Why Washington faces huge fallout from the Medicaid cuts in Trump’s megabill

The provision targets states like Washington that expanded Medicaid eligibility under the Affordable Care Act. It doesn't apply to the mostly Republican-led states that haven't done so. The Medicaid expansion is one of the most significant legacies of the Affordable Care Act, also known as Obamacare, a law that has drawn the scorn of Republicans for years and which they attempted to repeal during Trump's first term.

Carma Matti-Jackson, president and CEO of the Washington Health Care Association, said that even though older Americans aren't covered by the work requirements, they could face trickle-down effects if states divert funding to assist people who've lost coverage.

Added costsSome who continue to receive Medicaid coverage will pay more out of pocket.

The new law requires expansion states like Washington to charge up to $35 for some services for certain enrollees. Those whose incomes are between the federal poverty level and 138% of that level will have to pay. For a single person, the poverty level is $15,650 per year.

The new copay policy doesn't apply to primary care, mental health services, substance abuse treatment, emergency care in an emergency room or family planning.

This could lead to low-income enrollees forgoing care to avoid paying even modest amounts. However, states can choose to charge less than $35. While many states have already imposed some level of cost sharing, Washington has not.

Justin Gill, the president of the Washington State Nurses Association, expects to see more uninsured and sicker patients who'll further strain an already overstretched workforce.

"We're going to try and do the best that we can, but when the systems around us are working against us, at some point, you're going to see providers, nurses really kind of start to identify that this may not be something that's sustainable for them individually," he said. "And I think that that's a realistic threat that oftentimes people won't really appreciate until we get there."

Gill, an urgent care nurse practitioner in Everett, is frustrated with lawmakers who voted for the legislation but won't have to sit in the exam room when a patient comes in with a heart attack that could've been prevented with primary care visits.

And if hospitals become more jammed, that means worse care for everyone, Matti-Jackson said.

"So when my grandmother, who's in assisted living, falls and breaks her hip, or has a stroke and needs to get in, there's access issues," she said.

Finances and ObamacareThe legislation also limits taxes on health care providers that help underpin state Medicaid spending. Revenue from these taxes is used to unlock more federal dollars and the money ends up flowing back to the providers.

Washington levies such taxes on hospitals, nursing homes and ambulance providers. This change could especially hurt rural hospitals that rely on Medicaid spending to keep above water.

The bill also reduces what are called state-directed payments, which allow states to tell managed care plans, with federal approval, how much they should pay providers. The goal is to get hospital systems more money for taking care of Medicaid patients.

"Let's pretend like you were going to get $50 to take care of this patient," explained Kleweno Walley, the Harborview CEO. "With this program, you would get $60 now. That's not necessarily anywhere near what a commercial insurance would pay, but at least it's more than what the base Medicaid payment was."

These state-directed payments and provider taxes bring in nearly $2.4 billion annually in Washington, according to state health officials. Critics liken these financing mechanisms to money laundering.

Those with Obamacare plans will also face new barriers to enrolling and won't be allowed to automatically reenroll.

This will impact young healthy people who won't be bothered to jump through more hoops to get insurance, Brice said.

The law also restricts subsidies for Affordable Care Act marketplace coverage for some lawfully present immigrants, like asylum seekers and refugees. Earlier versions of the legislation aimed to lower Medicaid payments to states like Washington that cover immigrants without legal status using state dollars, but that provision didn't win final approval.

UW Medicine estimates it'll lose $365 million per year because of the law, said Kleweno Walley, whose hospital in Seattle is part of the University of Washington system. But that's "just the icing on top," she said, as hundreds of millions more in hospital funding could be at risk depending on how many people lose insurance coverage.

She worries the long lead time for some of the provisions to kick in will make it harder for the public to understand the legislation's impact.

"My fear is that people will forget," Kleweno Walley said, "and then it'll slowly trickle out and cause ripple effects."