What the GOP’s tax bill means for your health care

If you’re among the 78 million people on Medicaid or the 24 million with a health plan from the insurance marketplaces, changes to how you qualify for and enroll in coverage — and what medical providers are available to you — could be on the way.

Republicans are looking to squeeze savings from these two major programs that provide many lower-income and disabled Americans with health coverage, as they hustle to pass a huge, tax-cut-extending legislative package President Donald Trump has demanded before July 4. The bill narrowly passed the Senate on Tuesday and is now headed back to the House — which approved a different version of the bill in May — for final passage.

To help pay for the measure, Republicans have proposed changes estimated to cut more than $1 trillion from Medicaid, Medicare and Obamacare, with the bulk of the cuts coming from Medicaid. Those provisions will lead to at least 17 million people losing their health insurance over the next decade, according to estimates from the nonpartisan Congressional Budget Office.

A number of Republicans have expressed concerns about cutting too deeply into health care programs, but several senators who voiced doubts about the Medicaid provisions ended up supporting the bill.

Here’s a look at how the biggest GOP health proposals on the table could affect Americans.

Republicans have proposed several changes for people at or just above the poverty line. This group of people, whose income is between 100 percent and 138 percent of the federal poverty level (roughly $32,000 to $44,000 for a family of four), are known as “expansion” enrollees, since the 2010 health care law expanded Medicaid to include them.

Right now, states verify that these individuals are eligible for coverage just once a year, typically around the end of the year during enrollment season. The GOP’s House and Senate bills would require states to do an extra eligibility check every six months, starting in 2027. That could open the door to people losing coverage midyear.

And the GOP measures would open a second door to otherwise eligible people being kicked off coverage. They call for a big new requirement: Adults under age 65 in this expansion group must work, volunteer or go to school at least 80 hours a month. States would also have to verify this twice a year, potentially requiring enrollees to submit paperwork again.

“That’s going to be disruptive to individuals,” said Jay Ludlam, deputy secretary for North Carolina’s Medicaid program. “It’s going to create a lot of red tape.”

Republicans say these work requirements will ensure able-bodied adults who can work are working. But most people with that level of income are, by definition, already working, according to the nonpartisan health policy organization KFF. So coverage losses would be mostly among eligible people failing to submit sufficient documentation, health policy experts say.

The bill includes exemptions for certain groups of people, including pregnant women, people who are disabled and parents with dependent children who are 13 years or younger. But even those who qualify for exemptions will have to submit paperwork proving that they do not have to abide by the work requirements, which in turn could cause people to lose coverage.

The GOP bills create another new requirement for expansion enrollees. They could be charged a co-pay of $35 when they visit a doctor, clinic or hospital. This wouldn’t apply to primary care, mental health or substance abuse services, and only nominal co-payments could be charged for prescription drugs.

Some states already charge a very small co-payment for visits. In North Carolina, it’s $4. But the GOP plan would significantly raise the amount that could be charged, which state Medicaid officials say could be a deterrent to seeking care.

In most states, people have from Nov. 1 to Jan. 15 to sign up for a federally subsidized private insurance plan. But the GOP legislation would cut that sign-up period down to six weeks, ending it on Dec. 15. So if people discovered a problem with their health coverage early in the year, they wouldn’t have an opportunity to sign up for a different plan.

The GOP legislation would also prohibit automatic reenrollment, a practice offered by many employer-sponsored plans. More than half of returning marketplace enrollees were automatically reenrolled for plans this year. But under the proposed changes, people would need to take action every year — even if they want to continue in their same plan.

And the GOP measures would put stricter guardrails around the federal subsidies that 93 percent of marketplace enrollees rely on to make their premiums more affordable.

The way it works right now, consumers can go to healthcare.gov or their state marketplace website and buy a subsidized plan that starts almost immediately. The state has 90 days to verify eligibility, and in the meantime enrollees can enjoy the lower premium.

But under the GOP changes, subsidies would be withheld until the state verifies eligibility. So if someone purchased a plan with a $900 monthly premium, for example, they would need to pay that full price even if they qualify for subsidies lowering their payment to just $300, until their eligibility could be confirmed.

This requirement would also apply to people in special circumstances who are allowed to sign up outside the normal enrollment period, like those who have had a baby or gotten a divorce. Having a baby would be a big problem, experts say, because the baby couldn’t be added to a plan without a Social Security number — and that takes weeks. Many employer-sponsored plans provide newborns with coverage for 30 days for that very reason.

It could become harder to find a clinic to provide an abortion. Both GOP measures would cut abortion providers out of Medicaid entirely, meaning they couldn’t even bill the program for non-abortion services such as birth control and cancer screenings.

That could shutter some abortion clinics. More than half of patients who go to Planned Parenthood, the nation’s largest abortion provider and a longtime target of conservatives, are on Medicaid. The organization says roughly one-third of its nearly 600 clinics could close if the GOP legislation becomes law, and 90 percent of those clinics are in states where abortion is legal.

“I don’t think we’re being dramatic when we say defunding Planned Parenthood has really significant ramifications for health care in this country,” said Laurel Sakai, the organization’s national director of public policy and government affairs.

Hospital closures — particularly those in rural areas and those that serve many low-income patients — are already a long-standing problem. That could be worsened by the GOP measures, which would eat further into their Medicaid revenue and increase the number of uninsured patients showing up at their emergency departments.

Under the House bill, hospitals would stand to lose $321 billion over the next 10 years and would face another $63 billion in costs from serving a larger uninsured population, according to an analysis by the Urban Institute and the Robert Wood Johnson Foundation.

The Senate version would cut even more from hospitals. The reduction in what is referred to as the provider tax, along with restrictions on state-directed payments, would cut another $375 billion in federal Medicaid spending.

Some senators, including Susan Collins (R-Maine), one of three GOP senators who voted against the bill, expressed concern about the impact that reducing the provider tax could have on rural hospitals in their states. The Senate added a $50 billion rural hospital fund over five years to the final version of the bill; Collins had pushed for more money to be added to that fund.

But it’s clear that shrinking the Medicaid program will disproportionately affect hospitals that serve large Medicaid populations.

Executives of such hospitals are bracing for cuts that could force them to scale back services, causing ripple effects across their communities that would affect patients regardless of what kind of insurance they have. Patients without insurance will delay care, add to hospitals’ costs and lengthen wait times for all patients, they say, driving health systems to cut back on services.

“Coverage of less people will result in more avoidable hospitalizations because of sicker patients, more emergency room visits and ultimately avoidable deaths,” said Ngozi Ezike, CEO of Sinai Chicago, a health system with 70 percent of patients covered by Medicaid.

While seniors rely on Medicare to cover their medical expenses, that program doesn’t cover long-term care. So if they run out of other funds, such as long-term care insurance or savings, they turn to Medicaid, which covers more than 60 percent of nursing home residents in the United States. Medicaid generally pays for a semiprivate room, which can cost more than $100,000 a year.

One of the major ways nursing homes boost their Medicaid funds is by paying a tax to states, which states then return in the form of higher Medicaid payments. But by limiting these taxes, the GOP measures would undercut the dollars going to nursing facilities.

That could make it harder for seniors to find a spot in a nursing home, if the lower payments prompt facilities to shutter.

“Their coverage will be at risk,” Katie Smith Sloan, president and chief executive of LeadingAge, a Washington lobbying association for operators of nonprofit senior-care facilities, said in May. “Either the home itself will have to make up for that loss in some way or they will simply have to say, ‘We can no longer support people on Medicaid’ and close those beds.”

Daniel Gilbert and Fenit Nirappil contributed to this report.