What the Big Beautiful Bill Means for Hospitals, Underserved Communities — Sept. 3, 2025 Transcript
Rachel Jones/NPF (00:06):
Hello and welcome to today’s National Press Foundation Medicaid webinar, what the big beautiful bill means for hospitals and underserved communities. My name is Rachel Jones and I’m the Director of Journalism Initiatives with NPF. Today’s discussion is sponsored by the Academy Advisors, a partnership of more than 30 nonprofit health systems comprised of 600 hospitals and serving patients in 40 states and communities nationwide. The Medicaid health insurance program was established 60 years ago as the largest funding source for medical and health related services for low-income Americans. An estimated 70 million children, older adults and people with disabilities rely on Medicaid for essential care. But ever since the Trump administration’s big, beautiful bill was signed on July 4th, analysts media and health advocates have argued that the new rules and eligibility requirements could eliminate health coverage for 10 million people over the next decade. Today, we’ll hear from experts who will strengthen journalists grasp on this key issue and help communities prepare for possible outcomes.
(01:24):
First, we’re joined by Akeiisa Coleman, a senior program manager with the Commonwealth Fund. She’s responsible for Medicaid grants and coordinating the cross program Medicaid initiative. Akeiisa also advises on strategy around federal and state coverage policy and helps execute projects and events to inform and educate policymakers. Akeiisa is joined by Dr. Gary Wiltz, the Chief Executive Officer of Teche Action Clinics. Teche is the network of 16 federally qualified community health centers, located in seven parishes in southwest Louisiana with the main site in Franklin, Louisiana. Next we’re joined by Julia Drefke, who is a public and community affairs executive with Adventist Health. She leads public affairs policy and advocacy, community impact and grants strategies across its entire system of health facilities in California, Oregon, and Hawaii, and journalists. Gabby Birenbaum rounds out our panel. Gabby is the Washington correspondent for the Texas Tribune. She covers the Texas Congressional Delegation and the impact of federal policy in Texas. You can read the full bios of our panelists on our website at nationalpress.org. Akeiisa, I’d like to start with you because you’ve prepared an informational presentation about the basics of the legislation.
Akeiisa Coleman/Commonwealth Fund (03:09):
So let’s just walk through some of the key provisions around Medicaid that will be, I’ll highlight some of the timeline and anticipated impacts. So first, the one piece I think most folks have heard about is a mandatory work requirement. This is for adults in the Medicaid expansion population, and we’ll start effectively the beginning of January, 2027. It’s 80 hours a month of qualifying activities that could be work, enrollment in school or volunteering. There are exemptions for pregnant women, individuals with disabilities, and parents with dependent children under the age of 14. A key thing to note about the exemptions, we won’t know exactly what the criteria for determining or applying for those exemptions are until CMS releases guidance. Additionally, states cannot modify these provisions of the work requirement through the 1115 waiver process. So they have to move forward with implementing work requirements. And if people lose coverage due to the work requirement, they are locked out of the marketplace. So if their income is at that 100 to 138% of the federal poverty level, even though they should qualify for premium assistance, they will not be eligible and able to access that and have affordable coverage.
(05:04):
Key impacts here, this is creating new hurdles for Medicaid enrollees to get and stay covered, in part because they have to prove they are meeting the work requirement prior to enrolling in the Medicaid program. And then in order to maintain their coverage, they have to again prove that they’re meeting the reporting requirement. It also increases the cost to administer Medicaid at the state level. So eligibility and enrollment systems have to be updated so that they can do the verification of employment or other community engagement activities, which that in itself is a pretty heavy big task. They’ll also most likely need additional staff to oversee. So this has implications for state budgets in addition to the coverage implications. Estimates are that around, I think the final CBO estimate was 5.3 million people are expected to lose Medicaid coverage due to the work requirement by 2034. So another key provision in the law is that it delays the eligibility and enrollment rules that were implemented under the Biden administration.
(06:30):
These would simplify and streamline eligibility and enrollment for what we call the non magi population or the traditional Medicaid population as well as the children’s health insurance program and some other groups. So the implementation is delayed until January of 2035. So this maintains existing barriers for Medicaid enrollees to get and maintain coverage. So those things that would’ve simplified and streamlined the eligibility process for all Medicaid enrollees is not going to happen or states are not required to do that. So it makes it more difficult for vulnerable seniors to participate in the Medicare Savings Program to get assistance with Medicare premiums and cost sharing. That’s anticipated to be a 1 billion fewer enrollees that are dual eligible. It also allows waiting periods, annual and lifetime limits and premium lockouts in chip. That is expected to mean that one point to one 3 million fewer. We will have 1.3 million fewer enrollees in chip. So these were things that were supposed to reduce some of the barriers to staying covered and enrolled. Another area that a lot of people may have heard about is legal immigrants being prohibited from participating in Medicaid.
(08:20):
So HR one changes the definition of qualified immigrants eligible for Medicaid and chips starting in October of 2026, limiting the lawfully present. Immigrants eligible for Medicaid to green card holders, certain Cuban and Haitian immigrants and what we call COFA migrants, lawfully residing children and pregnant people within the five-year waiting period for Medicaid eligibility can still be covered in states that opt to waive the five-year waiting period. So this reduces affordable coverage options for lawfully present immigrants, including asylees, refugees and survivors of domestic abuse and trafficking. The same group of immigrants are excluded from SNAP and Medicare starting this year, and there’s a good number of states that waive the five year waiting period for children and a slightly smaller number that waive it for pregnant women. So last piece before we open it up for a little bit more hearing from more people, the law requires more frequent eligibility checks for the expansion group. So the eligibility for the expansion group will be every six months starting in at the same time as the work requirement. So again, creating new hurdles for Medicaid expansion, enrollees to maintain coverage and also increasing costs to administer the state Medicaid program. So I’ll stop there.
Rachel Jones/NPF (10:18):
Thank you for that solid baseline. Let’s pivot now to the clinician’s perspective of these new policies. Gary, can you tell us about Teche Action Clinics and the Louisiana communities you serve and some of the central concerns that you have about the new legislation?
Dr. Gary M. Wiltz/Teche Action Clinics (10:39):
Well, just to give you some perspective, Teche, actually we changed our name. We’re the oldest community and the first community health center in the state of Louisiana known as FQHC [Federally Qualified Community Health Centers]. We’ve been around 50 years now, and I have a unique perspective because I came to the charity hospital system here in Louisiana and trained in that system and knew how it was before we had Medicaid expansion.
We’re located in South Louisiana, as you mentioned before, home based in Franklin serving about 20,000 patients, half of which are Medicaid recipients in six different parishes, high incidence of chronic disease, diabetes, hypertension, obesity, cardiovascular disease. And I guess the thing that strikes me most is that I’ve seen what this looks like Before, when I first came into the movement, we had, and I know we’re going to talk about deserts, but we’re in a rural community and the nearest hospitals were 50 miles away.
(11:44):
We provided the base of the foundation as I call it in healthcare, which is primary care. And if that system foundation gets weakened, it’s just going to exacerbate the whole system because people will show up. Thank God we still have amala rules where people can present and have to be treated, but we don’t have to guess on what the impact is going to be. We have real data that shows the impact. When we expanded Medicaid in Louisiana in 2016, covering almost a half a million more people, we went from an uninsured rate of 22% down to about 10%. We saw a spike in increase in the number of patients that were being diagnosed with hypertension, diabetes, picking up colorectal cancer, breast cancer, increasing access, and we have the data objective studies to prove that you contrast that to what they tried to do in Kentucky in 2017.
(12:48):
I think a lot of you remember when they put those work requirements and knocked a whole bunch of people off the rolls. The biggest concern that we have, and I’m give some people the benefit of the doubt, they say they don’t want to knock folks off the rolls. I’ve seen firsthand unintended consequences of legislation that was put. It looks great on paper, but I’ve seen and personally experienced patients. I’m an internist. I’ve seen patients that got kicked off Medicaid in the middle of breast cancer treatment that died. So whatever you put, and we know that is going to happen. So all the well intentions that we’re talking about connecting people from work to welfare to work, it sounds great on paper, but we don’t know what that looks like. And people with the populations we deal with are complicated. They use burner phones, they don’t, they’re hard to access and we already means test them when they come into our center. And lemme just say that I belong to the National Association of Community Health Centers. We’re serving 34 million people, the largest primary care network in the nation in all of us. About half of our funding comes from Medicaid. So it’s going to be a big challenge with unintended consequences, and I can get into a little more detail later as we start talking about it, but I’m very, very concerned, very, very concerned about the chaos confusion and the criteria that the devil’s in the details. I don’t know what the details are like
Rachel Jones/NPF (14:27):
I remember you saying that this whole devil’s in the details issue is central to this. And that’s a good segue for us to turn to Julia because one of the consistent themes that I’ve seen about this issue is the complexity of Medicaid policy and how health systems will have to cope with these changes. So because you oversee hospitals in California, Oregon, and Hawaii, what are some key concerns for health system administrators who will have to navigate these changes?
Julia Drefke/Adventist Health (14:59):
Yeah, thank you and thank you National Press Foundation for having me here. One of our key concern is the complexity in navigating policy changes implemented differently in each state. While the federal framework is uniform, each state is going to interpret operationalize requirement to reflect their own regulatory changes, whether that’s through their own Medicaid structure, their payer landscape. So that means that we’ll be dealing with not just one set of changes, but possibly three distinct regulatory frameworks. A particular concern is how states will respond to the reduce in the federal match that we’re getting from Medicaid. States will have definitely different capabilities on backfilling those losses. While California is large and has diverse income, I think California will struggle just because of its scale. 15 million people are on Medicaid in California, our Medicaid population is larger than some states like Pennsylvania. So just the scale of it will cause a problem that uneven capacity within the three states is going to create a larger financial risk and instability. So what we’re trying to do is we’re looking at this challenge, making sure that policies don’t pull us in different directions, that we don’t create inefficiency, drive up administrative costs and compromise care delivery. We want to ensure that there’s alignment across the states, but also advocating for flexibility and clarity so that we can focus on sustainability and access in our communities.
Rachel Jones/NPF (16:42):
Let’s now go to Gabby as a journalist who’s been covering this legislation and its impact in communities. Can you tell us about what you’ve learned from the early responses from Texans who rely on Medicaid?
Gabby Birenbaum/Texas Tribune (16:57):
Yeah, so Texas is a non-expansion state, right? So it already has one of the strictest Medicaid programs in the country. Some of the programs in the national bill, like barring certain legal immigrants with legal status from accessing Medicaid, Texas has already done that, right? In Texas you really have to be, I think for a family of four, you have to be earning less than $300 to qualify or you have to be disabled, have a child with a documented disability pregnant or over 65, and that income qualification only applies to parents. It’s already really stringent. And so I think a lot of the hospital systems in Texas, the provisions they were most worried about things like changes to the federal mat rate were left out of the bill. And the rural health fund that they did include, they hope they’re not quite sure exactly how it’s going to be implemented, could offset some of the losses.
(17:46):
They do expect to see in annual funding that the state from the federal government for Medicaid. And I think there certainly are concerns, particularly in rural areas where the payer mix certainly is more reliant on Medicaid and in places like the Rio Grand Valley, which has a lot of Medicaid users. But for Texas, I think a lot of the concern is with the Affordable Care Act, because Texas has such a strict Medicaid program, the A CA has really backfilled for a lot of people what would be the expansion population in other states. And so I think that’s an area where hospital systems advocates have an enormous amount of concern.
Rachel Jones/NPF (18:24):
This is an important issue for journalists to keep in mind. I think there are about 10 states that are non expansion, and so that’s something to consider when you’re reporting. Let’s go back to Akeiisa now because we’ll want to now start to unpack some of the more technical aspects of the legislation. So if you would share the rest of your presentation with us, that’ll get us started in the right direction.
Akeiisa Coleman/Commonwealth Fund (18:50):
Absolutely. I’m happy to do that. So let’s walk through some of the more weedy and potentially more nuanced pieces of Medicaid provisions in HR one. So first up, there’s a new cost sharing requirement for the expansion group. So for individuals in the expansion group with incomes above a hundred percent of the poverty level, they’ll have to start contributing or paying copay or premium starting in October of 2028. That cost sharing is not supposed to exceed $35 for any service or in line with the existing statute, more than 5% of household income. One significant difference from previous demonstrations with cost sharing, providers can deny service for failure to pay a copay at the time of service. So again, this is introducing new hurdles for Medicaid expansion enrollees to access care.
(20:07):
Because some people’s income fluctuate over the course of the year, either due to seasonal employment, changing hours worked per month, they may actually wind up paying more than 5% of their income and enrollees may avoid care because they don’t think that they can afford that cost sharing resulting in an increased emergency department utilization. This also increases the cost to administer the state Medicaid program as they may need additional staff to oversee compliance with that cost sharing requirement. So we know lots about how premiums and copays have worked in other states and generally it is not been good. And I can point you to some data specifically about that in a couple of states.
(21:11):
Actually, one thing before I move on from that, there is data from a handful of states that notes that when we’re talking about premiums, the cost to collect premiums from Medicaid enrollees is often more than the value of the dollars collected for those premiums. So this is not necessarily efficient or effective way of managing the program in terms of costs as well as providing or putting additional burdens on Medicaid enrollees. So this piece is a little bit more wonky. States often pay for their Medicaid program through taxes on providers. We say providers loosely because those taxes include entities like hospitals, managed care companies and nursing facilities. And so the losses that states and local governments can no longer implement new provider taxes. So they can’t add a new provider type or increase the rate of their provider taxes already established as of the enactment of the bill. So provider taxes are now frozen at 2025 levels and beginning in by 2032 expansion states will have to potentially lower their provider tax rates to meet a lower safe harbor threshold.
(23:04):
So effectively this is potentially reducing how the availability of funding that states will have to pay their share of Medicaid and potentially makes it harder for states to raise revenue for their portion of Medicaid costs. 22 states are impacted and we have to begin reduce, and I think it’s 17, we’ll have to begin reducing their threshold for to meet the new requirements. So this is just a quick snapshot of states with one or more of the different types of provider taxes that maybe this is only partial list because all states except for Alaska have a provider tax on the books.
(24:03):
The last piece I want to touch on is Medicaid managed care state directed payments. So these are utilized by states that have managed care programs as a way to incentivize providers to participate in the program. They can be used as value-based purchasing arrangements do provide incentive payments for quality care provided. They also effectively can bring Medicaid reimbursements in line with Medicare rates or even go higher and be as high as the average commercial rate in the state or a particular region within the state. So the law reduces how much those state directed payments can be for Medicaid providers to 100% of Medicare rates and expansion states and 110% of Medicare rates and non-expansion states already approved. State directed payments should be grandfathered in but cannot be adjusted.
(25:15):
These are generally submitted every year or every two years. So this is somewhat problematic. It reduces state options to ensure provider participation in Medicaid. It also reduces revenues for providers and in some instances may threaten their financial stability as that reimbursement, that total Medicaid reimbursement, bringing them above Medicare or closer to commercial rates makes it more attractive to participate in the Medicaid program and helps them keep their doors open. So this is just a highlight of the estimated reductions in payments to hospitals. If state directed Medicaid payments are limited to a hundred percent of Medicare rates in 19 of the 25 states for which data are publicly available, total Medicaid payments to hospitals could drop by at least 20%. So this is a significant change. I do have some resources that will be available. I’m not going to run through all of those now, but I just wanted to highlight that when you get the slides, there will be a whole bunch of different resources available for your use.
Rachel Jones/NPF (26:42):
Thank you for this terrific primer akisa. I want to remind all of our panelists that one of the objectives of this will be to offer up some tangible story ideas for journalists to produce. So be thinking about that. But now let’s go back to Gary, who is from a Medicaid expansion state, and that means that policymakers expanded the program to cover people up to 138% of the poverty level. But under the new legislation, states will have to decide whether they’re going to fill any gaps. And I wanted to ask you, Gary, based on your experience, how likely are state officials to fill those gaps?
Dr. Gary M. Wiltz/Teche Action Clinics (27:28):
That’s an interesting question. The first move of medicine is the first what do no harm? And we found that closely by reducing barriers because we want people to come in to get access to care because early prevention, of course is the best. Early detection is the best prevention. We’ve seen this, as I said before, play out in the past when we had high uninsured rates and people did not come into care Early on we had what was a charity hospital system, and it was great if you lived in a city where there was a charity hospital system, if you lived in a rural community, then you didn’t have access to primary care. And as I said 50 years ago, I remember folks coming in presenting late in the hospital setting because they never had primary care. The state, the Medicaid budget is probably the biggest component of state government spending face, they call it.
(28:39):
It’s not managed care. I call it managed money. And where are you putting that money? In what buckets? You mentioned the hospitals because of Medicaid expansion. We did not have one hospital close in Louisiana under the previous administration of Governor of John Bell Edwards, not one. I mean they actually got it used to work on that disproportionate share payment at the end of the year. That doesn’t help get cash flow when you’re going from month to month. Right? In community health centers, we had patients receiving $200 worth of services and paying us on a sliding fee scale, five or $10. If we vert back to that, I can tell you right now our operating budget is $28 million. I will have to shut down services at some places. We’ll have to lay off some folks. Again, not knowing what Louisiana is, a poor state. A third of the state is on Medicaid.
(29:36):
What people don’t realize, and you mentioned it earlier, the nursing home, 74% of the people in Louisiana are covered in nursing homes are covered by Medicaid. It is a complex. Medicaid is not just a simple thing that is multiple pots, multiple people being served in multiple ways. And if you start knocking those folks off the rolls, it’s going to cost us in human terms pain and suffering, but also on the finance. There’s no way the state can make up that gap and there’s no way that you can cut $950 billion out of Medicaid. Medicare, you put aside 50 billion as I don’t know what that 50 billion, I think 25 billion is going to be evenly divided among the states. The other 25 billion is up for grabs. I guess there’s no way you can make up a $950 billion deficit the way that it’s being projected. They’re going to be winners and losers and they’re going to be people that are going to unfortunately suffer and die because they won’t have access.
(30:44):
All the reasons that were mentioned earlier are going to play out. I like to say Louisiana, we are primed to deal with natural disasters and hurricanes. We are very resilient, but the ones that do ascend the most are these manmade disasters. This to me is equivalent to a manmade disaster that we are about to face and it’s creating a lot of anxiety. Like I said earlier, we don’t know what to expect. We already means test people. We saw this happen with the BPR spill. Commercial fishermen, you’re talking about seasonal workers. These folks don’t operate in the same, we treat a lot of commercial fishermen. They don’t keep records. They don’t have income that they report all the time. So it’s hard to put them in pigeonholes and means test them because they’re not. This is so antithetical because they don’t want to be dependent on the government. They want to be self-sufficient, but in order to qualify that to get help, it is a paradoxical situation we find ourselves in sometimes.
Rachel Jones/NPF (31:54):
But Gary, that is actually a terrific sort of story idea when we think about how journalists could get at this issue. So I appreciate you adding that. I want to now ask Julia to talk about the issue of rural communities. Over 20% of Americans actually live in rural communities. So you serve states like Oregon, which is 31% rural and Hawaii where only 10% of the land is classified as urban. So can you share some demographics of your organization’s rural population?
Julia Drefke/Adventist Health (32:33):
Yeah, happy to. Adventist Health operates in three states. As you mentioned. We have 20 hospitals, over 300 clinics, 70 rural healthcare clinics. Actually 60% of our footprint is rural. Most people don’t think of California as rural, but 90% of the population lives in 5% of our landmass. And we serve the interior agricultural center of Central Valley all the way up to Northern California. So 75% of our patients are in Medicare and Medicaid. And one third of the population lives in what we call a primary health shortage area. Just like Dr. Wilts was talking about, why this is important is because people in rural communities are going to be disproportionately affected by this.
(33:25):
In the past 10 years, we’ve had 100 rural hospitals close, and I think that we have about a third that are a risk of closing, and this is going to amplify this and push it faster. Rural hospitals and rural community clinics struggle because of the universal challenges that a lot of our hospitals face, like rising labor costs and supply costs. But rural hospitals are unique in that we also have staffing challenges. We have problems with low patient volumes, and then the majority of our patients that we see Medicaid and Medicare don’t actually cover the cost of caring for ’em.
(34:02):
The Kaiser Family Foundation actually estimated that the federal spending and rural areas is estimated to drop by 137 billion. So echoing what Dr. Wilt said, the $50 billion is not going to cover the rural areas. So this means that rural hospitals are going to have to make tough decisions about closing reducing services, which can mean longer ER wait times, fewer maternity wards, trauma care going away. I think one important piece that I would love for everyone to take away from this is that our hospitals do not have a Medicaid door. So when we have to close services or when clinics have to close services or change things, that impacts the entire community, not just the Medicaid population. And I think that’s one piece that I would love for everyone to take away is that this is whether you’re on Medicare or you have commercial insurance, this is going to impact your community one way or the other.
Rachel Jones/NPF (35:04):
It’s an important message to take forward. I’d like to now ask Gabby, in your terrific notes that you sent to me about your coverage and your reporting, you noted that the most critical provision in non-expansion states like Texas will be the lack of expanded premium tax credits. Can you tell us what you mean by that?
Gabby Birenbaum/Texas Tribune (35:27):
Yeah, so as I mentioned, the A CA covers a lot of that. What would be an expansion population in Texas and other non-expansion states, particularly people who are making between a hundred percent, 138%, but also up to 150% of the poverty level. And so in 2021, Democrats in Congress as part of the American Rescue Plan expanded the advanced premium tax credits. Those are tax credits that are paid directly to insurers that on a sliding scale drive down the percent of a cost of a premium that someone on an a c plan has to pay. So they both put a cap for what percent of income someone would ever have to pay towards a premium that drove a lot of people’s premiums, especially on the lower end of the income scale, down to $10 for example, per month. And it also addressed what’s called the subsidy cliff.
(36:18):
So previously people making 400% or above of the poverty level were not eligible for tax credits and the law expanded it to that population. So that’s a lot of pre retirees. For example, people who work for themselves, small business owners. So that could be someone that’s making $60,000 but without that tax credit likely wouldn’t be able to afford insurance or is now able to afford a better insurance plan, a silver plan than they would before. And so what was not in this bill was an expansion or an extension of those tax credits which expire at the end of the year. And so for people in Texas and all across the country, but especially in non-expansion states, that’s concerning because that’s expected to drive down the number of people who are going to sign up for a enrollment and the people who are left are probably going to be older, going to be sicker, it’s going to be a bigger risk pool.
(37:12):
And so that has ripple effects all throughout the healthcare system. That means premiums are likely going to go up for everybody on the A CA. Texas insurers have already submitted, I think the average was 24% average premium increase for next year. Factoring in that these tax credits have not been extended. And that means especially in rural areas where like I mentioned the payer mix is worse, the juice might not be worth the squeeze for certain insurers to offer a plans in these rural counties. And so those are all things that I think journalists should be monitoring as we get into next year. And if there’s no deal here in Congress on the tax credits,
Rachel Jones/NPF (37:47):
We do have a couple of questions from viewers, but before we get to them, I’d like to ask each of our speakers to talk about the impact on child health in America. And I’ll start with you Akeiisa. So what are you hearing from state and local policymakers about their concerns about how these changes will affect children?
Akeiisa Coleman/Commonwealth Fund (38:10):
I haven’t been hearing directly from state legislators or state policy makers. What I have been hearing from is consumer advocates and other stakeholders that their concerned about two things. One, the changes around immigrants, legal immigrants and how during the first Trump administration we saw a chilling effect, what we call a chilling effect, where people who were eligible for public programs and services chose not to and utilize those programs even if their children were citizens and eligible for those things or they themselves were eligible with their status because they were afraid it may affect their ability to get that legal permanent residency status. And so with all of this attention and talk about undocumented immigrants being kicked off of Medicaid, which is not at all what HR one does, I think we will see again some of that chilling effect, and I think it may have already started, where people are avoiding utilizing care enrolling in Medicaid or the children’s health insurance program because of their fears about it impacting their status or being inappropriately detained by ICE or others to verify their status. The other piece is that because we know approximately 1.3 million legal immigrants are going to lose Medicaid coverage, often what happens is when a parent loses coverage that impacts the child, their legal citizen child’s access and utilization of healthcare services. So when parents have coverage, kids are more likely to have coverage and more likely to utilize an access care. So I’ll stop there.
Rachel Jones/NPF (40:40):
Gary, how about the communities that you serve and the children that you see?
Dr. Gary M. Wiltz/Teche Action Clinics (40:45):
Well, let me just say that overall, Louisiana ranks 50th by the healthcare foundation for healthcare. But one of the positive things that Louisiana has done right is the CHIP program. We’ve actually been a leader in covering children and I gained my concern and anxiety is for the reasons I mentioned, having a chilling effect on kids getting enrolled. We’re seeing a decrease enrollment in the public school systems. We’re seeing decreased access and some of the head start programs and some of the folks that are just afraid to, I bring forth their information, if you will, they don’t know There’s a lot of anxiety out there. But again, if we can, it’s just so much of a ripple effect. I mean, the state is taking a position that it’s not mandated for children to get vaccinated. The parents can opt out. A child, a young child can’t tell you yes or no, A 2-year-old, they want to get immunized. So it’s going to have all kinds of effects in that regard. And what we’ve seen the children effect on the message that even the public health units, the public health people can say the statements that they can make. They used to advocate a lot and do a lot of outreach for campaigns for promoting vaccinations among children. And we haven’t seen that There’s been a chilling effect on that part of it also. So
Rachel Jones/NPF (42:37):
Thank you. I think we’d also like to hear about what Julia is seeing when it comes to children in the Adventist health population.
Julia Drefke/Adventist Health (42:49):
Yeah, we’re definitely concerned more than one in five of our children live in families with income. Below the federal poverty level, about 20% of the communities we serve are on free and reduced lunches. So these changes to Medicaid, just like Akeisha had said, mostly are targeted towards the parents. But something to consider is Akeisha showed that the changes in provider tax and state directed payments, it’s really difficult to find a specialist that takes Medicaid. If you need a specialist or a surgeon, pediatric specialists or surgeon that takes Medicaid, it’s already very difficult. We have citizens in rural communities having to travel to LA three or four hours to get a specialty pediatric that’s just going to be exasperated by these changes in the Medicaid payments. We’re going to see less and less specialties that take pediatric. And the other point I would mention is I’m concerned about the SNAP benefits. We’ve been focusing on Medicaid of course, but food security is the baseline for health. And so with the changes in SNAP benefits, I’m really afraid of what that does to our children, our communities, their parents. Living in a home where you’re food insecure is not good for health overall. So yeah, there’s definitely going to be a ripple effect here.
Rachel Jones/NPF (44:17):
Gabby, when you’re interviewing families and people in communities about this topic, what are you hearing about their concerns about child health?
Gabby Birenbaum/Texas Tribune (44:28):
Yeah, I mean, I think this is a huge deal in Texas because the Medicaid program is so restrictive. About 75% of Medicaid enrollees in the state are children. So any changes, administrative or otherwise to Medicaid that make it more difficult to enroll is invariably going to affect children in that population more than anyone else, as others were mentioning. I also think the climate of fear for immigrants around engaging in any sort of government program that involves sharing data and your status is certainly I think deterring people from even seeking care. One interesting group I talked to in my reporting was an organization of free clinics, so sort of the bottom of the safety net in the medical system. And they’re really worried, I think, and with children, any population about just too much demand for their clinics and not having the adequate staff or funding available because they worry that so many people are going to drop through the insurance safety net and free clinics are sort of the only place that they can get this treatment. And so I think it’s just a lot of tough decisions for families. I think as Dr. Wilt was mentioning, people have expressed to me concerns about people are going to go longer without seeking care for problems that don’t feel urgent to them and then it won’t be until it is urgent or perhaps too late that they do seek care for issues that could be managed if they sought them earlier in the process. And so I think that’s a lot of the concern that I’m
Dr. Gary M. Wiltz/Teche Action Clinics (45:57):
Hearing. Can I just comment, Rachel on what Julia said, this SNAP program and you hear I was about to say something again. You hear Robert Kennedy talking about food is medicine the antithesis of what you’re trying to accomplish if you promote healthier foods, if that’s the question about snap, we do meals on wheels to our senior citizens. Their mission is to just keep people from starving. They can’t even get into the nutritious meal component of it. The other ripple effect of Medicaid that Gabby and everyone else mentioned, not only does it cover your healthcare, the big barrier in rural communities that we have, but we don’t have public transportation. So these Medicaid, these MCOs provide transportation. We have language barriers. We have all these other barriers that are a ripple effect for access to care that the program, you wouldn’t think you would say, well, Medicaid is going to cover your medical costs. It’s so much more than that that people don’t, I think fully appreciate the ripple effect of having that coverage provides to our citizens.
Rachel Jones/NPF (47:08):
I’d like to get to the three questions that we have, but be prepared to share story ideas that you might have after they’re answered. So the one was emailed from Christie McGinn who asked, will the one big beautiful bill make any distinction between Medicaid providers and that are for-profit or nonprofit? Julie, is that a question that you can take for us?
Julia Drefke/Adventist Health (47:37):
Yeah. There’s nothing that is laid out in the bill between for-profit and not-for-profit. I would say that, and this is generalizing, not not-for-profits, tend to go into communities that are harder to serve. It’s our mission, it’s mission based. We don’t have shareholders. Any money that we make, we’re required to invest it back in. So I would just say that not-for-profit hospitals and not-for-profit clinics and things like that are probably going to be disproportionately impacted through this just because of generally speaking, the communities that we end up serving through our mission.
Rachel Jones/NPF (48:20):
Gary, can you address the question about consequences for veterans who rely on Medicaid?
Dr. Gary M. Wiltz/Teche Action Clinics (48:27):
Well, can I address that other one? Because I don’t want the audience to think this war is me and we’re wring our hands and we’re shrinking away from this fight. Okay. That’s not at all what’s happening with us. We have a very progressive campaign to keep our communications in contact with our patients. We went through this scenario with the Medicaid unwind and we put a whole infrastructure to place where we were texting, we had billboard messaging, we were reaching our barbershops, gorilla warfare, making sure if you got a letter or if you got cut off that you came in. So we get you reinstated. We’re looking right now for the devil in the details on what do you mean by volunteer requirement? What do you mean by work requirement? Educational requirements. So we have a task force that are, that’s looking to try to create venues to satisfy some of these requirements that they’re talking about. So we’re trying to be proactive on our end, anticipating what that might look like. So I don’t want the S to think that we’re just going to sit down and just passively take this as it’s coming to us.
Rachel Jones/NPF (49:40):
Ironically, you’ve just answered one of the three questions, which was from journalist Kirsten Garris who wondered what’s your advice to patients about what they can do. And apparently you’ve taken absolutely proactive stance in terms of communicating, but
Dr. Gary M. Wiltz/Teche Action Clinics (49:55):
We treat about 300,000 veterans in community health centers. And so yeah, we are currently engaged with them. We work in close injunction. A lot of our communities have VA a clinics. Amazingly. It’s just amazing to me how many of our veterans don’t have knowledge of all the services that they or eligible for. So that’s another whole population. I can’t tell how many people we are referring to the VA and through our social services, connecting them to resources that a lot of ’em have health and mental health issues. But that’s a big gap that the connection to service that they’re not getting, that we are filling that void. We are there for them, but the VA has much more resources than we have. So that’s a big gap that we’re trying to close to get them quickly.
Rachel Jones/NPF (50:47):
Thank you, Gary. Akeissa, which patients that are most likely to lose nursing home coverage are going to have a challenge finding organizations that will take their families in?
Akeiisa Coleman/Commonwealth Fund (51:05):
I mean, so nursing care is a mandatory Medicaid benefit. So while we may see some closures of nursing facilities, we’re not anticipating major shifts in access to nursing facility care for Medicaid enrollees. However, home and community-based services are an optional benefit. And so those are the personal care that comes into home, into the home to help with activities of daily living or to help with things like grocery shopping, sometimes helping people to balance their checkbook and do some light cleaning around the house in addition to direct health services or assistance. Those are optional and are likely to be on the chopping block. We know from past economic declines that when states have to make those difficult budget decisions, adult dental and home and community-based services are often on the chopping block as our provider reimbursement rate reductions and ending optional, optional eligibility groups. So that could be a limit or a cap on the number of people who can enroll in chip. It can be adding waiting lists for a home and community-based services rather than just cutting entire groups out of those services. So we’re more likely to see people not having access to those home and community-based services and being forced into nursing facility care because they can’t get those services that help keep them in the home because that is a mandatory benefit. Now, if a nursing facility does close, that just may mean that people have to travel further and further to see their family in a nursing care and nursing facility.
Rachel Jones/NPF (53:24):
We are near the end of our session, but I did want to make sure to respond to the question about each of you coming up with at least one story idea. So I’m going to start with you, Gabby, because we do have a question from Rachel Black who’s also in a red state. She says, what strategies have you used to strengthen your understanding of complicated Medicaid policy?
Gabby Birenbaum/Texas Tribune (53:52):
Yeah, I mean, this is a great question. I actually only started with the Texas Tribune two months ago, and I had come from working at the Nevada Independent, which was an expansion state. So I’d say a completely different ballgame here. I think every state has a ton of orgs that advocate particularly I think in the children’s health space that I found really helpful to sort of just give me overviews of what sort of fight has been at the state level up to this point on expansion, for example, or other goals. Hospital organizations have been helpful in associations, free clinics, like I mentioned, groups that represent free clinics have been helpful. Just healthcare policy, people who have worked for past governors or state senators, state legislators, things like that. But yeah, I’ve just really relied on a lot of the various organizations that have been in Texas, in my case on the ground, doing the work for years, both in the policy space and in the healthcare space.
Rachel Jones/NPF (54:48):
Julia, can you share a story that you would like to see produced about this topic?
Julia Drefke/Adventist Health (54:55):
Yeah, actually, Shirley Smith had a question that I think is relevant in terms of a story. We know that work requirements are going to be hitting able-bodied adults, but how they define able-bodied when those regs come out. So Shirley mentioned someone who has a disability, but they’re not totally disabled. How’s that going to impact them? Trying to find stories around that. How long will a mother have after she gives birth a year, nine months? Those type of, it’s all these in-between scenarios. Someone who has a disability who’s working 18 hours a week but now has to do 20, how do they find
those extra two hours and how does that impact the disability? So there’s a lot of gray areas that would be interesting for our journalists to look into.
Rachel Jones/NPF (55:48):
Thank you. Gary, what is your wishlist for a story that you’d like to see produce?
Dr. Gary M. Wiltz/Teche Action Clinics (55:55):
Well, I can give you a reference with PBS actually came down to Franklin and did a story that was very well done. It was on the news hour, I guess several weeks ago, maybe a month ago, where they interviewed one of our patients who’s a working mother of three, and I think she did a great job dispelling the myth of the welfare queen, or they keep making this mythical character of someone sitting on a college playing video games. That is not the typical recipient, the recipients that we see in a state where a minimum wage is 7 25, most of the people that we treat are hardworking, multiple job working people that can’t afford health insurance. And so without Medicaid, they would not have access. They have access to us and community health centers, but when they need diagnostic testing done in a hospital setting, that’s what Medicaid provides us to do, the comprehensive component of it. So I think any story that can dispel this myth and dig, do a deeper dive into what’s the profile of the typical Medicaid recipient that they’re talking about, because like Julius, a lot of these people are working, and I think people have this misconception out there that these are lazy trying to get over people. That’s not the experience that I’ve had in doing this for almost 50 years.
Rachel Jones/NPF (57:21):
Thank you. Do you have any story ideas you’d like to share?
Akeiisa Coleman/Commonwealth Fund (57:26):
I was just talking with someone about an issue that is a little bit under the radar in terms of the reconciliation bill and that there’s an address verification requirement. So as you’re enrolling in Medicaid, they have to be able to, the state Medicaid agency is supposed to verify your address, which we know for expansion states, the homeless population, those people who are unhoused are not stably housed. They’re couch surfing, moving from place to place. They don’t have a set address. And how are these changes going to impact them when, as Gary was saying, that Medicaid coverage and support services that community health centers provide those connections that can be made to other services that individuals are eligible for may be limited, restricted based on not having that Medicaid access or coverage because of that address verification requirement. And so how is that going to be treated going forward? That’s definitely something that one of those devil on the details piece that is really going to have an impact on a particularly vulnerable population.
Rachel Jones/NPF (58:54):
And with that, our Medicaid and the one big beautiful bill webinar has come to a close. I’d like to take this opportunity to thank our panelists, Akeiisa Coleman of the Commonwealth Fund, Dr. Gary Wiltz of Teche Action Clinics, Julia Drefke of Adventist Health, and Gabby Birenbaum of the Texas Tribune for making the complexity a little bit clearer when it comes to this topic. And I’d also like to thank our sponsor, the Academy advisors, for this opportunity to provide an expert briefing for journalists. For those of you joining us virtually today, we’ll be posting the video of today’s conversation along with a transcript and ASOS informative overview on our website@nationalpress.org. Thank you all for watching.
###
