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Difficult health care choices may be on horizon for Md.

Senate GOP proposal would likely require state to pony up money or cut coverage

Physicians and health workers join House Democrats to speak out on the impact of the Republican health care plan, on Capitol Hill in Washington, Thursday, June 22, 2017. (AP Photo/Andrew Harnik)

Physicians and health workers join House Democrats to speak out on the impact of the Republican health care plan, on Capitol Hill in Washington, Thursday, June 22, 2017. (AP Photo/Andrew Harnik)

Maryland could have to decide between cutting coverage or spending a lot more money to fund health care if the U.S. Senate Republican plan to replace the Affordable Care Act were to become law.

In this May 23, 2017, file photo, Senate Majority Leader Mitch McConnell of Ky., right, accompanied by Sen. John Barrasso, R-Wyo., speaks on Capitol Hill in Washington. (AP Photo/Jacquelyn Martin, File)

In this May 23, 2017, file photo, Senate Majority Leader Mitch McConnell of Ky., right, accompanied by Sen. John Barrasso, R-Wyo., speaks on Capitol Hill in Washington. (AP Photo/Jacquelyn Martin, File)

The Better Care Reconciliation Act unveiled Thursday would cut federal funding for Maryland’s Medicaid expansion as well as subsidies available on the individual health exchange market while repealing the individual mandate requiring consumers to have insurance.

Maryland would be left with the decision to either raise state spending on health care or to cut coverage.

“It is likely that some people will lose coverage,” said Jonathan Weiner, a professor of health policy and management at Johns Hopkins’ Bloomberg School of Public Health.

“When the tale of Obamacare is done … it is likely the state will either have to help the health care dollar go further, come up with more taxes, or drop people. … There’s no other way.”

Losing coverage

The Republican plan to amend the Affordable Care Act centers on ending one of the law’s trademarks: Medicaid expansion.

Starting in 2021, the bill would phase out the expansion, which has covered hundreds of thousands in Maryland.

A January report by Maryland’s non-partisan Department of Legislative Services estimated that under current law, the state’s share of spending for Medicaid expansion would be $350.2 million in 2021. But the total cost of the program will be $3.5 billion that year. Under Obamacare, the federal government picks up all of the difference.

But under the Senate health care proposal, the state would see its Medicaid funding from the federal government grow at a slower rate. Instead of increasing at the inflation rate of health care costs, Medicaid funding would grow at the smaller general inflation rate.

So, to keep its Medicaid coverage in place, the state would have to come up with hundreds of millions — if not billions of dollars.

At the same time, the Better Care Reconciliation Act would repeal the Affordable Care Act’s individual and employer mandates and cut subsidies available on the individual exchange.

Currently, those making 400 percent or less than the federal poverty line can qualify for subsidies to help purchase a silver plan on the market. Under the Republican plan, you must be making less than 350 percent of the poverty line and your subsidies apply towards a lesser bronze plan.

The subsidies would disappear entirely after 2019.

No subsidies and no requirement for coverage could leave the individual health exchanges in a perilous state. Already, CareFirst,the dominant insurer on Maryland’s health exchange, has asked for rate increases of more than 50 percent, due in part to projected drops in enrollment because of lax enforcement of the individual mandate.

“I do think that coverage will probably decrease,” Weiner said. “I’m not so sure that deductibles will decrease,” a stated goal of the Republican plan.

Preparing for changes

Wary of changes to the Affordable Care Act under President Donald Trump’s administration, the Maryland legislature created the Maryland Health Insurance Coverage Protection Commission this year.

“Maryland is really at risk here,” said Vincent DeMarco, who will serve on the panel. “This is where key recommendations are going to be made on how to protect Maryland’s health care, no matter what they do or don’t do in Congress or the Trump administration.”

The commission will meet for the first time Aug. 1, with a report due in December.

As they meet, commission members will have to consider how Maryland moves on without federal dollars, if the Republican legislation passes. Since the proposal has been revealed at least five Republican senators have said they cannot vote for the bill in its current form. Given the Republican Party’s slim majority in the Senate, it can only afford to lose two votes and still pass the bill.

The legislation would leave states more room to innovate on their own through a waiver program.

“States would have options,” said Dylan H. Roby, a professor of health services administration at the University of Maryland’s School of Public Health. “My fear would be they don’t have a bunch of money to play with.”

He pointed to programs put in place in Massachusetts and Minnesota, both before and after the Affordable Care Act. In Massachusetts, the state provided more money to supplement the subsidies provided on the exchange. In Minnesota, officials engineered a more robust reinsurance program.

Weiner, the Hopkins professor, suggested that because Maryland has a more liberal government than most states and has been committed to the Affordable Care Act, the Senate plan’s provisions to allow innovation could be a “silver lining.”

He offered one suggestion — that Maryland piggyback off of its all-payer system for hospitals to create an all-payer system for primary care providers as well, thus reducing health costs.

“I’m optimistic if any state can try to protect its citizens from the negative impact of Trumpcare, Maryland is definitely one of them,” Weiner said. “But I’m not optimistic that people won’t be hurt.”


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