Six months after his first full day in office, Gov. John Bel Edwards announced enrollment was open for an expanded Medicaid program to reach Louisiana residents in the health gap — those who earn too much for Medicaid but not enough to afford health insurance. It attracted more than 175,000 people on its opening days.
In January, Edwards signed an executive order opening the program to people with incomes up to 138 percent of the federal poverty level (roughly $16,200 for a single adult and $33,400 for a family of four). The expansion, part of the Affordable Care Act (ACA), aka Obamacare, had been blocked by former Gov. Bobby Jindal. According to the Edwards administration, the state and taxpayers have paid 40 percent of health care for uninsured people, with those patients often relying on expensive emergency room care at a cost to the state of nearly $1 billion a year.
Today, nearly 350,000 people in Louisiana are covered under the Medicaid expansion. But that could change, along with the thousands of people receiving health coverage through the Obamacare health insurance marketplace. President-elect Donald Trump has said repeatedly he'll "repeal and replace" the ACA on his first day in office. A December report from the Urban Institute estimates 921,000 people in Louisiana could lose their health insurance by 2019.
Taking it down could be easy, but replacing it and ensuring continued coverage for millions of people who depend on the ACA is something else entirely. Without a clear directive from Trump and his cabinet, health agencies in Louisiana hesitate to announce or draw battle plans as they brace for a likely impact. But state health officials are concerned repeal of the ACA, or removal of key parts of it, could dramatically affect thousands of mostly poor Louisianans who otherwise are unable to afford insurance or health care.
Ironically, Louisiana residents — who voted overwhelmingly for Trump — could stand to lose thousands of dollars in subsidies for their health care. According to a recent report from the Kaiser Family Foundation, as of March 2016, Louisiana residents enrolled in the ACA health marketplace received nearly $742 million in annual tax credits to reduce monthly health care premiums. The average subsidy in Louisiana is $362 per month. Nationally, it's $291.
"Although President-elect Trump has not yet indicated any specifics, some of his promises made during the campaign would have a profound and significant impact in Louisiana," said Robert Johannessen, communications director with the Louisiana Department of Health (LDH).
What might be on the table, and what's at stake?
Gutting the ACA
Republicans could resurrect a "reconciliation" bill to gut key parts of the ACA. President Barack Obama vetoed a similar attempt this year, after Republican lawmakers passed the Restoring Americans' Healthcare Freedom Reconciliation Act in December 2015 to kill funding for several essential parts of the ACA. The act would have ended the federal health care exchange, phased out health care subsidies for lower-income families, removed the "individual mandate" tax penalty for people who don't have insurance, and phased out the Medicaid expansion through 2017. (The measure also attempted to end federal funding for Planned Parenthood.)
In his notes on the bill's impact, budget committee chairman U.S. Sen. Mike Enzi, R-Wyoming, wrote that, if passed, the measure "would increase the number of people without health coverage ... by about 22 million people in most years after 2017."
Phasing out Medicaid
Louisiana is among 31 states that expanded the availability of Medicaid through the ACA. If Republicans phase out Medicaid, Louisiana's "working poor" would gradually lose insurance coverage through the program. Since the expansion in June, Louisiana has had "many hundreds" of new patients receiving treatment for diabetes, breast cancer and heart disease "at considerably less cost than if they were diagnosed later when their illness is more advanced," Johannessen told Gambit.
Coverage under the Medicaid expansion began July 1. Since then, more than 34,000 people have received preventative health care or seen a primary care doctor for the first time, according to the LDH. More than 3,200 women have received screenings for breast cancer; 37 were diagnosed with the disease. More than 2,600 people received a colon cancer screening; 671 people had a colon polyp removed, and 32 people were diagnosed with colon cancer. More than 1,100 people were diagnosed with and are now receiving treatment for heart disease. Nearly 500 people were diagnosed with diabetes.
Johannessen said the LDH is "analyzing the financial impact to the state for each of the different options that have been proposed so far," and the department and the Edwards administration will share concerns and findings with state legislators. "We are committed to working with President-elect Trump's administration to ensure continued access to affordable health care to Louisiana residents," Johannessen said.
Ending the individual mandate and marketplace
The "individual mandate" requires people to have health insurance or be subject to tax penalties. Republicans attempted to remove the mandate using legislation that failed earlier this year. Health agencies fear that if there is no requirement to have insurance, the pool of low-income insured healthy people (who don't "need" insurance) could become smaller, leaving the market open only to lower-income people who use health services more often.
According to the Urban Institute, eliminating the individual mandate in 2017 also would create "a significant erosion of the private nongroup insurance markets inside and outside the marketplaces that year, with lower coverage (an additional 4.3 million uninsured), some midyear insurer exits, substantial financial losses for insurers ($3 billion), and displacement and financial losses for consumers having to change plans."
More than 214,000 people in Louisiana enrolled or were re-enrolled in health insurance coverage through the federal marketplace in 2016, according to the U.S. Department of Health and Human Services (DHHS). (Nationwide there were more than 12 million.) Nearly 90 percent of Louisianans who enrolled through the marketplace qualified for an average tax credit of $362 a month; 83 percent are eligible for coverage that costs $100 or less after tax credits.
More than 125,000 children in Louisiana are insured through the state's Children's Health Insurance Program (CHIP), which covers children under age 19 in low-income families and offers checkups, immunizations, prescription coverage, dental and vision care, emergency services and hospital care. Combined, 1.3 million people in Louisiana rely on Medicaid and CHIP each month. The Urban Institute predicts Louisiana will lose $23 million in Medicaid and CHIP funding from 2019-2028.
impacts to communities
The ACA has dropped more than $11 million into community health centers in Louisiana to help enroll people in the marketplace. Since 2013, that funding has helped sign up more than 206,000 people. Those health centers and offsite locations (34 centers with 197 offsites, according to the DHHS) also provide primary care to nearly 345,000 people — including 198,000 African-Americans and nearly 25,000 Latinos.
According to the Kaiser report, 52 percent of the state's Medicaid recipients are black; 66 percent of people in Louisiana with employer-provided health coverage are white.