Kathleen O’Brien at her workplace in Point Breeze North on July 9. In her left hand she holds medical forms related to her son. (Photo by Caleb Kaufman/PublicSource)
Millions stand to lose health coverage under the new law. Doctors worry people will leave conditions untreated until they are “so much sicker.”
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Medicaid is the reason Kathleen O’Brien’s son can walk and ride his bike without falling.
The federal health insurance program has allowed him to “be a teen in the way that his peers are,” she said. Her son has a genetic condition that led to his ACL becoming severed, which she said required surgery that would have cost $80,000 without insurance. Medicaid covered it, along with a year of biweekly physical therapy.
“He’s not being yelled at anymore for sneaking onto the school elevator,” O’Brien said. “Or people not believing him when he tells them that his knee hurts.
“None of that could have been addressed without Medicaid,” she said, adding that even with a plan through Pennsylvania’s public insurance marketplace, the copays would have put care out of reach.
Her son, whose identity she kept private, is one of almost a quarter million people in Allegheny County who rely on Medicaid for health insurance, along with tens of millions nationwide, many of whom are now wondering if their coverage will decrease or disappear after Congress approved President Donald Trump’s tax cut legislation this month.
The “One Big, Beautiful Bill,” which Trump signed July 4, extends tax cuts that were set to expire this year and offsets some of the cost by cutting more than $1 trillion in Medicaid spending over the next decade, among other spending cuts. The Trump administration claims the cuts are intended to combat waste and fraud. The nonpartisan Congressional Budget Office’s analysis of one version of the bill estimated that it would result in nearly 11 million people losing insurance coverage in the next 10 years.
“Taking care of people who don’t have insurance is so hard because they are so much sicker when they come in.”
dr. paula jernigan, upmc shadyside pulmonologist
There are numerous unanswered questions about how the new law will play out, and who it may push out of Medicaid.
- There are new work requirements, but it’s not clear who qualifies for exemptions.
- It’s unknown how each state will navigate a new limit on the fees they can charge health care providers to help pay for Medicaid coverage.
- States are responsible for administering the changes mandated by Washington and the exemptions, and Pennsylvania’s plans aren’t yet developed.
“I haven’t seen anything concrete,” said John English, a 77-year-old Medicaid recipient on a fixed income, who lives in Homestead. “That’s what worries me the most. That’s what keeps me up at night.”
Work requirements raise questions
Kiki Koutsouflakis, a notary public in Slippery Rock, said she relies on Medicaid for thyroid medication and a birth control medication that was prescribed to treat a condition that she said would otherwise make her “passively suicidal” multiple times per month.
Now, Koutsouflakis is worried that the work requirements created by the new law will block her access to Medicaid.
The law requires the roughly 20 million people covered under the Affordable Care Act’s Medicaid expansion — mostly adults without dependents — to record 80 hours per month of work, education or community service or meet medical or disability exemptions.
Koutsouflakis transitioned to working part time to accommodate burnout stemming from autism — a condition she was only diagnosed with last year after struggling to work full time at a tech company.
She works 24 hours per week in her current job — normally enough to meet an 80-hour monthly requirement. But she wonders, what if she gets sick and misses just two shifts?
“My concern is if I end up with COVID again and I miss more than two days of work, am I going to get kicked off of Medicaid?” Koutsouflakis said. “I don’t know how strict they’re going to be.”
The law calls for exceptions to the work requirement for people who are “medically frail” and gives states the option to grant exemptions for people who end up in an inpatient hospital.
Marian Jarlenski, a professor at the University of Pittsburgh’s School of Public Health, said there are many details that are still unknown about how the law will be implemented, partly because it will be administered at the state level. Numerous states, including Pennsylvania, have never enacted work requirements for Medicaid before.
“The details really matter,” Jarlenski said. “Let’s say you’re going through cancer treatment and some people have side effects that last for six or 12 months. What’s the work requirement? Who has to certify it? How many doctors do you have to have sign off?
“I think it’s really concerning for people with chronic health conditions … How sick do you have to be?”
Who will lose coverage?
The Congressional Budget Office, which provides nonpartisan analysis of the impact of proposed bills to inform legislators before they vote, said in June that the version of the new law passed by the House would result in 11 million people losing health insurance in the next 10 years.
The report estimates the biggest chunk of that group, or 7.8 million people, will lose coverage because of the changes to Medicaid. The work requirements alone will lead to loss of coverage for 4.8 million people, according to the report.
Exactly who those people are is the subject of debate along political lines. Republicans maintain that their law is aimed at rooting out waste and fraud from the system, and they are seeking to kick people off of Medicaid who are able to work and choose not to out of convenience.
“The 35-year-old guy sitting at home playing video games in his mom’s basement, he’s gonna have to go to work, because we put work requirements in place,” said House Majority Leader Steve Scalise, R-Louisiana, on Fox Business last week.
Sen. Dave McCormick, a Pittsburgh Republican who voted to pass the law, said in an interview with a Central Pennsylvania NBC affiliate that Medicaid was “never designed to help working-age men that weren’t working.”
But Jarlenski said the Republicans’ description of Medicaid abuse is misleading, because “Medicaid provides health insurance, not a welfare check.
“I’m not sure how you could survive based on Medicaid coverage [alone],” she said. “All the research that I’ve seen shows that the majority of people enrolled in Medicaid are working or in school already.”
A KFF analysis found that among adult Medicaid recipients who are below retirement age and not on Social Security disability programs, 92% were working full- or part-time or preoccupied by caregiving, illness or disability, or school.
Opponents of the new law say the work requirements will result in qualifying individuals losing coverage due to bureaucracy.
“We have seen how this works in other states,” said state Rep. Mandy Steele, D-Fox Chapel, at a press conference last week. “This is designed to make things intentionally difficult for Medicaid recipients who are already struggling … You’re going to have to upload documents, and you better not miss a call from a caseworker or guess what? You’re going to be knocked off those benefits.”
States will have to verify that a recipient meets the requirement at least once every six months, with discretion to do so more frequently.
“They’re full of crap,” said U.S. Rep. Chris Deluzio, D-Aspinwall, about Republicans who say they are pursuing waste in the system. “There is not waste and fraud that 22,000 people in my district receive their health care from. They know that.”
An interlocking system
The American health care system contains many interwoven parts, and many people are impacted by more than one of them.
English, the Homestead retiree, relies not only on Medicaid but also SNAP, or food stamps — another program subject to reduced funding by the law. He receives about $220 per month from the food program and subsists on that along with about $1,000 from Social Security. He said he can get by on the roughly $50 weekly food budget, but that it keeps him from eating healthy.
“It’s expensive to eat healthy,” English said. He said he’s afraid SNAP cuts could further restrict his food choices.
O’Brien’s son relies on Medicaid, but she is covered by Pennsylvania’s Pennie marketplace, which was set up through the Affordable Care Act. Her plan allows her to afford some of the care she needs, but not all. She said she is delaying necessary tests for her eyes, liver and gallbladder, as well as blood clot testing, because the copay would total $700 and she “can’t pay for those tests and pay rent and pay for groceries at the moment.”
Barring further congressional action, the monthly premiums for public marketplace plans like the one O’Brien uses will go up for many people next year.
Premium subsidies created by a 2021 federal COVID relief law, offered to anyone making up to four times the federal poverty rate, are set to expire at the end of this year, and it’s unclear whether the Republican-controlled Congress is intent on extending them.
If not, enrollees would face premium payments on average 75% higher starting next year, according to KFF.
John Fournier, the Allegheny County manager, said in addition to providing insurance for hundreds of thousands of county residents, Medicaid also fuels hundreds of millions in programs provided by the county’s Department of Human Services.
“A lot of people assume that Medicaid is an insurance program for low-income people, and it is for sure, but it is also an important subsidy for safety net programs administered by state and local governments,” Fournier said, listing mental health services and care for homeless people as affected programs. “Cuts to Medicaid don’t just affect the individuals that are involved in those programs, but it’s going to have a seriously deleterious effect on all manner of social services across the entire county.”
Doctor fears for preventive care
Dr. Paula Jernigan, a pulmonologist at UPMC Shadyside Hospital, remembers the days before the Affordable Care Act, when millions more Americans lacked health insurance. Her most harrowing stories from her job stem from that era, when more people delayed care and let conditions deteriorate.
“Taking care of people who don’t have insurance is so hard because they are so much sicker when they come in,” Jernigan said. After a slew of people became insured as a result of the ACA, “We started seeing people who didn’t have their asthma taken care of or their COPD [chronic obstructive pulmonary disease] taken care of. Their lives improved.”
With some 16 million people possibly losing coverage from the combined effects of federal policy changes in the next decade, Jernigan said, “I see all of that backsliding now.”
English said he came down with a terrible case of shingles when he was uninsured, just before he turned 65. “It really was a nightmare. Everything had to be out of pocket,” he said. “I couldn’t afford medications. I was using homeopathic remedies.”
Now he has access to inhalers through a combination of Medicare and Medicaid plans, which would otherwise cost $350 apiece. Without coverage, just one inhaler would cost him more than a third of his monthly retirement income. The inhalers treat his COPD — the same disease Jernigan said often went untreated in uninsured people before the ACA’s passage.
Charlie Wolfson is PublicSource’s local government reporter. He can be reached at charlie@publicsource.org.
This story was fact-checked by Jamie Wiggan.
This article first appeared on Pittsburgh’s Public Source and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
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