What ending Medicaid expansion would mean for Coloradans

Rachel Graves has had a headache for going on seven years.

The migraines began in 2010, just as she was about to start law school. No medication could stave them off, but the symptoms were treatable: She graduated and started working, first as a public interest attorney and then as a representative for underpaid workers. But after a few years, other curious symptoms set in. Dizziness. Low body temperature. The headaches got worse.

Suddenly Graves, who lives in Aurora, couldn’t leave the house, and she soon realized that her illness was too severe to allow her even to work from home. In 2016, having used up all of her disability leave, she was terminated from her job. And Graves, now 43, a former journalist and licensed attorney, went on Medicaid.

Despite seeing “a zillion” specialists, Graves still doesn’t have an official diagnosis. She worries that if the Republican-proposed American Health Care Act passes, she never will.


Days before he took office, President Donald Trump vowed that under his new healthcare plan, “We’re going to have insurance for everybody.” He said insurance would be better and cheaper than what patients have under the Affordable Care Act. But the ACA replacement legislation proposed by House Republicans Monday known as the American Health Care Act has patients, policy analysts and elected officials fearful that if if it passes, the impact on millions of Americans could be devastating. Two House committees approved the measure today.

One of Colorado’s biggest concerns about the Republican bill centers around the proposed phase-out of Medicaid expansion. Like 30 other states, Colorado chose to expand its Medicaid program under the ACA, bringing coverage to an additional 400,000 people, including Graves, who would not have qualified previously. Expansion also boosted employment and grew the state GDP.

Until 2016, the federal government reimbursed 100 percent of healthcare costs for those who qualified for Medicaid under the expansion. Under the ACA, the feds will continue to reimburse these costs to states at a rate of 90 percent through 2020 and beyond. Colorado currently pays for its share of the reimbursement with the state’s hospital provider fee.

RELATED: What’s Colorado’s hospital provider fee, who cares and why? 

According to a post by Natalie O’Donnell Wood of the Bell Policy Center, the Republican health plan proposes repealing the expansion in 2020 and requiring states to pay a much higher percentage of the cost. That could lead to a rise in premiums to offset additional costs. If health insurance premiums soar, if people don’t get help with paying higher costs, or if they lose Medicaid coverage, hundreds of thousands of Coloradans will lose health coverage because they can’t afford it. That puts us right back to where we started before the ACA,” she writes.

Analysis from the Colorado Health Institute (CHI) estimates that if this change happened next year, Colorado would need to find $780 million to continue covering the current expansion population.

In a departure from convention, the House is attempting to push the AHCA through Congress without a cost analysis from the nonpartisan Congressional Budget Office. That move has provoked not just Democrats, but also some Republicans in the Senate to balk.

Colorado Hospital Association President and CEO Steven Summer says that without the analysis from the Congressional Budget Office, it’s simply too early to gauge the effects of the proposal. “We don’t know how they’re planning to pay for this because we don’t have the CBO analysis,” he said. “But the concern is that, as constructed, this may not be a fiscally sound bill.”

Summer worries that Colorado will not be able to fund its current level of healthcare coverage for Medicaid recipients when expansion is repealed. He also says that he thinks — though he doesn’t know for certain — that some of the bill’s funding proposals won’t leave enough money to subsidize people who otherwise can’t afford insurance. Without those subsidies, he says, many Coloradans may simply choose to go without.

In other words, if health insurance premiums increase to the point that they are unaffordable, fewer people will be insured, and overall health costs will continue to increase without a means to pay for them.

Elderly and lower income people will be hit the hardest. According to this interactive map created by the Kaiser Family Foundation, Coloradans of all ages making less than $20,000 annually will see their healthcare subsidies decrease by at least 5 percent under the new plan, with bigger changes in rural areas. Statewide, lower-income Coloradans over the age of 60 will typically see their subsidies shrink by over 50 percent.

Summer says that having to foot the bill for a greater share of Medicaid costs will be particularly burdensome in Colorado, where the Taxpayer’s Bill of Rights, or TABOR, places a cap on state tax revenue. That means additional funds raised over the cap will have to be returned to taxpayers.

Despite the lack of economic analysis, politicians are already weighing in on the proposal.

Sen. Michael Bennet publicly slammed the bill for “going in the opposite direction” of what Americans need. Speaking to Colorado Matter’s Ryan Warner, Bennet called the proposal “a $600 billion tax cut for the very wealthiest Americans that’s masquerading as health reform.”

Sen. Cory Gardner and three other Republican senators wrote a letter to Senate Majority Leader Mitch McConnell Monday criticizing an earlier version of the bill for inadequately protecting patients in Medicaid expansion states, including Colorado.

“While we support efforts to repeal and replace the Affordable Care Act and make structural reforms to the Medicaid program, we are concerned that the February 10th draft proposal…does not provide stability and certainty for individuals and families in Medicaid expansion programs or the necessary flexibility for states,” the letter stated. Gardner’s office did not respond to multiple requests for comment on the March 6 version of the bill.

Colorado lawmakers, too, have weighed in on the measure. Sen. Larry Crowder, an Alamosa Republican who has staked a position on making sure rural hospitals are not adversely impacted by changes in federal healthcare law, said Tuesday that his first read of the draft indicated Medicaid expansion would be intact for quite a while, a key factor in ensuring rural hospitals stay afloat. “We have to safeguard our rural hospitals,” he said.

“I like the 30 percent surcharge if you let insurance lapse,” Crowder told The Independent. “People sign up for [insurance] and then get off of it after they utilize it.” This would instill the idea to people that once they get on insurance they should stay on it. But he also said he appreciated Gardner’s comments in favor of preserving Medicaid expansion.

Sen. Irene Aguilar, a Denver physician who led the campaign for the single-payer Amendment 69 ballot measure last year, told The Colorado Independent Tuesday that she’s still waiting to see the financial analysis for the bill. The financial analysis “will show the bill’s flaws,” she said. “It’s Obamacare without the individual mandate.”


The illness makes it hard for Rachel Graves to read these days, but she’s read “the headline version” of the AHCA proposal. In the past, she would have read the Republican bill in its entirety: Before starting law school, she worked for years as a freelance journalist writing about healthcare. Ironically, she embarked on a career in law in order to have a job with health insurance.

Now, she hopes her health will improve enough to allow her work at least part time. If that happens, she will lose her Medicaid coverage, facing private insurance premiums up to 30 percent higher. She worries that if she recovers but then falls ill again, under the new plan, she won’t be able to get back on Medicaid.

Keeping up with all the paperwork, she says, can take hours each day. “Not working, being on Medicaid, getting a bit of private disability insurance—that is basically a full time job.”

Her unique situation makes her particularly sympathetic to the struggles of people on Medicaid, and she hopes that policymakers will come around to understanding that sick people aren’t at fault. “There’s this sense out there that there’s a lot of abuse of these programs,” she said. “I wish that people were more sympathetic to the idea that people don’t choose to be poor, and they don’t choose to be sick.”

Even though she had Medicaid for much of 2016 and additional private insurance for all of it, Graves said she spent $15,000 out-of-pocket on medical expenses last year. Without coverage, medication will be prohibitively expensive. In response to Utah Republican Congressman Jason Chaffetz’s recommendation that Americans invest in their own healthcare rather than “getting that new iPhone,” Graves said, “One of my medications, I would have to ‘not buy’ six iPhones a month to pay for.”

Despite the high stakes, or perhaps because of them, Graves is hopeful that political infighting might keep the new healthcare proposal at bay.

Noting the conflict between Republicans who think the bill is too extreme and those who don’t think it goes far enough, she said, “I’m just sitting here hoping that those two sides will never be able to satisfy those two extremes and won’t be able to pass it.”


Photo credit: Naval Surface Warriors, Creative Commons, Flickr