by Mary Kuhlman
by Morgan Watkins
by Jason Bailey
by Glynis Board, Jeff Young
The Congressional Budget Office’s (CBO) review of the health care repeal bill passed by the House weeks ago estimates that 23 million Americans would lose coverage, many low-income and older individuals’ health care costs would rise, and people with poor health would be left with unusable and unaffordable insurance options. The American Health Care Act (AHCA) would unravel the healthcare gains Kentucky has experienced in the last three years and go beyond that by inflicting ongoing damage to the original Medicaid program.
Kentucky’s uninsured would dramatically rise.
The main portion of the AHCA was left unchanged from the original version – the effective elimination of Medicaid expansion and a permanent and ongoing cut to traditional Medicaid called a per capita cap. This would result in 14 million fewer Americans covered by Medicaid. The 472,800 Kentuckians who gained coverage through Medicaid expansion would lose it, and the remainder of the 1.4 million children, seniors and people with disabilities covered under Medicaid are at risk of losing benefits, coverage and access to care. The CBO score also predicts there will be six million fewer Americans covered through the individual market and three million fewer covered through employer coverage.
Plans would become more expensive for older Americans and most low-income people and likely cover less.
For most people with lower incomes costs would rise as the bill abandons premium subsidies based on incomes in favor of less generous, age-based assistance. Older, low-income people are harmed even more so: the CBO estimates that for a state which does not accept a waiver under the MacArthur Amendment, a 64 year old earning $26,500 would see her premiums after tax credits rise $14,400, and in a state that did seek a waiver they would rise $11,900.
People with pre-existing conditions would be vulnerable to prohibitively high premiums and insufficient benefits.
The new part of the healthcare bill allows states to waive insurer requirements so that premiums can be based on health history, and insurers would no longer be required to provide a basic suite of benefits. According to one estimate, 1.8 million Kentuckians have a preexisting condition, putting them at risk of prohibitively high insurance costs. In addition, annual or lifetime limits on what insurers will spend on their coverage would be allowed to return, a practice that could leave the people who need care the most without usable coverage. The CBO says that individual insurance markets in states covering 1/6 of the population would become unstable, meaning people with health conditions may be unable to find coverage at any price.
Health care reform should move us forward, not cover fewer people.
Kentucky’s uninsured rate was cut in half under the ACA, more than any other state. The result was more people receiving needed care and a big jump in provider revenue. The AHCA doesn’t build on this success, it tears it down and through the per capita cap contained in the plan ends the Medicaid program as we know it. The latest CBO score is another piece in a growing mountain of evidence that the AHCA takes our healthcare system in the wrong direction.
The deep cuts to the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) in President Trump’s budget proposal would be devastating to Kentucky — particularly in rural parts of the state. SNAP provides critical assistance to prevent low-income Kentuckians from going hungry, lifts many out of poverty and leads to better outcomes for children in struggling households. The proposed cuts to SNAP are made by shifting 25 percent of the cost to states, putting pressure on them to reduce benefits and make cuts to the program that include imposing a work requirement after three months even in areas with persistently high unemployment.
Here is what we could expect to see in Kentucky:
Increased pressure on state budget
The shifting of SNAP costs to the state in the budget proposal starts at 10 percent in 2020 and increases to an average state share of 25 percent by 2023. It seems unlikely our state would come up with the required portion, especially given our state’s serious budget problems (which would worsen further under the other cost shifts in the President’s budget). Kentucky’s required match would be $245 million in 2023 based on the cost of SNAP in Kentucky in 2016 — and a total of $1.7 billion over the next 10 years. To put this in perspective, $245 million is more than the state spends each year on the entire community college system ($181.6 million in 2017). We are already underfunding education and our child welfare system, among other critical areas — not to mention the great need for additional investment in the state’s pension system.
The cost pressure on the state would be even worse when the economy hits a downturn given that state revenue sags during recessions at the same time the need for food assistance goes up. That means SNAP wouldn’t be able to respond to the next recession as it has in the past, when it helped boost the economy and allow struggling families make ends meet.
Benefits reduced below cost of bare-bones healthy diet
Currently SNAP benefits are set federally and reflect the cost of the most basic healthy diet. In Kentucky that means an average of $1.36 per person per meal. With the cost shift to states in the Trump budget, the Agriculture Department would let states cut benefit levels in order to keep costs down — which could mean that low-income Kentuckians, including children and seniors, would no longer be guaranteed access to a basic diet.
Time limits imposed for unemployed Kentuckians who live in high-unemployment areas
SNAP already restricts benefits to 3 months out of every 36-month period for those not raising minor children unless they are working 20 hours a week; although this provision is often called a “work requirement” states don’t have to provide a work assignment to enable individuals to meet this obligation. However, states can waive the requirement for areas that have persistently high unemployment as defined by long-standing Labor Department standards, and as of April 2016, 112 Kentucky counties had waived this requirement. However, President Trump’s budget proposal would restrict the time limit waiver narrowly to just areas with at least 10 percent unemployment. In Kentucky that could mean just 15 counties qualify despite so many more continuing to struggle economically.
Elimination of state option that supports working families and doesn’t penalize families that save
In addition to income eligibility requirements, SNAP also has an asset limit, which provides a disincentive for families to save (for instance, for future educational or medical expenses); the asset limit’s complexity also makes it expensive to administer and prone to error. However, Kentucky is 1 of more than 40 states with a waiver that enables the easing of the federal assets limit, allowing households with savings of more than the federal limit of $2,250 (or $3,250 for households with an elderly or disabled member) to participate through a simpler enrollment process called categorical eligibility. This waiver would be eliminated in the president’s budget.
Some states, though not Kentucky, have expanded income eligibility somewhat to support working families who otherwise experience a benefits cliff. These waivers would also be eliminated.
Termination of minimum monthly benefit low-income seniors & Kentuckians with disabilities rely on
Currently a minimum monthly benefit of $16 is provided to households of one or two people who qualify for SNAP, which goes primarily to low-income seniors and people with disabilities who would otherwise qualify for a benefit of $15 or less. While the minimum provides a relatively small amount of assistance, it is essential toward helping many Kentuckians make ends meet, and the Trump budget proposal eliminates this benefit. In Kentucky, 22,000 households (23,000 individuals) received the minimum benefit in 2015. This would mean an annual SNAP cut of $3.6 million to Kentucky based on 2015 numbers.
Penalties for large families
SNAP benefits are scaled to reflect household size, but President Trump’s budget would cap additional benefits based on household size at families of six despite there being more mouths to feed in many households. This means benefits would be cut for families with several children or who live with grandparents and other family members.
Cuts especially harmful to rural parts of the state with greater economic challenges
As seen in the table below, Kentucky’s 5th Congressional District in the eastern part of the state has the most to lose in the budget proposal given its particularly large number of SNAP recipients and continued economic difficulties. In fact, Kentucky’s 5th Congressional District had the 6th largest number of households receiving SNAP of all Congressional Districts in the nation.