ICYMI: The Megabill, Medicaid And Rural Americans

0:07You're listening to the 1A Podcast. I'm Jen White, and this is In Case You Missed It, where we bring you some of the week's most important conversations you might have missed. In Washington on Friday, President Donald Trump celebrated the passage of his signature tax and spending bill into law. That's after House Republicans muscled it through Congress, meeting their self-imposed Fourth of July deadline. At nearly 900 pages, the legislation is a sprawling collection of tax breaks, spending cuts, and other Republican priorities, including new money for national defense and deportations. It will also reduce Medicaid spending by more than$1 trillion over the next decade.

0:44That will result in an estimated 11.8 million people losing health insurance coverage, according to KFF News. Among those hardest hit, rural Americans. Here's Kentucky Governor Andy Beshear, a Democrat, speaking to CNN's Dana Bash. His state is one of the 40 that expanded Medicaid under the Affordable Care Act in 2010. About one-third of Kentucky residents are on Medicaid. Well, this law is devastating. It's the single worst piece of legislation I've seen in my lifetime, and it is a congressional, Republican, and presidential attack on rural America. In my state alone, 200 ,000 people are going to lose their coverage.

1:23Those are 200 ,000 Kentuckians that deserve to see a doctor when they're sick. 20 ,000 healthcare workers are going to lose their jobs, and we've got up to 35 rural hospitals that are typically the second biggest employer in their communities that may close their doors. And what that means is our economy takes a huge hit. And then whether you have private insurance or Medicaid, if you live in rural America, you have to drive hours just to see the doctor that used to be in your community. That was Kentucky's Democratic Governor Andy Beshear on CNN this weekend. What kind of challenges could people living in rural areas face under the new law?

2:01And what ripple effects that the law have across the rural public health system. Jessica Glenza joins us after the break to discuss all that and more. Jessica is a senior health reporter at The Guardian. And for all the latest on the bill, be sure to visit npr.org or tune in to your local NPR member station. Back with more in a moment.

2:24Jessica, welcome to the program. Thank you for having me. So Medicaid is the single largest health insurance program in the U.S. It covers about 71 million U.S. residents. What does Medicaid currently cover and for whom? Medicaid covers a whole suite of health care, the same way that your employer-sponsor coverage covers all of your different health care. It covers health care overwhelmingly for the low-income, disabled, and elderly. So just to give you a sense of scale, Medicaid covers about half of all births across the United States. That number sort of fluctuates between four and five in 10 births and is the primary payer for six in 10 nursing home residents.

3:05So it's an incredibly important program. So under this law, why are rural Americans particularly at risk? So some rural areas tend to be disproportionately dependent on Medicaid because it can be harder to get employer-sponsored coverage. and because people living in rural areas tend to have lower incomes than people living in metro areas. So some good examples of rural areas that could be particularly hard hit are eastern Kentucky, West Virginia, and California's Central Valley, which is very agriculture dependent. So those are just some examples. And of course, we heard Kentucky Governor Andy Beshear at the top talking about how many rural hospitals could close in his state.

3:50The reason why it could have a sort of compounding impact on rural residents is because not only are people dependent on Medicaid, but the institutions that serve them are also dependent on Medicaid. So these hospitals that are disproportionately dependent on Medicaid are operating under incredibly tight margins. And when you take away Medicaid, uninsured people get sick too. So they are still going to visit these hospitals and emergency rooms, but they will overwhelmingly become part of the hospital's what's called uncompensated care. In other words, there'll be a cost to the hospital, and the hospital will not get paid for providing them care.

4:31So as a result, we could see the closure of many hospitals. Is there also concern that people who lose Medicaid coverage might also delay care, leading to more serious illness? Absolutely. So interestingly, before this bill really picked up speed in Congress, a very important study was published in the National Bureau of Economic Research that found over the course of more than a decade, the expansion of Medicaid, which people may recall was a key provision of Obamacare way back in 2010, that expanding Medicaid to people who earned a little bit more money, save 27 ,000 lives. So I think that when you talk about historic expansion of Medicaid saving lives, you have to also think about and historic cut to Medicaid and what lives will be lost as a result, because people will delay care because they fear financially ruinous bills.

5:25Congressional Republicans in favor of the law say it targets waste, fraud, and abuse in the Medicaid system. What evidence is there of waste, fraud, and abuse in the Medicaid system? Yeah. Well, when you listen to what congressional Republicans are saying about waste, fraud, and abuse, what they tend to say is sort of a secondary point is we're targeting waste, fraud, and abuse and people who should have never been on Medicaid in the first place. And what they appear to be implying when they make those statements is people who they think should have a job and therefore employer-sponsored coverage.

6:00Able-bodied people they refer to often. That's accurate. So able-bodied people. So I think that's a political question. If you think that people who are stitching together two to three part-time jobs but aren't eligible for employer-sponsored coverage anywhere else should have health care, then I think Medicaid expansion is a good answer to that politically. Politically, if you don't feel that way, then perhaps you agree with Republicans. Either way, whether you agree or disagree, the fact is that people without insurance still get sick, and they still go to the hospital, and they still cost money to treat.

6:43So it has a systemic impact whether or not you agree that people have a right to health care. Now, Republicans in the Senate tacked a$50 billion fund onto the legislation to cushion the blow to rural hospitals, and the money will be distributed starting in 2027. It'll continue for five years. What are rural hospitals and health care centers saying about how far that money will go? Well, I think that they, without addressing the rural health care fund directly, for instance, I read a statement from the American Hospital Association this morning that expressed just a real disappointment with the fact that the legislation was passed in spite of many warnings about how dire this could be to hospitals.

7:25So even though there is a rural health care fund, I think it's pretty, you know, what experts said to me is it's pretty simple math. There's a$50 billion fund for rural health care, but you're taking a trillion dollars out of Medicaid. And if the rural health care fund only lasts for five years, but the expectation is the impacts of the legislation will go for a decade or longer, for instance, Congressional Budget Office estimates that we're going to see 17 million more uninsured people by 2034, it appears pretty evident that rural hospitals and all hospitals are going to lose substantial amounts of money, whether or not there's an additional fund to try and cushion the blow.

8:04Now, it's interesting because there's the law, but then there are also about a dozen states that have written trigger laws into Medicaid expansion plans. How do those work? So to think about how trigger laws work, I want to take you all the way back to 2010 when Obamacare was passed and the federal government expanded Medicaid to those people who were low income, as we said before. So this was very politically contentious, people may remember, and eventually states had to opt into the program. So in politically competitive states, like, for instance, Arizona or North Carolina, the only way that the state legislature could get Medicaid expansion over the line was to include a provision in the law that unwound Medicaid expansion if the federal government ever paid less.

8:56So the federal government right now pays for 90 % of the costs of Medicare expansion beneficiaries. That's people earning up to 138 % of the federal poverty level. And so states said, if at any point the federal government decides to give us less than 90%, then we're going to unwind this program. Now, those laws are all written differently. And I think the best expression of this was a lesson in federalism, according to one person at Georgetown University. So North Carolina appears to have, you know, perhaps the most perilous situation where they wrote a law that said any state funds expended on the Medicaid expansion population could unwind the program.

9:34So the architect of North Carolina's Medicaid expansion, he believes that this congressional law could hit the kill switch, in his words. But not all state trigger laws are written that way. So it's unclear the extent to which Medicaid expansion could be impacted. It's going to be very state by state. And then the second thing that we haven't talked about yet is the way that these complex, that there are some very complex financial maneuvers states use to finance Medicaid expansion in competitive states, especially where it's contentious to raise taxes. So the congressional bill also capped some of those financial maneuvers.

10:11That means that in the next state legislative season, we're going to see a lot of discussion about how to handle these new financial pressures. But as you said, Jessica, uninsured people get sick too. So what are you watching for most immediately with these cuts to Medicaid? I think that you can go from the top down, the pressure on states, then the pressure on hospitals, and then the pressure that will be on people and their own finances and how they handle it. And as I said at the top, whether we see lives lost because of these historic cuts to Medicaid. That's Jessica Glenza. She's a senior health reporter at The Guardian.

10:48Jessica, thank you. Thank you. This program comes to you from WAMU, part of American University in Washington, and distribute it by NPR. I'm Jen White. Thanks for listening. And we'll talk more soon. This is 1A.