For the first year in history, over half of all visits to Sacramento County’s emergency rooms in 2016 were paid for using Medi-Cal, the state’s insurance program for the poor that was expanded by the passage of the Affordable Care Act, often called Obamacare.
So what happens to those people if Obamacare is repealed by the U.S. Congress?
The Republican plan to repeal and replace the Affordable Care Act is the American Health Care Act of 2017 and was passed by the House of Representatives in May. The House bill would roll back Medicaid expansion, which opened eligibility to millions more people. (Medicaid is called Medi-Cal in California.)
Cuts to Medi-Cal expansion, which is currently being entirely paid for by the federal government, means that the program will go back to serving just some of the lowest-income individuals and not everyone who may need it. The Congressional Budget Office estimated that implementing the AHCA will result in 23 million more uninsured people by 2026.
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The U.S. Senate is currently crafting its own bill. The latest reports show Republican support coalescing behind eliminating the expansion over the next seven years.
The Medicaid expansion has had a profound effect in Sacramento and across California.
In 2013, 35 percent of emergency room visits in Sacramento County were covered through Medi-Cal, while 15 percent were uninsured. Just three years later, 51 percent of visits were covered through Medi-Cal while the proportion of uninsured visits dropped by more than half to 7 percent, according to the Office of Statewide Health Planning and Development.
Statewide, in 2013, 30 percent of emergency room visits were covered through Medi-Cal and 16 percent were uninsured. The proportion of visits covered through Medi-Cal rose to 45 percent in 2016 as uninsured visits dropped to 8 percent.
It could become harder for those kicked off Medi-Cal to afford care. The AHCA’s method calculates tax credits based only on age and excludes those making over $75,000 a year, meaning that a 20-year-old earning $30,000 a year may get the same credits as one earning $75,000 a year. By contrast, the ACA takes into account a number of factors, including location and income, when determining tax credits.
The AHCA would disproportionately cost more for the poor and older adults not yet eligible for Medicare, the insurance program for the elderly, according to the Kaiser Family Foundation, a nonpartisan organization conducting health policy research.
People with an income of $20,000 would pay significantly higher premiums across all ages. Premiums for a 27-year-old would increase from $960 to $2,560 while premiums for a 60-year-old would increase from $960 to $13,190 – a change of 1,277 percent, even with tax credits, according to the Kaiser Family Foundation.
Access to specialty health care such as oncology would be limited under the AHCA. About 47 percent of visits to doctors’ offices are for medical or surgical specialties, according to the California Department of Health Care Services.
Under the AHCA, however, states would have a per capita cap, or a set limit for how much a state can spend on Medicaid. This may restrict states’ abilities to provide costly specialty care for enrollees who need it, said Christopher Perrone, director of the California Health Care Foundation’s Improving Access team. The AHCA would also allow states to opt out of providing some benefits currently mandated by the ACA, such as maternity care.
For potentially millions of Californians and over 100,000 Sacramento County residents who gained coverage from the ACA, being unable to afford health insurance under the AHCA would mean having to pay out of pocket for medical expenses, Perrone said. They may also rely on community and nonprofit clinics that specifically provide care for the uninsured, but access to specialty resources would also be severely limited.
Hospitals and other health care systems will likely also be hurt, Perrone added. They may incur debt from providing emergency services to uninsured patients, reducing their abilities to invest in new technologies and other forms of innovation, he said.