HARI SREENIVASAN: But first: As we heard, Senate Republicans are pushing hard to pass their own bill next week to replace and overhaul the Affordable Care Act.
One of the key issues, major cuts to Medicaid, the joint federal-state program that provides health care to low-income Americans, the elderly and disabled. It was expanded under Obamacare. But now 14 million Medicaid recipients stand to lose that coverage under a bill passed by the House.
Reports out tonight say there will be even deeper cuts under the Senate version.
Special correspondent Cat Wise reports from Los Angeles on how these cuts could directly affect patients.
CAT WISE: A homeless man on Skid Row hoping to finally get a roof over his head. A middle-class mom earning an income to care of her disabled son. A working-class truck driver getting care for his complex medical problems.
Three very different lives, with a common thread now at risk of being cut: Medicaid.
Los Angeles is well known for its Hollywood stars with glamorous lifestyles. But the city is also home to many who are less fortunate. The working poor and homeless here have benefited from the Affordable Care Act. In fact, about 1.2 million residents gained health insurance through the Medicaid expansion.
But all that may be about to change. The Republican plan to replace the Affordable Care Act, passed by the House of Representatives in May and now being considered by the Senate, would fundamentally alter Medicaid in two key ways.
First, the ACA’s Medicaid expansion — that offered states the option of covering most non-disabled childless adults with incomes below and just above the poverty line — would end within several years.
PRESIDENT DONALD TRUMP: We’re going to get this passed through the Senate. I feel so confident.
CAT WISE: The House bill, which President Trump cheered in May, but has since reportedly called mean, also calls for converting the entire program from one with no cap on dollars spent to one where states get a fixed amount of money.
It would give state governments more flexibility about how to spend Medicaid dollars, but would cut the amount they receive by more than $800 billion over a decade, according to the Congressional Budget Office.
SEN. MITCH MCCONNELL, R-Ky., Majority Leader: I think we will have ample opportunity to read and amend the bill.
CAT WISE: A Senate version, which would eventually need to be merged with the House bill before becoming law, is still being crafted, but is said to include many of these same adjustments, though with a potentially longer rollback of the Medicaid expansion.
California stands to lose more than any other state under the House version, $6 billion a year starting in 2020, and more than $24 billion by 2027. Those cuts could have a big impact on this group.
WOMAN: I think you have hypertension, diabetes, neuropathy.
CAT WISE: For the last several years, Los Angeles County has been deploying teams of nurses, mental health and substance counselors and formerly homeless peer advocates throughout Skid Row.
Their goal is to improve health outcomes for this medically complex and costly homeless population by giving them a home. This Housing for Health program uses Medicaid dollars to fund supportive services, like mental health counseling and substance abuse treatment in locations where new housing is being offered.
On the day we tagged along, the team reconnected with a client who had been wanting to get off the streets.
WOMAN: Are you familiar with the (INAUDIBLE)
WOMAN: No? OK. So, that’s like — that’s the one everyone likes, because you can get your own room.
MAN: That sounds like my kind of room.
WOMAN: Yes, exactly. Yes.
WOMAN: It was a blessing to find him here. We will basically link him to services and help him get to the point where he wants to be.
CAT WISE: Nearly 3,000 people have received housing so far, and the goal is to get 7,000 more off the streets by 2020.
DR. MITCH KATZ, Director, Los Angeles County Health Agency: We have had dramatic drops in emergency department visits and hospitalizations following housing people.
CAT WISE: Dr. Mitch Katz is the director of the Los Angeles Health Agency, and he has been leading the county’s effort. We met at the Star Apartments, a 100-unit building in the heart of Skid Row with a community garden, various counseling services and a health clinic on the main floor.
The monthly rent is covered by county general funds, donations, and residents. But the services provided are covered by Medicaid. Dr. Katz took me on a tour of a recently vacated unit.
DR. MITCH KATZ: You will see that, although the space is small, it has everything that you would need. You have a refrigerator, stove, sink. It’s not grand, but it really changes somebody’s life.
Over a hundred people came directly out of the hospital bed, or directly from the emergency room, and are now living here. And I can take care of them for way less than it costs to be in the hospital, and they will have a much higher-quality life.
CAT WISE: The ACA’s Medicaid changes have also been felt by a much wider swathe of the population, low-income, often working adults who previously had no access to health insurance.
And that was the story for 60-year-old Jorge Arias, a former self-employed truck driver. Arias, who has had Medicaid for the last two years, is a patient at the Saban Community Clinic, a non-profit federally qualified health center which opened its doors to low-income clients 50 years ago.
Last year, Arias had emergency surgery after a heart specialist determined he had three blocked arteries.
Without insurance, he says:
JORGE ARIAS, Patient, Saban Community Clinic: I would not even be alive, you know, because, no medications, no doctors.
JULIE HUDMAN, CEO, Saban Community Clinic: Well, we see about 18,000 to 20,000 patients a year; 10,000 of them have Medicaid, and over 8,000 of them got it with the expansion under the ACA.
CAT WISE: Julie Hudman is the CEO of the clinic.
JULIE HUDMAN: Before we had the ACA, someone would come in and, depending on their income, we’d take a co-pay, and it typically was around $18 per person. Now, when a patient comes in with Medicaid, we receive about $200 for the visit. The difference between the $18 and the $200, $225 is, you know, a huge source of revenue for us, and allows us to stabilize, to keep our doors open, and then actually expand services.
MAN: So, how have you been this week?
WOMAN: Fine. Yes, I’m good.
CAT WISE: Some of those new services include mental health counseling, which could be cut back if the clinic loses funding.
Traditional Medicaid programs, like those for the disabled and long-term care for the elderly, could also be impacted. Victoria and Steve Rosen are the proud, adopted parents of 16-year-old Max, who has a number of health problems due to prenatal exposure to drugs and alcohol.
VICTORIA ROSEN, Max Rosen’s Mother: So this is Max. When we first met him in the NICU, he had a very rough beginning.
CAT WISE: Max is the recipient of a Medicaid-funded program called In-Home Supportive Services.
Victoria earns about $3,500 a month through the program to help Max with things like personal care and feeding. That financial support has been key for the family because helping Max is a full-time job, and Victoria hasn’t been able to work outside the home.
VICTORIA ROSEN: It helps us survive, basically. I mean, before this, we were, you know, in debt. We don’t spend a lot of extra money. And all the money we spend is on Max.
CAT WISE: But many supportive Medicaid service programs like this one are considered optional under traditional Medicaid, and if states have to take on more financial responsibility for Medicaid with the new Republican plan, health analysts and program leaders say the optional services are likely to be cut.
To the Rosens, that doesn’t make a lot of sense.
STEVE ROSEN, Max Rosen’s Father: IHSS saves money. It would be more expensive to take care of someone like Max in an institutional setting than it is to have him in his own house.
CAT WISE: Many Republicans say these programs may be important, but Medicaid is simply out of control.
MICHAEL CANNON, Director of Healthy Policy Studies, Cato Institute: Medicaid has grown into this incredibly wasteful program, rife with fraud, siphoning lots of money away from the people the program should be helping.
CAT WISE: Michael Cannon is the director of health policy studies at the Cato Institute, a libertarian think tank. Cannon is concerned the current legislation being considered by Congress wouldn’t go far enough in axing federal Medicaid regulations and turning over control to the states.
MICHAEL CANNON: So, what Congress should be doing here is saying to the states, look, we don’t know how to run these programs better than you. We will continue our contribution to your Medicaid programs, but we’re going to give you a fixed amount of money. It’s not going to grow from one year to the next, but we’re also going to give you full flexibility to run your programs the way you think is best for your state.
States will have a much greater incentives then to eliminate fraud, to make sure that those Medicaid dollars are being spent on the people the program was meant to help, and not on the people the program wasn’t meant to help.
CAT WISE: Back in Los Angeles, the health department’s Dr. Katz says he has no problem working within a budget as long as it is a fair one.
DR. MITCH KATZ: If you give me flexibility, I can do a better job. And I could do a better job for less money. But I can’t do 70 cents on the dollar. Then, I’m actually going to have to cut services.
CAT WISE: While the health care debates continue in Washington, the teams on Skid Row are still hitting the streets looking for people to help, and hoping they can do so for a very long time.
For the PBS NewsHour, I’m Cat Wise in Los Angeles, California.