As President Trump recently observed, health care is complicated. For years politicians, academics, providers, and ordinary folks have struggled to improve the health-care system while lobbying for their particular interests. The issues involved include hospital payments, insurance coverage, access to care, provider payment, Medicare and Medicaid funding, quality of care, and state versus federal payment obligations. Each of these interest groups has valid concerns, including the concerns of seniors.
The Republicans in Congress have filed a bill (the American Health Care Act) that would repeal and replace “Obamacare.” As the legislative process moves forward, it is becoming clear that the legislation does not answer all of these concerns. The numbers are enough to make a person gasp. If the legislation passed as written, some 14 million Americans would lose their insurance next year, according to the Congressional Budget Office. By 2026, the CBO said in a report released last week, some 24 million people would be uninsured. Although there are many other major changes in the bill, the increase in uninsured is perhaps the most frightening.
Seniors are fortunate in this particular legislative debate because Medicare cuts are not on the table (at least for now). However, to the extent that Medicaid pays for long-term care and support services, there may be big changes in how Medicaid is treated.
Medicaid currently pays a share of costs of care (in most cases) while the state pays the other part of the bill. The proposed legislation would change that open-ended payment system to a capped amount of federal payments to the state. Each state would decide how to spend its payments, but the fear is that the capped payments will not keep up with the cost of health care. There is also a fear that the switch to a capped amount of payments would result in a cost shift to the states. In turn, such a cost shift may cause states to cut back on their Medicaid programs.
If you are wondering why you should care about Medicaid, consider long-term care. Medicaid is the primary payer for nursing home care and for community-based long-term care. Eligibility for nursing home coverage under Medicaid involves spending down assets and income to a low level. It is not clear how or whether the bill, if enacted, will retain the current level of these benefits.
There are specific provisions in the bill that would affect older persons age 55 to 64 who are not yet eligible for Medicare. These individuals will face a private premium that is based on age rating, with older persons paying more in premiums. This penalizes older individuals who will also be disadvantaged by a change in federal premium subsidies favoring younger persons.
There are many other changes to health care that in the aggregate fundamentally reorder our health-care system. The bill is controversial and has received little support from Congress. The bill is expected to reduce the federal deficit by $337 billion and that may be sufficient to gain the support of deficit hawks. But it will not meet the needs of many people, including the millions of persons who will become uninsured. In the heat of debate, it can be easy to focus on costs and data and to forget that the programs exist for the benefit of recipients. Before we end health-care benefits for 14 million people, we must think carefully about the potential for human suffering.
Deb Thomson is co-chairwoman
of the Board of Directors of the Council on Aging.
