Brigid Bergin: It's the Brian Lehrer Show on WNYC. I'm Brigid Bergin from the WNYC and Gothamist newsroom. Filling in for Brian today. For the first time in modern US history, a president and Congress are advancing policies projected to increase the number of uninsured Americans by the millions. Alongside the extension of Trump's first-term tax cuts, the reconciliation bill passed Tuesday by the Senate includes deep structural changes to Medicaid and the Affordable Care Act. It would reduce federal Medicaid spending, tighten eligibility requirements, impose new work rules, and let enhanced subsidies for ACA marketplace plans expire at the end of the year.

According to estimates from the nonpartisan Congressional Budget Office, those changes could leave as many as 16 million people without health insurance over the next decade. The bill still needs final action in the House, but if enacted, it would mark a big shift in the role of the federal government in ensuring health coverage, rolling back decades of incremental progress in the only developed country in the world without universal health coverage. To help us understand what's in the bill, how it would work, and what's at stake for patients, states, the healthcare system more broadly, we're joined now by Julie Rovner, Chief Washington Correspondent for KFF Health News and the host of the podcast What the Health. Hey, Julie, welcome back to the show.

Julie Rovner: Thanks for having me.

Brigid Bergin: Julie, just start us off with what kind of bill is this and what are the major health care provisions tucked inside?

Julie Rovner: Well, this is what's called a budget reconciliation bill. This happens-- This is part of the budget process that Congress does. We have the annual spending bills that we hear so much about that if Congress doesn't pass, the government shuts down. Reconciliation bills come into play when Congress passes a budget resolution that wants to change permanent spending. Not the things that are in the annual spending bills. Either taxes or what's called mandatory spending. Most mandatory spending is in health care. It's Medicare and Medicaid, and the Affordable Care Act.

That's why whenever there's a budget reconciliation bill, we can expect to see a lot of health provisions in it. That's exactly what's happened this time. It's just that in the past, reconciliation's usually been used to expand health coverage, and this one's being used to contract health coverage.

Brigid Bergin: Listeners, we can take your calls on the health care changes inside Trump's reconciliation bill, which the Senate passed yesterday. Do you rely on Medicaid or ACA coverage? What would these changes mean for your ability to seek health care? Call and help us report this story. The number 212433 WNYC, that's 212-433-9692. You can call or text us at that number. Julie, there's a lot in this bill aimed at reshaping Medicaid. What stands out to you most about the approach it takes?

Julie Rovner: The approach-- In 2017, the last time Congress had this big fight, they advertised that they were trying to repeal the Affordable Care Act. They called it repeal and replace. There was this huge fight. This bill would in many ways do as much to reduce health coverage as that bill would have, but they're not calling it a repeal of the ACA. They're going after much the way they're going after Medicaid is going after the states that expanded Medicaid using the Affordable Care Act. This really is sort of a backdoor repeal of the Affordable Care Act.

It would do a lot of very nerdy technical things that would, as you very eloquently put in your intro, just make it harder for people to get and keep, and afford coverage.

Brigid Bergin: As I understand, there's been some state-level experiments with work requirements before, like in Arkansas. Can you tell us what happened there and how this might play out on a more national scale?

Julie Rovner: Yes, that's right. We've seen this movie. Basically, there's a lot of public support for the idea of work requirements in Medicaid for saying that if you're going to get this government benefit, you should do something. You should go to school, volunteer, look for a job, work at a job. That's very popular. Also, by the way, most people on Medicaid either are working or going to school, or caring for someone who can't care for themselves. Most people you can't sit at home and live on your Medicaid benefit. It's not a cash benefit. It pays healthcare providers when you need medical care.

What we found, and primarily in Arkansas, is not that people couldn't meet the work requirement or that they didn't meet the work requirement. It's that they couldn't jump through all the procedural hoops of reporting that they were meeting the work requirement, so we ended up with 18,000 people getting dropped from the Medicaid rolls before. It was basically the whole experiment was stopped by a judge that we've seen that it's really the administrative burdens that are put up by the work requirements, not the work requirements themselves that end up having fewer people on rolls and therefore saving money, which is part of what this whole exercise is for Congress.

They're trying to offset some of the costs of the tax breaks that they're renewing.

Brigid Bergin: As I mentioned, the Congressional Budget Office projects that depending on how it all gets implemented, up to 16 million people could lose health insurance. It's mind-blowing. Who's most at risk there?

Julie Rovner: As a result of the bill itself, with the changes to Medicaid and the procedural changes to the Affordable Care Act, it would be about 11.8 million as it was passed by the Senate. There's another four and a half, five million people who could lose coverage because in 2021, Congress, during the Biden administration, increased the subsidies for people on the Affordable Care Act, made them larger for lower-income people, and extended them up the income scale that enabled many more people to afford coverage. Now we have like 24 million people who have ACA coverage through these state-based marketplaces.

Those extra subsidies expire at the end of this year. Congress could renew them. Most of the people that get these subsidies are Republicans. They're in red states, but Congress, at least so far, has chosen not to do that. That's part of the overall estimate that as of the end of this year, with this bill and Congress's failure to renew those subsidies, it would be somewhere around 16 or 17 million fewer people who would have health insurance.

Brigid Bergin: I want to go to Bill in Beacon. Bill, thanks for calling WNYC.

Bill: Thank you. The first thing I want to say is Brigid rocks.

Brigid Bergin: Thanks, Bill.

Bill: My simple question is, given the fact that the American Medical Association killed universal health care when FDR tried to implement it, where are they now? Why aren't--

Brigid Bergin: Oh, we're not sure what happened to Bill's-- Oh, Bill's back. Sorry, Bill.

Bill: Oh, I'm sorry. Okay. The AMA were the main factor in killing universal health care when FDR proposed it, and here we are with another huge effort to kill health insurance for people. Why isn't the AMA standing up against this?

Brigid Bergin: Bill, thanks for that question. Julie, where is the AMA on this?

Julie Rovner: They're against this bill. They have said that. The AMA doesn't have the clout that it had in the 1940s and 1950s, and even as recently as the 1980s. Not as many doctors belong to it. Doctors are no longer all that powerful. Hospitals are sort of the predominant lobby right now, and hospitals don't like this bill either. Because if there are more people who are uninsured, they're still going to have to care for them, and they're not going to get paid. In fact, there's a big concern in this bill about rural hospitals that could either go under or have close things like their obstetrics units or their emergency rooms the very expensive units of some of these hospitals.

Congress doesn't react to the health care industry the way it used to. It does to some extent, but right now there is a united medical community that is against this bill, and the people who are pushing it don't seem to be taking that very much to heart.

Brigid Bergin: Julie, we have a listener who writes a question that I'm not sure you're going to have the details on. I know you cover this nationally, but several people are asking, can you share more about what the expected implications are for New York specifically? Do you know any of the fallout on a state-by-state basis?

Julie Rovner: I have seen state-by-state lists. I don't remember the exact fallout, but I can tell you that every state and certainly every state with rural areas, of which New York is obviously one, is very concerned about what this could do and what this could for health care access in those sort of far-flung areas. Obviously, with many people losing Medicaid, that would affect the city, too. It would affect the city's hospitals, but they're not as dependent on Medicaid as a source of funding as some of the smaller hospitals in more rural areas.

Brigid Bergin: Julie, as I understand, the Senate parliamentarian did strike down some of the proposed Medicaid changes before the final vote. What was ultimately ruled out, and what stayed in the bill?

Julie Rovner: Well, one of the things that she ruled out were the bans on allowing legal immigrants to get Medicaid. Illegal immigrants are not allowed to get Medicaid. There are several states, however, that use state-only funds to pay for undocumented people to have health coverage on the theory that if you're living here, you could get sick, and if you get sick, it would be better to treat you than to have you spread contagious diseases to others. There was a provision in the Senate bill, I believe it was in the House bill, too, that would have reduced the federal matching rate for states that used their own money. I think it was seven states.

The parliamentarian said, no, you can't do that in a budget reconciliation bill. There are very, very strict rules for what can be included in that bill, because in the Senate it can avoid a filibuster and can pass with only 51 votes. Therefore, everything has to be primarily budget related. One of the other things that the parliamentarian knocked out was a provision that would have banned Medicaid funding for gender affirming care. That had to get dropped. There was a provision, this was from the House bill that would ban funding to Planned Parenthood for 10 years.

Now, abortion has never been covered. This is all covered by the Hyde Amendment. You can't use federal funds to pay for abortion. Basically, this says we're going to kick Planned Parenthood out of Medicaid entirely. All the other things Planned Parenthood does, contraception, STD testing, cancer screening, just basic primary care, you won't be able to do that either, and collect from Medicaid for it. The parliamentarian originally said they couldn't do it. Then they came back with a one-year ban, and the parliamentarian said that's okay, so that's what's in the bill as it passed the Senate.

Brigid Bergin: Julie, I want to bring in another caller. Let's go to Tan in Austin, Texas. I think originally from Brooklyn. Tan, thanks for listening to us in Austin.

Tan: Hello. Thank you for having me. I'm currently a graduate student for physical therapy, and currently I can't really work. I'm actually on Medicaid and on multiple government programs. I wanted to know how this would affect graduate students because most of us can't really be employed while we're doing our studies, and we're going to be expected to even go into the health care field. Insurance is a great financial burden as well. Thank you.

Brigid Bergin: Tan, thanks for that question. Julie, any sense of how that will impact someone who's a student and not working?

Julie Rovner: Well, going to school is one of the exceptions to the work requirement. Presumably, you'd not be covered, but the challenge and the challenge that we're going to see with all of these is having to report that and having to prove it every month to your state Medicaid agency to remain eligible for Medicaid. That's what we saw. It wasn't just Arkansas. We've seen this in Georgia and to a smaller extent in New Hampshire, some other states that have had Medicaid work requirements. It's the reporting that tends to trip people up, not the fact that they are actually meeting the requirements.

Brigid Bergin: Julie, Trump and supporters of this reconciliation bill say these policies are about reducing fraud, making sure the public benefits go to "the right people." How much do we know about how much fraud actually exists in Medicaid and whether what they're proposing actually addresses it?

Julie Rovner: Well, of course, there is fraud in all the federal health programs. Of course, the fraud is mostly perpetrated by healthcare providers or people posing as healthcare providers, because that's where the money goes. As I said, the money doesn't go to the individuals. There are probably some people who are on Medicaid who are no longer eligible, but they are greatly outnumbered by the people who are eligible, but for one reason or another have difficulty basically proving that eligibility on a regular basis.

Right now, the rules say that you have to sort of re-up your eligibility once a year. This would change it to twice a year. Would that filter out some people who aren't eligible and should no longer be there? Yes, but would it also filter out a lot of people who are still eligible and just can't prove it? Also yes.

Brigid Bergin: We know that Medicaid is jointly run by federal and state governments. If this passes, how much room will states have to shape what it looks like on the ground? Could that lead to really different experiences depending on where someone lives?

Julie Rovner: Yes, it's a really good question. Yes, it absolutely could. There will be guidelines for how states will have to do this. One of the big concerns is that this would be setting up a whole new bureaucracy for a lot of states, and there's no money for them to do it. They would have to basically spend money that's now going to benefits to create these new ways of people proving that they're doing something for 80 hours a month.

Brigid Bergin: Can you talk us through some of the most significant changes to the ACA in this package?

Julie Rovner: Yes, they're quite technical. As I mentioned, one of the big things is something this bill doesn't do, which is extend those increased subsidies that were passed in 2021. There's also some smaller things like not allowing sort of auto-re-enrollment for people, shortening the enrollment period, making it harder for people to enroll during sort of the non-open enrollment period, which, as I just said, would already get shorter. There are a lot of technical things that the CBO suggests will end up with many fewer people either being eligible or getting coverage.

Brigid Bergin: I want to talk a little bit about some of the other programs that are cut through this bill. We've had a listener who texted, not just a loss for Medicaid coverage. Don't forget the deep cut of SNAP, which sustains proper nutrition to millions of Americans. It's catastrophic for me and millions like me. Julie, can you talk about what are some other major programs that are being hit by this bill?

Julie Rovner: Yes. Well, SNAP is obviously the next biggest cut, and basically it says that states would have to take over a share of SNAP funding. Now, unlike the federal government, states have to balance their budgets every year. States aren't mostly sitting on big surpluses that they can say oh well I guess we can spend more on food assistance or on Medicaid. It's really hard for them. Something we didn't even talk about is that the bill that passed the Senate would cut back on states' ability to raise their share of Medicaid funding.

That would be another way in which it would be more difficult for states to maintain these benefits, even if they did want to. Something else that sort of would follow from this, because this bill is not fully paid for. Even all of these cuts to the safety net do not make up for the increase in the deficit from extending these tax cuts. That will trigger what's called a sequester to Medicare, which remember, President Trump kept saying he didn't want to cut, but this would be an automatic cut of up to 4%. Again, that would be for healthcare providers, but there's already an issue of healthcare providers' ability to continue to serve Medicare patients. Medicare gets sort of dragged into this by default.

Brigid Bergin: Let's go to Stacy in Manhattan. Stacy, thanks for calling WNYC.

Stacy: Hi, I just told you screen. I'm a 62-year-old woman living in Manhattan. I have a master's degree. I used to work in advertising. It's been hard for me to get a job these last two years. I'm on Medicaid, and I am [inaudible 00:17:41], and it's really helping me. I just wanted to say that I might not be the average face of Medicaid and all these entitlements, but that's who it's going to affect, everybody, not just the people you might expect.

Brigid Bergin: Stacy, thanks for your call. Julie, I want to know, we have another listener who texted this moves Medicaid away from being a safety net for people and more towards being a subsidy for employers who don't want to pay for their employees health care. Medicaid should exist for people who lose work or can't work, not to enable large corporations who don't want to provide adequate benefits to employees. Any reactions to both the caller and that text? Anything we need to fact-check in there?

Julie Rovner: Yes, the Republicans keep saying, "Oh well, you can just get a job and then you can get health insurance." That's not how it works. In fact, Republicans have been working for four decades to make sure that jobs don't have to provide health insurance. Many of the jobs, particularly at the lower end of the income scale, do not. Many people are in fact, on Medicaid, and that's been controversial because some of them are sort of large companies that have a lot of low-paid workers, and it would be, they say, prohibitively expensive to offer them health insurance, and now many of them can get Medicaid.

There are also people who, like the caller, simply can't find work and end up on Medicaid. That's what the expansion under the Affordable Care Act was for. That's who it was aimed at, at the people who for reason or another, couldn't work or didn't have a job but still needed health insurance.

Brigid Bergin: Julie, we've talked about how the Senate has passed its version of the bill. Can you talk about the path forward in the House? I understand, I think there's some voting going on. It might be procedural. How many changes are expected, or is this likely to head straight to the president's desk with these cuts within it?

Julie Rovner: Well, it only heads straight to the president's desk if there are no changes. If the House approves the Senate version of the bill, it goes straight to the president. If the House makes any changes, then it has to go back to the Senate, and the House is indeed debating it. They overcame that first procedural hurdle. A lot of people didn't get back to Washington yesterday because we had a lot of storms, and a lot of the flights were grounded. I think that was the same in New York. It appears that they are moving ahead. We will have to see what happens. I honestly don't know.

There are an awful lot of Republicans who say they don't like the Senate version of the bill, and they won't vote for it, but there were an awful lot of Republicans who said they wouldn't vote for it the first time around, and in the end, they did because most of these are Republicans do what Donald Trump wants, and what Donald Trump wants today is for them to approve the Senate bill so that he can sign it on July 4th.

Brigid Bergin: Well, I know you will be watching all of those details, and I'm sure we will be talking about them more going forward. We're going to leave it there with Julie Rovner, Chief Washington Correspondent for KFF Health News and host of the podcast, What the Health. I love that name. Julie, thanks so much for joining us today.

Julie Rovner: Thanks for having me.

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