MICHEL MARTIN, HOST:
If you've been following the story of this megabill that the Senate is debating, you've heard us call it a tax and spending bill, which it is because the tax piece of it is the most expensive, but it's also a health care bill that includes more than a trillion dollars in cuts to Medicaid. To talk about the impact those cuts could have, we've called Adrianna McIntyre. She's an assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health. Good morning, Professor. Thanks for joining us.
ADRIANNA MCINTYRE: Good morning. Thank you for having me.
MARTIN: So over the weekend, the Congressional Budget Office - which is nonpartisan - estimated that the Senate bill could lead to some 11.8 million people - almost 12 million people - losing health insurance over the next decade. What's in the bill that would lead to that result?
MCINTYRE: Yeah, so there are changes to both Medicaid and the marketplaces that were created by the ACA, the Affordable Care Act. But the cuts to Medicaid are doing the biggest lift here. About three-quarters of those coverage losses are going to be attributable to the Medicaid policies. And I would say that the Medicaid cuts in this bill are a little bit less direct than some of the cuts we've seen in previous bills that were more explicitly about repealing the Affordable Care Act. These are policies that largely make it harder for people to get and stay enrolled in Medicaid. Work requirements would be new to the Medicaid program, and that's the largest driver of coverage losses.
MARTIN: So, you know, you've researched things like the impact of paperwork requirements on people's participation in health programs. So what does the research tell us? I mean, 'cause there has been research on this about the impact on Medicaid recipients when you add work requirements because a lot of people think, well, that just makes common sense. A lot of these people are working anyway. What's the big deal?
MCINTYRE: Right, right. So there are two states that have tried work requirements in the past -Arkansas and Georgia. Arkansas tried work requirements during the first Trump administration, and when they implemented them, about a quarter of people who were subject to the work requirements fell out of coverage. They did not stay enrolled. And when they were surveyed, it turned out that the vast majority of them either were working - as you said, most Medicaid beneficiaries are already working - or they were doing something else that meant that they were in compliance with the work requirement. They may have been in school. They may have been caring for a child or an older relative with disabilities. But the state didn't know that, so they had to kick them out of the program. And that's the real rub with work requirements.
The state does not necessarily automatically know, you know, how many hours you're driving for Uber or, if you're self-employed, how many hours you're working, or even for many ordinary employers, whether you're working. And they certainly don't know about your caring for family members. They don't know necessarily if you are in school. You have to go in and report this. And in the challenges, people often don't realize that they have to comply with these requirements, or they have trouble doing it in the way that the state needs, right? Producing the documentation that the state will demand. Will they ask for pay stubs? Will they ask, you know, a doctor's note if you're caring for a relative with disabilities? A lot of these details still haven't been worked out. But what we know is that when there's more paperwork, more people lose coverage.
MARTIN: OK.
MCINTYRE: At the end of the day, it's more of a paperwork requirement than a work requirement.
MARTIN: So Senator Ron Johnson, Republican from Wisconsin, was on the program yesterday, and he said that the Senate bill preserves coverage for disabled children. Let's listen.
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RON JOHNSON: We're not talking about traditional Medicaid that covers disabled children, you know, the vulnerable. That we want to preserve. We're talking about the Obamacare addition to it, where you have single, childless, working-age capable adults, childless adults that are being reimbursed 90 cents on the dollar by the federal government, exploiting Medicaid and putting those children at risk.
MARTIN: OK, so his argument seems to be that the expansion of the program to other groups threatens the financial integrity of the program, or that making these cuts preserves it for the people he says it was originally intended for. How do you respond to that?
MCINTYRE: I just don't think it's correct to say that pulling less vulnerable young adults out of the program makes the program stronger for our more vulnerable beneficiaries, the people who need Medicaid a bit more. And that's in part because the - when you have more people who are uninsured, health care providers, particularly health care providers in rural areas and health care providers that are already struggling financially - hospitals and clinics that are at the margin already - are going to close, and they're not just going to close for the people who lost Medicaid. They're also going to close for those vulnerable people on Medicaid, and they're going to close for the people who are not on Medicaid. There are nursing homes that are concerned about what - whether they're going to be able to sustain in the absence of a trillion dollars in Medicaid. I think it's just hard to say that you're going to pull a trillion dollars out of the Medicaid program without it having negative effects on the health care system.
MARTIN: So you're saying that there's a knock-on effect through hospitals, primary care providers and others beyond the people who are intended to experience these cuts.
MCINTYRE: Precisely. When you cut Medicaid, it doesn't just affect Medicaid beneficiaries. It affects everyone.
MARTIN: That is Adrianna McIntyre. She's a professor of health policy and politics at Harvard. Professor McIntyre, thank you.
MCINTYRE: Thanks for having me. Transcript provided by NPR, Copyright NPR.
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