The GOP-controlled Senate revealed a draft of its plan to repeal and replace the Affordable Care Act, also known as Obamacare, on Thursday, to mixed reviews.
While the details are still being worked out as Senators, officials and journalists read through the 142 page draft that had been kept secret until Thursday, several provisions are clear.
The bill would eliminate certain taxes enacted under the Affordable Care Act while also getting rid of the individual mandate that people carry insurance, purchasing it through a state-run insurance exchange if not available through an employer. The Senate bill would also offer more generous, income-based subsidies to those people purchasing insurance on an exchange than the American Health Care Act passed by the House, which based subsidies on age, but these would still be less generous than those under the Affordable Care Act.
Republican President Donald Trump, who had called on Senators to produce a health care plan with "heart," told reporters the bill will need "a little negotiation, but it's going to be very good."
One of the more significant changes in the Senate bill would be a rollback of the expansion of Medicaid eligibility under the Affordable Care Act, and a cap on future federal Medicaid funding. Medicaid is the federal insurance program for low-income people, children and those with disabilities, as opposed to Medicare, which is for seniors 65 and older.
Locally, such a rollback and then cut to federal Medicaid funding could affect many low-income people seeking health and dental care in Carroll County, but it may have an outsized effect on agencies that take care of people with disabilities. Agencies such as The Arc of Carroll County, which presently supports 700 adults and children with intellectual and developmental disabilities.
"Of the services that The Arc of Carroll County provides to our individuals that we support, 50 percent comes from the federal Medicaid program. Maryland matches the other 50 percent," said Don Rowe, executive director of The Arc. "It plays a tremendous role in funding the services for our clients."
The Medicaid expansion under the Affordable Care Act allowed The Arc to begin supporting people who had been on a waiting list, Rowe said, as well as to add additional services, such as evening help for individuals with disabilities whose elderly parents could no longer provide the same care they could before.
"Maryland has really benefited from that expansion of Medicaid funding," Rowe said. "The worry and the fear we all have here, especially in Maryland, is that if that moves to some kind of a capped rate or a block grant, then all these people we have supported and are committed to, it's going to feel like the rug gets pulled out from under them."
Putting aside the cuts to Medicaid, Tammy Black, executive director of Access Carroll, the Westminster-based clinic offering medical, behavioral and dental services to low income clients, said she worries about changes few yet understand.
"I have not done a deep read on this new legislation. I am familiar with some of the speculative changes being proposed over the last month," Black said. "There is a lot of concern about what the ripple effect, or unintended consequences may be."
There certainly were such unintended consequences with the passage of the Affordable Care Act. Black said roughly 1,400 elderly people in Carroll County lost access to supplemental Medicare insurance after the Affordable Care Act transferred funding into Medicaid.
At the same time, the Medicaid expansion was a true blessing for Access Carroll clients, she said.
"What was good for the patients we were serving for years is we were able to get them on full insurance coverage through Medicaid," Black said. "That enabled patients to get their medications, and get surgeries and access to chronic disease programs."
Prior to the Affordable Care Act, surgeries that are simple and inexpensive if planned, such as hernia repair, Black said, had to be put off until the patient was in an emergency situation. That always costs the system more in the long run, she said.
At the same time, Black said there were things that desperately needed to be fixed in the Affordable Care Act, and which she was not certain were included in the Senate's bill. First and foremost of these, would be medical tort reform.
"We have to start delivering good health care, letting providers be what they are trained to be, and not having a lawyer and insurance company whispering in their ear," Black said.
Relatedly, she said, it would also make providing care to low-income clients easier, more effective and less expensive if rules of Medicaid reimbursement were streamlined.
"We have so many strings attached to being able to provide the right kind of care at the right time with the right providers," Black said. "You can't always do the right thing, you have to do what is reimbursable."
From that point of view, Black said, a Medicaid spending cap could be a good thing, spurring physicians to be more efficient in providing care, but only if they are given the freedom to do so. It is not clear if any such changes, or tort reform, will be a part of the final Republican health care plan.
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For agencies such as The Arc, where the funding math from Medicaid to services rendered is much simpler, the possibility of a cut and a cap provokes anxiety, Rowe said.
"That is the worry and the fear that probably every parent has," he said. "What happens if some of these agencies like The Arc go away? Or they can't continue to support my child in some way, or in the manner they are today, and we are elderly and we can't do it anymore. What happens?"
Maryland Gov. Larry Hogan, a Republican, has voiced his support for keeping the Medicaid expansion in place under whatever new health care plan might come out of the GOP-controlled Congress. On Thursday, his office issued its strongest statement yet on the topic.
"We know the current system needs to be fixed but the proposals that are being considered in Congress do not work for Maryland," said Deputy Communications Director Amelia Chassé. "Congress should go back to the drawing board in an open, transparent and bipartisan fashion to craft a bill that works for all Americans."