CHERYL TEVIS: Medicaid cuts would distort MAGA's vision of a clean bill of health

Never say never. Josh Hawley and I finally have found common ground! For several weeks the Republican senator from Missouri has been sounding the alarm about the impact of deep Medicaid cuts in the House reconciliation bill.

His concern focuses on its impact on hospitals. The House bill would slash about $625 billion over the next decade from the program which covers more than 71 million Americans.

Unfortunately, no one seems to be listening to Hawley. This week, when the Senate Finance Committee unveiled its draft version of the bill relating to taxes and Medicaid, the proposed cuts are even more draconian.

BUDGET CUTS ON THE BACKS OF HEALTH CARE PROVIDERS

About one of five Americans depend on Medicaid for health care insurance. However, in rural states like Iowa and Missouri, that percent is even higher. Medicaid, a combination of state and federal funding, plays a critical role in protecting vulnerable populations: children, seniors in nursing homes, and low-income adults who are self-employed, or work at jobs that don't offer health insurance.

Rural hospitals are the ultimate backstop when a string of bad luck or lifelong habits spiral into a medical crisis. And they operate on razor-thin margins. As a farm editor for over three decades, I sometimes examined the health of rural hospitals, and my stories often revealed they were on brink of life support.

Many of their patients were struggling financially. To make matters worse, the patients who walked – or were transported – through their doors also were older, sicker, and more likely to be injured or disabled on the job. They relied on Medicaid and/or Medicare. So did rural hospitals.

However, government reimbursement formulas typically didn't take into account the unique demographics of rural America, the lower patient volume, or the fact that private insurance is harder to come by. Although some reimbursement formulas have been reformed over the years, most still are inadequate when it comes to covering these costs.

It's always amazed me that elected leaders in state and federal government would pursue budget cuts to health care as a solution to their fiscal problems. What do they think happens when people can't pay for their necessary medical care? They delay care until they're much sicker, eventually ending up in the emergency rooms of local hospitals, where the costs of their medical care are exponentially higher. Who pays for this? First of all hospitals pay in the form of uncompensated care. Eventually, as taxpayers, we all do. And worst of all, people do die, Senator Ernst.

Beyond hospitals, draconian Medicaid cuts also would inflict a world of hurt on nursing homes and nursing home residents. Medicare doesn't cover long-term nursing home care. According to KFF, a health information nonprofit, about six million Americans use Medicaid to pay for long-term care. When my mother-in-law spent the last two years of her life at a nearby nursing home, she was one of the few residents who did not rely on Medicaid.

CUTS PUNISH THE WORKING POOR

Over 140 rural hospitals in the U.S. have closed since 2005. Since the end of 2020, more than 100 rural hospitals have closed their labor and delivery departments. In 2021 Medicaid covered about four in 10 births in the U.S. Hospitals also are vital to rural economic development; they're often the largest employer in the community and a major source of tax revenue.

NEWS FLASH: The majority of Americans on Medicaid already are working. Yet Iowa's four Republican members of Congress voted for the House Medicaid cuts. The legislation won't result in savings unless people are removed from Medicaid, so these reductions would be accomplished through burdensome and complex reporting mandates to log 80 work, education, or volunteer hours per month with their states, beginning as soon as the end of 2026. Adults with dependent children would be exempt from reporting hours to remain enrolled in the House version; the Senate version would only would excuse guardians whose children are ages 14 or younger.

Other more wonky provisions, such as the provider tax would be adjusted to shift more Medicaid costs from federal to states. (The cap would be lowered to 3.5%, down from the current 6% in the 18 states that expanded Medicaid under the Affordable Care Act. The Senate bill differs by exempting nursing homes and facilities for disabled individuals from the cap.) State-directed payments, allowing states to make supplemental payments for services covered in Medicaid-managed care contracts, also would be restricted in the Senate version. The House would grandfather these in.

Iowa would be one of the states hurt by this proposed cap. How would Iowa cope with these new costs? The Governor has spoken in favor of the reconciliation bill. Yet how would our state pay for private school vouchers after additional Medicaid costs are shifted from the federal level? As Senator Jack Reed recently stated in a fiscal 2026 budget hearing with Sec. of Education Linda McMahon, "If this budget passes, every state is going to make a difficult decision: Do I save my public education system or my health care system? Many of them can't do both."

In the last quarter of 2024, Iowa HHS enrolled about 703,000 residents in Medicaid. KFF estimates the loss of federal funding would result in more than 86,000 Iowans losing their Medicaid coverage. According to an analysis published by the Urban Institute and the Robert Wood Johnson Foundation, providers could lose more than $770 billion in revenue over the next decade under this bill. The cuts in health care provider reimbursements, added to the price tag of serving a larger uninsured population, would amount to $63 billion alone.

In 2018 Arkansas briefly implemented Medicaid work requirements. More than 18,000 lost Medicaid coverage before a federal court struck it down. But there was no statistically significant increase in employment.

And yet, in Iowa, our legislators have passed a work requirement, and the Governor applied for a federal waiver, despite this cautionary tale. Or, because of it?

HOW DO MEDICAID CUTS ADVANCE THE MAGA AGENDA?

The proposed Medicaid cuts are predicted to increase the number of uninsured Americans by as much as 7.6 million by 2034. This lack of insurance coverage will translate into a less healthy population and lower life expectancy. The U.S. already ranks as low as #30, compared to life expectancy in developed countries. And I'm not sure how the higher number of uninsured would help fulfill the Trump administration's MAGA goals.

Many states that expanded Medicaid rebranded their programs under a different name, and many Americans may be unaware their insurance is funded by Medicaid. Almost one-half of all kids in the U.S. receive health coverage through Medicaid. Many of them are chronically ill, or have special needs. For instance, in Iowa, we have Hawki for kids.

GOP talking points hammer home the need to remove the undocumented from Medicaid so that "real" Americans can be served. Some states use their own funds to offer insurance to undocumented immigrants, including pregnant women and children. The federal budget reconciliation legislation would reduce federal support to these states

The legislation also would truncate the annual open enrollment period for the Affordable Care Act, and prevent beneficiaries who are automatically re-enrolled in the Exchange from claiming subsidies.

Yet Senator Grassley is on the record as saying his main priority is "preventing the largest tax hike in history." He blithely asserts, "the needy . . will not lose coverage."

BACK DOOR TO ROLLING BACK HEALTH CARE REFORMS

Why? What is the goal? The most common explanation is the need to offset revenue lost from extending the 2017 tax breaks that primarily benefit the richest Americans. So we're decimating our nation's safety net for the sake of a few bucks that millionaires never would miss?

In fact, there's another motivation. Dr. Mehmet Oz, administrator at the Centers for Medicare and Medicaid Services, said the quiet part out loud during a recent hearing, calling the provisions a "health reform bill."

The GOP wants to roll back decades of progress made to insure Americans, thanks to Covid-19 expansions in Medicaid as well as the ACA exchanges. Iowa's uninsured rate dropped to about 7.2% in 2023 from more than 12.4% in 2013. The number of uninsured rose last year, when some expansions were allowed to expire. But health insurance coverage has improved substantially. As my former boss asked me years ago during a discussion over the ACA uproar: "What's the downside of healthier people?"

Massive Medicaid cuts are likely to result in a rise in medical debt, too, as well as bankruptcies. The Consumer Financial Protection Agency had excluded medical debt from credit reports, but with Trump's assault on it, who know if it will remain intact?

It's mean, folks. It's just plain, ugly mean. It's cost-shifting at its worst; outsourcing the financial responsibility for health to the state level: our public hospitals, nursing homes, social services, and law enforcement.

The GOP plan is to get the Senate bill to Trump's desk by July 4. Then it must be reconciled with the House, and approved by both. A total of 51 votes is needed for a reconciliation package, instead of normal 60 vote majority. Senate Republicans only have three GOP votes to spare.

Time will tell whether the same Josh Hawley who wanted to repeal the Affordable Care Act, and the Medicaid expansion will buckle under or continue to stand up to represent the health care concerns of his rural state constituents. What has changed his stance? Hawley has watched the Republican voting block expand to include a sizeable working class segment that believed Trump's promises to improve their lives. Instead they'd likely face longer wait times at hospitals, fewer services, and in some cases, hospital closures.

But it's not only low-income rural Americans who would be impacted. How many Americans confront the challenge of caring long-term for a parent now, or in the near future? Medicaid also pays for 25% of all mental health care, and 40% of substance use treatment in the U.S. Unless the GOP abandons the path it's on, access to care will decline for the insured, as well as the uninsured. When it comes down to health care, we all have skin in the game.