open enrollment period because they've experienced a loss of coverage or other life event or meet the rules for the low-income enrollment period. 'We have access to many data sources on the back end that we ping, to make sure nothing has changed. Most people sail through and are able to stay covered without taking any proactive step,' Altman said. If flagged for mismatched data, applicants are asked for additional information. Under current law, 'we have 90 days for them to have a tax credit while they submit paperwork,' Altman said. That would change under the tax and spending plan before Congress, ending presumptive eligibility while a person submits the information. A white paper written for Capital Policy Analytics, a Washington-based consultancy that specializes in economic analysis, concluded there appears to be little upside to the changes. While 'tighter verification can curb improper enrollments,' the additional paperwork, along with the expiration of higher premiums from the enhanced tax subsidies, 'would push four to six million eligible people out of Marketplace plans, trading limited fraud savings for a surge in uninsurance,' wrote free market economists Ike Brannon and Anthony LoSasso. 'Insurers would be left with a smaller, sicker risk pool and heightened pricing uncertainty, making further premium increases and selective market exits [by insurers] likely,' they wrote. Appleby writes for KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
Axios
01-07-2025
- Health
- Axios
What's at stake from GOP megabill's coverage losses
Nearly 12 million people would lose their health insurance under President Trump's "big, beautiful bill," an erosion of the social safety net that would lead to more unmanaged chronic illnesses, higher medical debt and overcrowding of hospital emergency departments. Why it matters: The changes in the Senate version of the bill could wipe out most of the health coverage gains made under the Affordable Care Act and slash state support for Medicaid and SNAP. "We are going back to a place of a lot of uncompensated care and a lot of patchwork systems for people to get care," said Ellen Montz, a managing director at Manatt Health who oversaw the ACA federal marketplace during the Biden administration. The big picture: The stakes are huge for low-income and working-class Americans who depend on Medicaid and subsidized ACA coverage. Without health coverage, more people with diabetes, heart disease, asthma and other chronic conditions will likely go without checkups and medication to keep their ailments in check. Those who try to keep up with care after losing insurance will pay more out of pocket, driving up medical debt and increasing the risk of eviction, food insecurity and depleted savings. Uninsured patients have worse cancer survival outcomes and are less likely to get prenatal care. Medicaid also is a major payer of behavioral health counseling and crisis intervention. Much of the coverage losses from the bill will come from new Medicaid work reporting requirements, congressional scorekeepers predict. Work rules generally will have to be implemented for coverage starting in 2027, but could be earlier or later depending on the state. Past experiments with Medicaid work rules show that many eligible people fall through the cracks verifying they've met the requirements or navigating new state bureaucracies. Often, people don't find out they've lost coverage until they try to fill a prescription or see their doctor. States typically provide written notices, but contacts can be out of date. Nearly 1 in 3 adults who were disenrolled from Medicaid after the COVID pandemic found out they no longer had health insurance only when they tried to access care, per a KFF survey. Zoom out: The Medicaid and ACA changes will also affect people who keep their coverage. The anticipated drop-off in preventive care means the uninsured will be more likely to go to the emergency room when they get sick. That could further crowd already bursting ERs, resulting in even longer wait times. Changes to ACA markets in the bill, along with the impending expiration of enhanced premium subsidies, may drive healthier people to drop out, Montz said, skewing the risk pool and driving up premiums for remaining enrollees. States will likely have to make further cuts to their safety-net programs if the bill passes in order to keep state budgets functioning with less federal Medicaid funding. The other side: The White House and GOP proponents of the bill say the health care changes will fight fraud, waste and abuse, and argue that coverage loss projections are overblown. Conservative health care thinkers also posit that there isn't strong enough evidence that public health insurance improves health. Reality check: Not all insurance is created equally, and many people with health coverage still struggle to access care. But the bill's impact would take the focus off ways to improve the health system, Montz said. "This is taking us catastrophically backward, where we don't get to think about the things that we should be thinking about how to best keep people healthy," she said. The bottom line: The changes will unfold against a backdrop of Health Secretary Robert F. Kennedy Jr.'s purported focus on preventive care and ending chronic illness in the U.S.
