How the Trump administration could affect your health care

Dec. 10--Nobody knows for sure what will happen to Alabama's Medicaid program under a Trump administration, and Matissa Moorer really needs to know.

Moorer's 14-year-old daughter, Kerstin, has cerebral palsy and epilepsy. Mother and daughter live near White Hall -- in Lowndes County, which doesn't have a hospital -- and routinely travel to Birmingham for care. Kerstin's condition has her sometimes relying on nutritional drinks like Pediasure to stay nourished, something Medicaid pays for.

"Without Medicaid, I couldn't even feed my child," Moorer said.

Moorer is among thousands of people who are likely watching closely as Donald Trump prepares to assume the presidency with a Republican Congress at his side. Both Trump and congressional Republicans have talked about big changes to Medicaid and the Affordable Care Act, though details are few and internal GOP disagreements are many. It's still unclear where everything will land.

The Anniston Star asked health policy experts and others for their best guesses about how the Trump era will affect health care for various groups of Alabamians. Here's what we found:

Alabama's uninsured

How many are there? 519,000 (source: Kaiser Family Foundation)

What could happen: Tax penalties for the uninsured will likely vanish.

Republicans have promised to "repeal and replace" the Affordable Care Act, without offering a detailed plan for what the replacement will look like. No matter how that plays out, the people most likely to be affected are people who buy individual insurance and those who don't have insurance at all, Cynthia Cox, a health care analyst for the Kaiser Family Foundation, said last week.

Cox offers a possible scenario: Republicans vote in early 2017 to repeal Obamacare, but with a two-year waiting period before the Affordable Care Act vanishes completely. That would give lawmakers some time to find a replacement.

"There's a sense the Republicans don't have enough votes to do repeal and replace immediately," Cox said.

Lawmakers may feel pressure to change some of the Affordable Care Act's most unpopular provisions immediately, to show they're doing something. The individual mandate -- which requires people to buy insurance or pay a penalty -- could be the first to go, Cox said.

That would lift a tax burden -- around $695 per year for an adult -- off people who don't have insurance at all. But it wouldn't help with their original problem: a lack of access to health care.

Nanette Mudiam, director of the St. Michael's medical clinic in Anniston, said the free clinic often sees clients with serious heart or kidney conditions that could have been prevented with regular medical care.

"We see the effects of lack of access to health care every day -- things like hypertension and diabetes that are not controlled," she said. "

Alabama's healthcare exchange users

How many are there? 165,000 (source: cms.gov)

What could happen: It's unclear if the healthcare exchanges and tax credits for buying insurance would go away.

Even if the two-year repeal happens, or something similar, it's unclear what will become of the people who buy their health insurance through exchanges set up under the Affordable Care Act.

Alabama never set up a statewide exchange; if the federal exchange goes away, it's not really clear where Alabamians will buy insurance. Nor is it clear whether tax subsidies to help some people pay for insurance -- a feature of Obamacare -- will survive.

"The question is, what will happen to your hairdresser, or your neighbor who's a contract worker -- people who buy their own insurance," said Mudiam, the clinic director.

People without an employer-provided health plan could go back to what they did before: buying insurance on their own.

"The individual market will still exist, but the number of people getting coverage will be drastically reduced," said David Becker, who teaches health care policy at UAB.

Trump has said he wants to open up more opportunities for insurance companies to sell across state lines, something that proponents say would increase competition and lower costs.

There's no guarantee even a Republican Congress would go for that, Cox said.

Alabama's Medicaid patients

How many are there? 900,000 to 1 million (sources: Kaiser Family Foundation, Alabama Medicaid Agency)

What could happen: A block-grant Medicaid could free the state to cut services.

Repeal-and-replace could lead to big changes in states like Kentucky, which expanded Medicaid to cover more of the working poor. Those states could see tens of thousands losing their health coverage. Alabama never expanded its program.

Even so, roughly 1 million Alabamians who depend on Medicaid for their health care. Most of them are children; all are poor, disabled or in nursing homes. The program is paid for with a combination of state and federal money.

Trump has said he wants to turn the program into a block grant -- giving a set amount of money to states for Medicaid and giving them a free hand to manage it. The state's Republican leaders, tired of years of budget-busting Medicaid bills, have said they want block grants too.

There are potential pitfalls for Alabama, though. Alabama covers fewer services than most states, so if the block grant freezes funding at current levels, Alabama will be stuck with less money than other states.

"It would lock in disparities that already exist across the states," Robin Rudowitz, an analyst for the Kaiser Foundation, said.

Becker, the UAB policy analyst, said that if a block grant is sufficiently generous, services could be unchanged. Some of the state's doctors, however, think a block grant could lead either to cuts in services or a cap on the number of people who can participate in the program

"Let's say they limit it to 800,000 people," said Marsha Raulerson, a Brewton pediatrician. "After the limit, the next person to apply, no matter how sick they are and much they qualify, would be told they're on a waiting list."

Alabama's Medicare patients

How many are there? 719,000 (source: Kaiser Family Foundation)

What could happen: Medicare could be converted to a voucher system. But not without a fight by seniors.

Trump has said he has no plan to touch Medicare, the federal insurance program that covers people past retirement age. Leaders of the Republican House majority, though, say they want to turn Medicaid into a voucher program -- giving seniors money to buy health insurance.

Proponents of the voucher plan believe private insurance companies would do a better job of controlling health care costs. Opponents say the vouchers likely wouldn't keep up with rises, over the years, in the cost of health insurance.

Still, there's a good chance the program will remain unchanged. If Trump maintains his stance Republicans would need a veto-proof majority to get the voucher plan through.

Past efforts to alter either Medicare or Social Security have gone nowhere, largely because of fierce opposition from seniors.

"We are very much prepared to defend Medicare," said Jamie Harding, a spokeswoman for the AARP of Alabama.

Veterans Administration, TriCare and other government care in Alabama

Number: 174,000 (source: Kaiser Family Foundation)

What could happen: Trump wants VA patients to have more choices of doctors, but it's unclear how that would work. Military dependents could get the option of tax credit to buy insurance.

Oxford resident and veterans' advocate Ken Rollins used to travel to the Veterans Administration hospital in Birmingham for medical care. Then the VA set up the Veteran's Choice program, which allows veterans more than 50 miles from a VA hospital to use private doctors who are nearby. Rollins says the program works well.

"Sometimes getting to Birmingham, when you're sick, turns out to be worse than what you're going to the doctor for," said Rollins.

Trump hasn't released detailed plans on care for the roughly 8 million people who use the VA system. But he has said he'd like to extend the Veterans Choice program to all VA patients, even those close to VA hospitals. He has also said "veterans should be guaranteed the right to choose their doctor."

That's not how Veterans Choice works right now. When Rollins makes an appointment, he has to go to a VA-approved doctor and get it cleared before the visit. A true choose-your-doctor approach, he says, could get expensive.

"You can't just walk into any doctor and say 'send the bill to the VA,'" Rollins said of the current plan. "If they did that, it would be hard to pay for."

Most veterans don't use the VA health system. Military dependents and some retirees get care from a separate system, Tricare, that wasn't discussed in the campaign. Tom Price, Trump's pick for secretary of Health and Human Services, has floated the idea of giving Tricare patients the option of a tax credit to buy health insurance.

Alabama's Medicare patients

Number: 2.2 million (source: Kaiser Family Foundation)

What could happen: Congress might lift the requirement that insurers cover birth control. Alabama's Medicaid program could wind up with additional costs, and someone would have to pay for it.

If you get your insurance from an employer-provided plan -- most people do -- Obamacare made relatively small changes to your health plan. Analysts at Kaiser say those changes are among the most popular elements of the health care law.

"Keeping your kids on your plan until age 26 is pretty popular," Cox said. "President-elect Trump has said he'll keep it."

Coverage for birth control, which has less support among Republicans, is less likely to survive repeal-and-replace, Cox said.

The biggest changes for the privately-insured, though, could come from the downstream effects of changes to other programs. Health care analysts say an end to the individual insurance-buying mandate could cause chaos in the insurance market.

Alabama raised some taxes in 2015 to pay for Medicaid, but the blow was softened when the federal government started picking up the entire tab for the state's children's health insurance program. That was a provision of the Affordable Care Act -- and the money could vanish if Obamacare is repealed.

"We're looking at another $60 million that could be needed," said Christy Cain, executive director of the group Alabama Children First.

Capitol & statewide reporter Tim Lockette: 256-294-4193. On Twitter @TLockette_Star.

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