September 2, 2025 • 42 mins
The One Big Beautiful Bill Act (OBBBA), President Trump’s Tax and Spend mega bill, recently passed Congress. It will strip billions of dollars from essential health programs while paying for billions of dollars in tax cuts for the rich, expand mass deportation programs, and continue to harm reproductive justice. Madeline Morcelle, Senior Attorney at the National Health Law Program, sits down to talk with us about OBBBA and how it’s going to particularly impact Medicaid.
Medicaid, the largest public health insurance program for people in the United States, including those of low incomes, currently provides coverage for over 71 million people. Medicaid is a critical line for people to access sexual and reproductive health care. OBBBA ushers in the most sweeping Medicaid cuts in U.S. history—specifically, $990 billion dollars in Medicaid cuts over the next decade and ending health insurance coverage for over 10 million people. Among other cuts, OBBBA imposes mandatory, nationwide work requirements on Medicaid expansion and partial expansion beneficiaries aged 19-64.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jennie (00:03):
Welcome to rePROs Fight Back, a podcast on all things
related to sexual andreproductive health rights and
justice.
Hey rePROs, how's everybodydoing?
I'm your host, Jennie Wetter,and my pronouns are she/her.
So y'all, I am recording thison Wednesday before the holiday
weekend.
I took an extra long weekend,and honestly, if you're
(00:27):
listening to this on Tuesday, Iam still out.
I just thought it would bereally nice to just take step
away and get recharged beforeeverything this fall ramps up.
I just am feeling a littleoverwhelmed with all the things
in the world and work and justthought you know what I have the
(00:47):
time to take off let's takesome time and enjoy a nice
holiday weekend and honestly gotreally lucky because the
weather in DC is supposed to begorgeous this weekend.
Normally this time of year,it's like really hot and humid
and sticky and you don't want togo outside but it is has been
gorgeous the last couple days inDC and it's supposed to be
gorgeous all weekend.
I've had my windows open; Iwould have them open right now
(01:10):
if it were if I weren'trecording so you all don't hear
all the background noise.
My cats are living their bestlives with the windows open.
So, I'm very much lookingforward to this nice weekend and
to go out and spend some timeoutside probably do some
reading.
I don't know if I haveanything that I've, like- I want
to read this book but I'm stillworking on trying to read down
(01:33):
my TBR list. I was doing sogood on it earlier this year,
y'all.
Like, so good.
But then there was a sale atBarnes & Noble that was like the
triple stamp, 25% offpre-orders, and
da-da-da-da-da-da.
And so, I did damage.
I bought a lot and did all ofthe work I had been doing to
(01:55):
read down my TBR.
But that's okay.
There are worse problems tohave.
And I'm an e-reader, so thatmeans I'm at least not living in
a house of books.
I mean, I have a lot of books,but, like, I can have a huge TBR
list on my e-reader and it'sjust my iPad so it's no big
deal.
But yeah, so my goal is to dowork on reading some of that and
(02:19):
spend some time outside andjust try to get away from
everything and tune everythingout and just take a step back
get offline and just try torelax.
And I know that's going to be alittle hard because, again, I'm
in Washington, D.C.
That means there's all thesefederal troops and they're in my
neighborhood.
(02:39):
I mean, I haven't seen NationalGuard in my neighborhood, but
there's a lot of other federalpolice in my neighborhood.
So, it's hard to get away fromall of that.
But I'm going to do my best totry to just take this weekend
and recharge and be ready to gofor the fall.
I just am feeling like I needthat a little bit.
(03:00):
I think all of the things arestarting to get to me and wear
me down and I know that's whatauthoritarianism thrives on is
to wear you down to make youwant to give up so I don't want
to give up. So, I'm going totake a weekend to recharge and
refresh and be ready to jumpback into the fray.
So, that's where I'm at rightnow.
I hope y'all had a good holidayweekend and did something fun.
(03:22):
Let's see what else.
Let's maybe do somehousekeeping.
I feel like it's maybe been alittle bit since I've done
some...
I don't know.
I'm really bad at keeping trackof that.
First, if you have any topicsyou would like us to talk about,
I always am open tosuggestions.
I want to make sure we'recovering things you all want to
hear about, so please feel freeto shoot me an email, jennie@
(03:45):
reprosfightback.com, or you canreach out to us on social media.
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(04:08):
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our merch store we have funmerch on Bonfire.
We'll have the link in the shownotes so it's really easy for
you to get to.
I finally ordered the thingsthat I had been having my eye
(04:29):
on; I got two t-shirts and a bagthey have not arrived yet but I
am very eagerly awaiting them.
I'm sure I will get some morethings, probably a coffee mug,
maybe a water bottle, some ofthe other designs.
We'll see, but they're reallyfun designs.
Liberal Jane did the majorityof them, but also our in-house
artist did some.
So, I am just very excited.
(04:50):
I love all of our stuff.
And if you want to rock rePROsFight Back merch, check out the
merch store in the show notes.
Okay, y'all.
With that, let's turn to thisweek's interview.
We are going to talk about the"One Big Beautiful Bill" that
passed earlier this summer.
It has going to have a reallybig impact on Medicaid, but also
on some parts of the AffordableCare Act.
(05:12):
And so, we're going to do adeep dive talking about all of
that today.
And I couldn't think of abetter person to have that
conversation with than MadelineMorcelle, who is with the
National Health Law Program orNHELP.
She is going to break it downfor all of us.
And it was a greatconversation.
I hope you enjoy it.
So, let's go to my interviewwith Madeline.
H i, Madeline.
(05:34):
Thank you so much for beinghere today.
Madeline (05:35):
Thank you so much for having me, Jennie.
Jennie (05:38):
Before we get started, would you like to take a second
and introduce yourself andinclude your pronouns?
Madeline (05:43):
Sure.
My name is Madeline Morcelle.
I'm a senior attorney at theNational Health Law Program.
My pronouns are she/her, and Ilead the National Health Law
Program or NHELP's work bridgingfederal health care reform and
sexual and reproductive healthadvocacy.
Jennie (05:59):
Okay, y'all.
First, an apology.
I have a cat who is like layingright here and is the Like the
world's loudest purr.
So, if you like hear weirdnoises in the background, that
would be Luna.
And I am sorry, but she is verystubborn and will not leave my
desk.
So, you're going to have todeal with it.
My apologies.
Okay, I am really excited tohave you on here.
(06:20):
There was the"One Big Beautiful Bill" that
passed, and honestly, I feeldumber every time I say it, but
let's talk about it.
And we're going to talk mostlyon its impacts on healthcare,
but before we can get to thatpart, what is the
"One Big Beautiful Bill"?
Madeline (06:40):
So the pretty disturbingly named
"One Big Beautiful Bill Act," orOBBBA, which is also known as a
big ugly bill, is PresidentTrump's tax and spend mega bill
recently passed by Congress.
This new cut in access toessential health services and
(07:01):
other essential services for theworking class by thousands of
billions of dollars andexpansion of the national debt
by $4.1 trillion aims to pay forhundreds of billions of dollars
into tax cuts for the megarich, expanded mass deportation
operations for ICE, and some ofthe other Trump administration
(07:26):
priorities that are reallyharmful to reproductive justice.
These cuts will phase in overthe coming years with some of
the biggest cuts to essentialprograms that help families
access health care, food, andother basic human rights, coming
in 2027.
Jennie (07:43):
So, I know we've had you on here a number of times to
talk about Medicaid, and that isone of the areas that is going
to be really impacted by thisbill.
But just in case people are notfamiliar, let's take that step
back real quick and talk aboutwhat is Medicaid.
Madeline (07:58):
Yeah, absolutely.
So, Medicaid is our country'sjoint federal and state health
insurance safety net program forlow-income communities.
It currently covers over 71million people.
That's one in five people inthe United States, including
almost half of adults in povertyand a critical mass of people
of reproductive age because ofstructural barriers to wealth.
(08:21):
It covers a higher share ofpeople of color and people with
disabilities.
The federal government hasgeneral rules that all state
Medicaid programs must follow,but states are responsible for
administering the program andgenerally have a good deal of
flexibility around how to dothat.
Medicaid covers a wide range ofservices, including preventive
(08:43):
services, prescription drugs,outpatient and inpatient care,
long-term care, treatments forpeople with disabilities, and is
also a critical lifeline forsexual and reproductive
healthcare.
It's the primary payer offamily planning services,
pregnancy-related services inthe United States, and also
(09:08):
provides coverage for criticalcare screenings, diagnosis for
conditions such as HIV,reproductive cancers, STIs,
really the gamut of sexual andreproductive health needs are
covered through Medicaid.
(09:28):
It also provides narrowcoverage subject to the Hyde
Amendment for abortion,including coverage for abortions
resulting from rape and incest,and also abortions that are
needed because a pregnantperson's life is in danger by
virtue of the pregnancy.
Jennie (09:49):
Okay, so like I said, one of the places that the big
ugly bill, much preferred,right...
attacked, went after isMedicaid.
So, what does this bill do toMedicaid?
Madeline (10:00):
So, this new law ushers in the most sweeping
Medicaid cuts in U.S.
history.
It cuts Medicaid by $990billion over the next decade,
ending health insurance coveragefor over $10 million.
people.
It cuts Medicaid eligibilitythrough a number of tactics,
(10:22):
which thus cuts access to sexualand reproductive health care
for low-income and underservedcommunities.
First, it ushers in a healthcare access feature that
advocates have fought to preventfor years, mandatory nationwide
Medicaid work requirements forMedicaid expansion beneficiaries
(10:44):
and folks in states that havepartially expanded Medicaid ages
19 to 64.
To be clear, these are Medicaidcuts by another name.
They constitute a third, morethan a third of the law's total
Medicaid cuts and onceimplemented will end health
insurance coverage, includingsexual and reproductive health
(11:07):
care access for 5.3 millionpeople just on their own, just
the work requirements.
And I can talk more about thework requirements in a bit.
The next, eligibility cut.
..and I'm just going to touch onsome of these; there's so much
in this bill, but there are somethings that I want to lift up,
particularly for theirimplications for sexual and
(11:27):
reproductive health.
The U.S.
has always severely restrictedimmigrants' eligibility for
public benefits.
From the inception of theseprograms, including Medicaid,
racist notions of worthinesshave shaped eligibility policy.
And before OBBBA, only greencard holders, refugees and
(11:49):
asylees, Cuban and Haitianentrants, and compact of free
association migrants, a verynarrow set of non-citizen
immigrants could enroll inMedicaid, often after a
five-year waiting period calledthe five-year bar, depending on
the category of immigrationstatus, which resulted in
(12:10):
numerous and really widespreadimmigrant coverage gaps.
But OBBBA widens this coveragegap by kicking refugees and
asylees, people forced to leavetheir countries of origin to
escape war, persecution, naturaldisaster out of the program
altogether.
And because of OBBBA, thesecommunities will be forced to go
(12:32):
without affordable sexual andreproductive health care access.
This is a profound reproductiveinjustice. OBBBA also reduces
Medicaid's retroactiveeligibility.
This is a policy that ensuresthat Medicaid eligible
individuals can receivereimbursement for health care
expenses incurred up to threemonths before their application
(12:53):
date for Medicaid, as long asthey met all the eligibility
requirements during that periodbefore the application.
This is a really importantenrollment protection for
families that protects them frommedical debt, ensures that
providers, including sexual andreproductive health care
providers, are paid for the carethat they deliver.
(13:14):
And it's especially importantfor pregnant people, because it
covers essential prenatal carereceived before applications are
processed and prevents harmfuldelays in care that can impact
intergenerational health andmake pregnancies more dangerous.
And so this bill, this law now,restricts retroactive
(13:36):
eligibility from three months tojust one, which will result in
increased medical debt andbarriers to care for families.
This law, beyond theeligibility provision, It also
contains a provision thatexcludes certain abortion
providers from participation inthe Medicaid program over the
next year, beginning on July4th, the summer, which was the
(14:00):
date that OBBBA was enacted.
This provision, often referredto as the abortion provider
"defund" provision, prohibitsMedicaid reimbursement to
entities that are tax-exempt,501c3s, that are essential
community members.
community providers primarilyengaged in family planning
(14:20):
services, reproductive health,and related healthcare services
that provide abortions beyondthe Hyde Amendment's narrow
exceptions and who received morethan $300,000 total in federal
and state Medicaid funding infiscal year 2023.
This provision locks PlannedParenthood providers as well as
(14:42):
some independent providers suchas Maine Family Planning out of
Medicaid program and will have adevastating impact not only on
access to abortion, but also onaccess to other sexual and
reproductive health services aswell.
This law also makes changes toMedicaid financing, making cuts
(15:04):
and imposing restrictions thatwill impact states' abilities to
finance their own share ofMedicaid funding because
Medicaid is a federal and statepartnership.
And so, both the federalgovernment and state governments
are responsible for putting upshares of total Medicaid
spending in each state.
(15:24):
And in order to cut federalMedicaid spending through sort
of a backdoor approach, Congressdecided to restrict states'
abilities to raise funds.
And some of these levers havespecifically allowed states to
increase reimbursement rates,for example, for family planning
(15:47):
services in states such asWashington and California.
These are policies calledstate-directed payments.
And there are really severerestrictions going forward on
state-directed payments as wellas provider taxes as a result of
this bill, which will result inincreasing, as with all of
(16:07):
these cuts, increasing budgetholes for states that they're
just not going to be able tomake up.
It's worth noting that overOBBBA's Medicaid cuts may force
states to drop optional sexualand reproductive health benefits
and eligibility categoriesbeyond what is in the law.
Federal Medicaid fundingcomprises the largest source of
(16:30):
federal funding for states.
It finances just underone-fifth of states' total
spending.
The amount of federal Medicaidfunding that states receive
hinges on actual programexpenditures.
So if states cover fewerpeople, say, because of the
largest eligibility cuts in UShistory for the Medicaid
(16:51):
program, then they're going toreceive less funding from the
federal government.
And coverage losses frompolicies such as work
requirements, retroactiveeligibility, the cuts to
immigrant eligibility, and othercuts in this law will cut the
federal funding that statesreceive by hundreds of billions
(17:13):
of dollars nationwide.
States aren't going to be ableto fill such a
gaping hole in their budgets as I said before. And many may pursue state-level Medicaid cuts in order to make up the difference.
And so, this is one of thereasons, you know, a lot of
states are convening speciallegislative sessions right now
to figure out how they're goingto deal with these budget
(17:33):
shortfalls.
And it's really important thatsexual and reproductive health
advocates have eyes on thosespecial sessions to watch what's
happening and engage.
Such cuts could directly orindirectly impact sexual
and reproductive healthcare accessfor Medicaid beneficiaries,
including not just thoseenrolled in some of the
(17:54):
eligibility categories we'vetalked about, such as Medicaid
expansion, but states may alsochoose to make up these
shortfalls by dropping optionalcategories, such as pregnancy
coverage extensions, familyplanning coverage expansions.
The Immigrant Children's HealthImprovement Act has options to
cover lawfully residingimmigrants who are pregnant or
(18:14):
children, which many states haveadopted.
All states have adoptedoptional coverage under the
Breast and Cervical CancerTreatment Program.
Some states may go as far toreverse Medicaid expansions
altogether.
And as well, states may pursuebenefit cuts or waivers of
benefit protections underfederal law.
(18:36):
For example, they may drop orplace limits on optional
benefits such as prescriptiondrugs, which are critical for a
wide range of sexual andreproductive health needs.
All 50 States currently coverprescription drugs, but that's
not a requirement.
It's optional.
States may drop doula coverage,which we've seen a great
increase in recent years, butit's not required.
(18:58):
They may drop state-fundedcoverage of abortion beyond the
Hyde Amendment's exception.
17 states cover abortionsbeyond Hyde exceptions for
Medicaid beneficiaries through atotally state-funded separate
program.
We may see states pursuewaivers of federal requirements,
(19:21):
such as the reallycomprehensive benefit for
children and youth that providesaccess to a lot of sexual and
reproductive health services, orprotections such as the
mandatory non-emergency medicaltransportation benefit, which
helps beneficiaries who facetransportation barriers access
(19:42):
sexual and reproductive healthcare.
So all of this is to say thatbeyond the specific cuts that
are in the bill, there are alsogoing to be downstream budgetary
impacts that could spiral toonly cause barriers to sexual
and reproductive health care forMedicaid beneficiaries and
entire communities to justreally soar.
Jennie (20:05):
Okay, so before we talked, I knew it was terrible
and that the cuts to Medicaidwere really bad and going to
have really severe impacts.
Somehow it was so much worsethan I thought.
There were definitely partsthat I hadn't necessarily heard
about.
Again, I'm not in the weeds onMedicaid, so there were
(20:26):
definitely areas that I was notas familiar with that we could
see impacts on.
Unfortunately, there is so muchthat is bad in this bill
related to health that we can'tdig deeper on multiple areas,
but let's talk about workrequirements.
I think that is one of thoseareas that the right is so good
(20:47):
at framing where they don'tsound like they are heavy lifts
or like aren't aren't going tobe devastating and you can have
those really basic I mean we'rejust asking people to work and
so if you don't know all thedetails or get deeper into it it
may seem reasonable so let'stalk about why this is such a
problem.
Madeline (21:07):
Yeah, so you know, work requirements have existed
in other public benefit programsfor decades now.
We've also seen workrequirements tested during the
first Trump administration inArkansas.
This is a reality.
Nationwide Medicaid workrequirements is a reality that
advocates have fought to preventfor years.
(21:27):
These, like I said, are trulyMedicaid cuts by another name.
And I mentioned this before,but these mandatory nationwide
non-wavable work requirementswill apply to Medicaid extension
beneficiaries 19 to 64 and alsopeople with partial Medicaid
expansion coverage under awaiver in states such as Georgia
(21:49):
and Wisconsin.
States have to implement thesework requirements by January
1st, 2027, notably aftermidterms.
And they may implement themearlier if they receive approval
from the Centers for Medicareand Medicaid Services or no
later than January 1st, 2028 ifthey request and CMS grants them
(22:13):
a one-time extension.
So, decades of researchdemonstrate that public benefit
work requirements do not improveemployment outcomes, their
purported purpose.
Most Medicaid beneficiaries whocan work already do so.
Instead, these are Medicaidcuts by design.
They force people to overcome alitany of barriers to show that
(22:34):
they're already working orqualify for an exemption.
The Congressional Budget Officeestimated that nationwide
Medicaid work requirements willaccount for OBBBA's largest
Medicaid cut, both in terms offederal funding cuts and also
increases to the number ofuninsured individuals.
Again, just this cut willincrease the number of uninsured
(22:58):
individuals nationwide by 5.3million people.
Under the new workrequirements, applicable
individuals will have to provethat they complete 80 hours of
qualifying work-relatedactivities per month, which is
quite high, or meet exemptioncriteria in order to enroll in
and maintain their Medicaidcoverage.
(23:20):
The law does not permit statesto waive these requirements, and
many people will be unable tomeet the monthly minimums due to
no fault of their own.
Low wage workers' hours areinfamously variable and out of
their own control.
My brother works for a grocerystore, and he is now a full-time
(23:45):
employee, but it took him yearsto get there.
And for years, he just wouldn'tget the hours he needed because
the manager didn't want to paymore full-time employees
benefits and so would purposelykeep hours low.
And this is a reality that somany working class people face
(24:08):
across the country.
Numerous studies on publicbenefit work requirements show
disproportionate sanctions,These are things like
termination of benefits forBlack people and people with
physical and mental healthconditions.
And at a minimum, states haveto verify these qualifying
activities or exemptions duringboth the month before
(24:30):
application and at least onemonth between eligibility
redetermination.
So at least every six months,but they can impose more onerous
verifications.
Just to really stress what thisdoes, like the
TLDR is that (24:46):
the way that this is structured is it actually shuts the front door on coverage. So, you need to prove that you’re already meeting the requirements before you can enroll. And just to really stress how backwards this is
We're really, really making ithard for people to enroll in
(25:20):
coverage as a result of theserequirements.
The law ostensibly exemptscertain populations from the
work requirements, such aspeople who are eligible for
pregnancy-related Medicaidcoverage or would be if they're
already enrolled in Medicaidexpansion, some people with
disabilities or chronicconditions, and parents,
(25:42):
guardians, or caretakerrelatives of disabled
individuals or dependentchildren 13 or under.
However, nearly three decadesof research on and experience
with public benefits workrequirements has demonstrated
that these exemptionsconsistently fail, sparking
widespread improper eligibilitydenials.
(26:03):
Exemption processes arenotoriously confusing, riddled
with complex paperwork andadministrative requirements, and
poorly publicized.
Oftentimes, the systems we'veseen have held weird hours.
So, you can only accesswebsites at certain hours.
That was true in Arkansas.
(26:23):
And applicants andbeneficiaries also often
experience significant powerdifferentials with program
caseworkers who have a lot ofdiscretion over whether to grant
exemptions and oftenarbitrarily deny them.
And we also have concerns aboutwhether states and the handling
(26:46):
applicant and enrolleesexemption-related data with
regards to, for example,pregnancy.
And that's a major area offocus for my work right now.
These work requirements, inshort, are Medicaid expansion
cuts that are only going toserve to further decimate access
to affordable sexual andreproductive health coverage for
(27:09):
people with low incomes andunderserved communities in the
41 states, including D.C., thathave fully implemented Medicaid
expansion.
It has profoundly improvedsexual and reproductive health
access for millions of peopleduring their reproductive years
and menopause thereafter.
Dozens of studies demonstratethe Medicaid expansion improves
(27:32):
sexual and reproductive healthoutcomes and reduces inequities.
And if Congress allows thesework requirements to go into
effect, millions of peoplenationwide will lose access to
this sexual and reproductivehealth care access lifeline.
Jennie (27:48):
I feel like it's also important.
I feel like we talked aboutthis briefly last time we talked
about Medicaid, but just areminder that a lot of people
may not know they're on Medicaidbecause it gets rebranded at
the state level.
I'm from Wisconsin.
So in Wisconsin, if you're onBadgerCare, that is Medicaid.
And so, there are a lot ofpeople who may not understand
that these cuts are going toimpact them.
Madeline (28:09):
Yeah, that's right.
Medicaid goes by a number ofnames across the country.
That's part of what is soconfusing.
So, when I was in grad school,I was covered by MassHealth.
That's Medicaid.
In Massachusetts, Wisconsin, asyou said, calls Medicaid,
BadgerCare.
Tennessee calls it TennCare.
California calls it Medi-Cal.
(28:30):
And there are otherstate-specific names too.
So if you're not sure, Googlewhat your state calls Medicaid,
because it's very likely thatsomeone, if it's not you that's
covered by Medicaid, somebody inyour circle is.
And it's going to impact them.
Jennie (28:46):
Unfortunately, Medicaid isn't the only area where we're
going to see health impacts inOBBBA.
What else are we going to see?
Madeline (28:53):
Yeah, so we're also going to see a lot of cuts to
affordable private healthinsurance coverage under the
Affordable Care Act.
We expect to see an additional4 million people lose coverage
due to these cuts, theseAffordable Care Act cuts.
(29:14):
We expect to see some of thecuts that are in OBBBA in the
private insurance space, forexample, include removing
eligibility for affordablehealth coverage for lawfully
present immigrants who are underthe federal poverty line.
We see limits on the specialenrollment periods in the
(29:39):
marketplace.
For example, there's alow-income special enrollment
period that helps individualswho turn back and forth between
Medicaid and marketplacecoverage enroll in marketplace
coverage mid-year outside ofopen enrollment if they suddenly
(29:59):
become ineligible for Medicaid.
And that is a really criticalenrollment protection for people
with low incomes.
And there are a number of otherchanges to private insurance
coverage that will impactpeople.
We're also going to see the endof extended premium tax credits
(30:23):
at the end of this year thathave helped millions of people
access affordable coverage.
And so, health insurancecoverage is about to get a lot
less affordable for many, manypeople in the working class
across the United States.
Jennie (30:40):
Well, I'm glad you brought up starting who's going
to be impacted because I thinkthat's a really important
consideration we need to thinkabout is: who is going to be the
most impacted by all of thesechanges?
Madeline (30:51):
Yeah, I want to be perfectly clear that this is an
assault on the working class.
We expect that in the comingyears, 10 million people with
low incomes will lose Medicaidcoverage, that number 4 million
people for marketplace coverage,and with this coverage,
affordable access to sexual andreproductive health care.
(31:14):
And the down effects of losinghealth insurance coverage is
going to cost many members ofthe working class their lives.
A joint Yale School of PublicHealth and University of
Pennsylvania study estimatedthat OBBBA's health care cuts
together to Medicaid and privatehealth insurance access will
(31:35):
cause over 50,000 deaths a yearnationwide once these provisions
are implemented.
And we can expect these impactsto disproportionately impact
low-income care communities ofcolor, people with disabilities,
immigrant communities, andother underserved communities.
And again, I want to beperfectly clear what these cuts
(31:55):
are paying for.
This was not a bill that savedtaxpayers money.
It increased the national debtby trillions by both increasing
the national debt and cuttingthese essential programs in
order to finance tax cuts forthe ultra wealthy, expanded mass
(32:15):
deportations by ICE and otheradministration priorities such
as the federal takeover andmilitarization of DC and other
democratic states that we'reseeing right now.
That's what this bill is reallyabout.
We are also going to see anescalation in sexual and
(32:36):
reproductive health careproviders shutting their doors
due to increases inuncompensated care from this
bill, including hundreds oflabor and delivery units that
have been closing in recentyears.
That number is just going toincrease nationwide as a result
of this law.
(32:57):
Particularly in ruralcommunities, maternal health
care apartheid means that peoplemust drive hours, sometimes
crossing state lines, to accesspregnancy-related care,
intensifying the risk ofcomplications.
Medicaid expansion has had aprotective effect on provider
(33:17):
budgets, helping keep theirdoors open for the communities
that they serve.
And this isn't just, you know,Medicaid beneficiaries, but also
locals in these communitiesthat are served by these health
care institutions.
So if you think like, well, Idon't have Medicaid, I checked
and I'm not covered by Medicaidand I'm not covered by these
(33:40):
affordable subsidies under theACA that are being gut by this
bill, don't think that this billis not going to impact your
healthcare access because byreally attacking the budgets of
sexual and reproductivehealthcare providers, including
labor and delivery units, thisis going to impact your access
(34:01):
as well.
You know, we see that Medicaidexpansion has helped keep doors
open also for individuals inneighboring non-expansion states
who travel across state linesto access care.
So if you're in a non-expansionstate and think this isn't
(34:23):
going to impact me, that's nottrue either, especially if
you're in a rural area,especially if you're near a
state border.
Expansion decreasesuncompensated care.
It increases revenue.
It improves provider operatingmargins, especially for
providers and particularlyhospitals in rural communities.
And all of these cuts, workrequirements and more will
(34:46):
undermine these benefits.
Coverage losses from this bigugly bill are going to drive up
the rates of uncompensated care,narrowing operating margins and
forcing many to shutter theirdoors.
For example, our friends at theNational Partnership for Women
and Families recently found that140 rural labor and delivery
(35:09):
units nationwide are at risk ofclosure or service cutbacks due
to the Medicaid cuts.
So it is a lot.
This law is so far reaching.
I think it's so much worse thanthe vast majority of the public
is aware.
And I would say that's bydesign.
(35:31):
Democrats brought up aresolution to President Trump
and kept saying there are noMedicaid cuts in this bill.
There are no Medicaid cuts inthis bill.
And Democrats raised aresolution and tried to get
Republicans to vote on aresolution agreeing that there
would be no Medicaid cutsthrough this bill.
(35:51):
And out of the other side oftheir mouths, they said, no,
we're not going to do that.
We're not going to vote on thisresolution, but there are no
Medicaid cuts in this bill.
Well, there are $990 billion inMedicaid cuts in this bill.
And that's the reality that nowthe U.S.
public is going to have to livewith.
Jennie (36:11):
Yeah, I really think about, I mean, so much of what
you said but, like, you know,tying it to, like, personal
thinking; I grew up in ruralWisconsin, my mom still lives in
rural Wisconsin, the hospital Igrew up going to is considered
a rural hospital, and thinkingof how much further my mom would
have to go to access care ifthat hospital were to close...
(36:32):
like, these are real impacts onpeople's lives and it gets so
often just gets lost and talkingabout the numbers and stuff is
like these are people who aregoing to struggle to find access
to health care and when theylose their coverage.
Okay, so now that the bill hasbeen passed, people may feel
(36:52):
like there's nothing they cando, but I'm sure that's not
true.
What can our audience do to getinvolved in this?
Madeline (36:58):
There are so many important ways to engage.
One of the ways right now, manystates are convening special
legislative sessions to reallyfigure out what they're going to
do to make up budget shortfallsand start implementing these
And so, keeping an eye on thosesessions and their implications
(37:20):
for sexual and reproductivehealth is really, really
critical.
And engaging in the process isreally, really critical.
If you are a federal advocatelistening in, a lot of these
policies are going to have to gothrough CMS to be implemented.
So, engaging in administrativeadvocacy in the coming years,
(37:45):
Engaging in comment writing,engaging in meetings with the
Office of Management and Budget,and just really fighting as
hard as we can to ensure thatthese provisions are implemented
in the least harmful waypossible.
If you are a state advocateworking with your state Medicaid
(38:06):
agency to mitigate damage,including making sure that some
of the notices that will go tobeneficiaries informing them of
these changes are clear.
Meet federal requirements.
Meet best practices.
That's going to be reallycritical.
Partnering with communityorganizers and across a wide
(38:29):
range of stakeholder groups onoutreach to really get the word
out so that people understandhow they can keep their coverage
if they, in theory, could keeptheir coverage.
If they're going to be kickedout of coverage, it's really
important that people are awarewhen that's going to happen so
(38:51):
that they can go and get theservices they've been putting
off sooner rather than later.
So, outreach really, reallyimportant.
There are also really importantlevers for getting involved in
state Medicaid administrativepolicy.
One of these is the MedicaidAdvisory Committee, which is a
(39:12):
space that advocates can getinvolved to inform state
Medicaid policy.
There are also beneficiaryadvisory committees for Medicaid
beneficiaries to help shapeMedicaid policy in their states.
All of this really, reallyimportant.
And NHELP is committed toensuring that the broader sexual
(39:32):
and reproductive health rightsand justice movement has the
tools it needs to work togetherto really do as much damage
mitigation as we can here.
And so if you are interested ingetting involved, please reach
out.
You can also, if you'relistening in and are interested
(39:54):
in getting involved in advocacyin general, you can learn more
and sign up for and NHELP'slistserv for our advocacy
resources and alerts and alsoaccess pre-existing resources at
www.healthlaw.org.
We also have a landing page forour OBBBA implementation damage
(40:16):
mitigation resources, which isgrowing, including an incredible
chart that one of my colleaguesput together with all of the
implementation dates, becausethese cuts are going to be
hitting at different points.
And that chart is so valuablefor creating a work plan of what
needs to happen in the comingyears in the states and at the
(40:38):
federal level.
Jennie (40:40):
That's going to be so useful to have.
Madeline (40:42):
Yeah.
Jennie (40:42):
Madeline, thank you so much for being here.
today I had so much fun talkingto you about such terrible
things.
Madeline (40:49):
Thank you so much for having me Jennie and holding
space.
I know that you know these cutsare deeply personal to so many
of us and it's a reallyhorrifying reality to face and I
really believe that we have itin us to fight to hold the line
on as much as we can for as longas we can and ensure that these
(41:13):
are implemented in the leastdamaging way to sexual and
reproductive health rights andjustice possible.
Thank you.
Jennie (41:21):
Okay, y'all.
I had a great conversation withMadeline.
I hope you enjoyed it and havea wonderful rest of your week
and I will see everyone nextweek.
[music outro] If you have anyquestions, comments, or topics
you would like us to cover,always feel free to shoot me an
email.
You can reach me at jennie,J-E-N-N-I-E at
reprosfightback.com or you canfind us on social media.
(41:43):
We're at rePROs Fight Back onFacebook and Twitter or
@reprosfb on Instagram.
If you love our podcast andwant to make sure more people
find it, take the time to rateand review us on your favorite
podcast platform.
Or if you want to make sure tosupport the podcast, you can
also donate on our website atreprosfightback.com.
Thanks all.
Welcome to rePROs Fight Back, a podcast on all things
related to sexual andreproductive health rights and
justice.
Hey rePROs, how's everybodydoing?
I'm your host, Jennie Wetter,and my pronouns are she/her.
So y'all, I am recording thison Wednesday before the holiday
weekend.
I took an extra long weekend,and honestly, if you're
(00:27):
listening to this on Tuesday, Iam still out.
I just thought it would bereally nice to just take step
away and get recharged beforeeverything this fall ramps up.
I just am feeling a littleoverwhelmed with all the things
in the world and work and justthought you know what I have the
(00:47):
time to take off let's takesome time and enjoy a nice
holiday weekend and honestly gotreally lucky because the
weather in DC is supposed to begorgeous this weekend.
Normally this time of year,it's like really hot and humid
and sticky and you don't want togo outside but it is has been
gorgeous the last couple days inDC and it's supposed to be
gorgeous all weekend.
I've had my windows open; Iwould have them open right now
(01:10):
if it were if I weren'trecording so you all don't hear
all the background noise.
My cats are living their bestlives with the windows open.
So, I'm very much lookingforward to this nice weekend and
to go out and spend some timeoutside probably do some
reading.
I don't know if I haveanything that I've, like- I want
to read this book but I'm stillworking on trying to read down
(01:33):
my TBR list. I was doing sogood on it earlier this year,
y'all.
Like, so good.
But then there was a sale atBarnes & Noble that was like the
triple stamp, 25% offpre-orders, and
da-da-da-da-da-da.
And so, I did damage.
I bought a lot and did all ofthe work I had been doing to
(01:55):
read down my TBR.
But that's okay.
There are worse problems tohave.
And I'm an e-reader, so thatmeans I'm at least not living in
a house of books.
I mean, I have a lot of books,but, like, I can have a huge TBR
list on my e-reader and it'sjust my iPad so it's no big
deal.
But yeah, so my goal is to dowork on reading some of that and
(02:19):
spend some time outside andjust try to get away from
everything and tune everythingout and just take a step back
get offline and just try torelax.
And I know that's going to be alittle hard because, again, I'm
in Washington, D.C.
That means there's all thesefederal troops and they're in my
neighborhood.
(02:39):
I mean, I haven't seen NationalGuard in my neighborhood, but
there's a lot of other federalpolice in my neighborhood.
So, it's hard to get away fromall of that.
But I'm going to do my best totry to just take this weekend
and recharge and be ready to gofor the fall.
I just am feeling like I needthat a little bit.
(03:00):
I think all of the things arestarting to get to me and wear
me down and I know that's whatauthoritarianism thrives on is
to wear you down to make youwant to give up so I don't want
to give up. So, I'm going totake a weekend to recharge and
refresh and be ready to jumpback into the fray.
So, that's where I'm at rightnow.
I hope y'all had a good holidayweekend and did something fun.
(03:22):
Let's see what else.
Let's maybe do somehousekeeping.
I feel like it's maybe been alittle bit since I've done
some...
I don't know.
I'm really bad at keeping trackof that.
First, if you have any topicsyou would like us to talk about,
I always am open tosuggestions.
I want to make sure we'recovering things you all want to
hear about, so please feel freeto shoot me an email, jennie@
(03:45):
reprosfightback.com, or you canreach out to us on social media.
We're at rePROs Fight Back onFacebook and Bluesky and
@reprosfb on Instagram.
I'm mostly on Bluesky if youwant to find me, so that is
@JennieInDC.
If you love the podcast, itwould really help if you could
subscribe, rate, and review uson whatever podcast platform you
(04:08):
are on— it helps other peoplefind the podcast— and make sure
you don't miss an episode if youhaven't subscribed.
So, highly recommend all ofthat.
And if you really love thepodcast, make sure to check out
our merch store we have funmerch on Bonfire.
We'll have the link in the shownotes so it's really easy for
you to get to.
I finally ordered the thingsthat I had been having my eye
(04:29):
on; I got two t-shirts and a bagthey have not arrived yet but I
am very eagerly awaiting them.
I'm sure I will get some morethings, probably a coffee mug,
maybe a water bottle, some ofthe other designs.
We'll see, but they're reallyfun designs.
Liberal Jane did the majorityof them, but also our in-house
artist did some.
So, I am just very excited.
(04:50):
I love all of our stuff.
And if you want to rock rePROsFight Back merch, check out the
merch store in the show notes.
Okay, y'all.
With that, let's turn to thisweek's interview.
We are going to talk about the"One Big Beautiful Bill" that
passed earlier this summer.
It has going to have a reallybig impact on Medicaid, but also
on some parts of the AffordableCare Act.
(05:12):
And so, we're going to do adeep dive talking about all of
that today.
And I couldn't think of abetter person to have that
conversation with than MadelineMorcelle, who is with the
National Health Law Program orNHELP.
She is going to break it downfor all of us.
And it was a greatconversation.
I hope you enjoy it.
So, let's go to my interviewwith Madeline.
H i, Madeline.
(05:34):
Thank you so much for beinghere today.
Madeline (05:35):
Thank you so much for having me, Jennie.
Jennie (05:38):
Before we get started, would you like to take a second
and introduce yourself andinclude your pronouns?
Madeline (05:43):
Sure.
My name is Madeline Morcelle.
I'm a senior attorney at theNational Health Law Program.
My pronouns are she/her, and Ilead the National Health Law
Program or NHELP's work bridgingfederal health care reform and
sexual and reproductive healthadvocacy.
Jennie (05:59):
Okay, y'all.
First, an apology.
I have a cat who is like layingright here and is the Like the
world's loudest purr.
So, if you like hear weirdnoises in the background, that
would be Luna.
And I am sorry, but she is verystubborn and will not leave my
desk.
So, you're going to have todeal with it.
My apologies.
Okay, I am really excited tohave you on here.
(06:20):
There was the"One Big Beautiful Bill" that
passed, and honestly, I feeldumber every time I say it, but
let's talk about it.
And we're going to talk mostlyon its impacts on healthcare,
but before we can get to thatpart, what is the
"One Big Beautiful Bill"?
Madeline (06:40):
So the pretty disturbingly named
"One Big Beautiful Bill Act," orOBBBA, which is also known as a
big ugly bill, is PresidentTrump's tax and spend mega bill
recently passed by Congress.
This new cut in access toessential health services and
(07:01):
other essential services for theworking class by thousands of
billions of dollars andexpansion of the national debt
by $4.1 trillion aims to pay forhundreds of billions of dollars
into tax cuts for the megarich, expanded mass deportation
operations for ICE, and some ofthe other Trump administration
(07:26):
priorities that are reallyharmful to reproductive justice.
These cuts will phase in overthe coming years with some of
the biggest cuts to essentialprograms that help families
access health care, food, andother basic human rights, coming
in 2027.
Jennie (07:43):
So, I know we've had you on here a number of times to
talk about Medicaid, and that isone of the areas that is going
to be really impacted by thisbill.
But just in case people are notfamiliar, let's take that step
back real quick and talk aboutwhat is Medicaid.
Madeline (07:58):
Yeah, absolutely.
So, Medicaid is our country'sjoint federal and state health
insurance safety net program forlow-income communities.
It currently covers over 71million people.
That's one in five people inthe United States, including
almost half of adults in povertyand a critical mass of people
of reproductive age because ofstructural barriers to wealth.
(08:21):
It covers a higher share ofpeople of color and people with
disabilities.
The federal government hasgeneral rules that all state
Medicaid programs must follow,but states are responsible for
administering the program andgenerally have a good deal of
flexibility around how to dothat.
Medicaid covers a wide range ofservices, including preventive
(08:43):
services, prescription drugs,outpatient and inpatient care,
long-term care, treatments forpeople with disabilities, and is
also a critical lifeline forsexual and reproductive
healthcare.
It's the primary payer offamily planning services,
pregnancy-related services inthe United States, and also
(09:08):
provides coverage for criticalcare screenings, diagnosis for
conditions such as HIV,reproductive cancers, STIs,
really the gamut of sexual andreproductive health needs are
covered through Medicaid.
(09:28):
It also provides narrowcoverage subject to the Hyde
Amendment for abortion,including coverage for abortions
resulting from rape and incest,and also abortions that are
needed because a pregnantperson's life is in danger by
virtue of the pregnancy.
Jennie (09:49):
Okay, so like I said, one of the places that the big
ugly bill, much preferred,right...
attacked, went after isMedicaid.
So, what does this bill do toMedicaid?
Madeline (10:00):
So, this new law ushers in the most sweeping
Medicaid cuts in U.S.
history.
It cuts Medicaid by $990billion over the next decade,
ending health insurance coveragefor over $10 million.
people.
It cuts Medicaid eligibilitythrough a number of tactics,
(10:22):
which thus cuts access to sexualand reproductive health care
for low-income and underservedcommunities.
First, it ushers in a healthcare access feature that
advocates have fought to preventfor years, mandatory nationwide
Medicaid work requirements forMedicaid expansion beneficiaries
(10:44):
and folks in states that havepartially expanded Medicaid ages
19 to 64.
To be clear, these are Medicaidcuts by another name.
They constitute a third, morethan a third of the law's total
Medicaid cuts and onceimplemented will end health
insurance coverage, includingsexual and reproductive health
(11:07):
care access for 5.3 millionpeople just on their own, just
the work requirements.
And I can talk more about thework requirements in a bit.
The next, eligibility cut.
..and I'm just going to touch onsome of these; there's so much
in this bill, but there are somethings that I want to lift up,
particularly for theirimplications for sexual and
(11:27):
reproductive health.
The U.S.
has always severely restrictedimmigrants' eligibility for
public benefits.
From the inception of theseprograms, including Medicaid,
racist notions of worthinesshave shaped eligibility policy.
And before OBBBA, only greencard holders, refugees and
(11:49):
asylees, Cuban and Haitianentrants, and compact of free
association migrants, a verynarrow set of non-citizen
immigrants could enroll inMedicaid, often after a
five-year waiting period calledthe five-year bar, depending on
the category of immigrationstatus, which resulted in
(12:10):
numerous and really widespreadimmigrant coverage gaps.
But OBBBA widens this coveragegap by kicking refugees and
asylees, people forced to leavetheir countries of origin to
escape war, persecution, naturaldisaster out of the program
altogether.
And because of OBBBA, thesecommunities will be forced to go
(12:32):
without affordable sexual andreproductive health care access.
This is a profound reproductiveinjustice. OBBBA also reduces
Medicaid's retroactiveeligibility.
This is a policy that ensuresthat Medicaid eligible
individuals can receivereimbursement for health care
expenses incurred up to threemonths before their application
(12:53):
date for Medicaid, as long asthey met all the eligibility
requirements during that periodbefore the application.
This is a really importantenrollment protection for
families that protects them frommedical debt, ensures that
providers, including sexual andreproductive health care
providers, are paid for the carethat they deliver.
(13:14):
And it's especially importantfor pregnant people, because it
covers essential prenatal carereceived before applications are
processed and prevents harmfuldelays in care that can impact
intergenerational health andmake pregnancies more dangerous.
And so this bill, this law now,restricts retroactive
(13:36):
eligibility from three months tojust one, which will result in
increased medical debt andbarriers to care for families.
This law, beyond theeligibility provision, It also
contains a provision thatexcludes certain abortion
providers from participation inthe Medicaid program over the
next year, beginning on July4th, the summer, which was the
(14:00):
date that OBBBA was enacted.
This provision, often referredto as the abortion provider
"defund" provision, prohibitsMedicaid reimbursement to
entities that are tax-exempt,501c3s, that are essential
community members.
community providers primarilyengaged in family planning
(14:20):
services, reproductive health,and related healthcare services
that provide abortions beyondthe Hyde Amendment's narrow
exceptions and who received morethan $300,000 total in federal
and state Medicaid funding infiscal year 2023.
This provision locks PlannedParenthood providers as well as
(14:42):
some independent providers suchas Maine Family Planning out of
Medicaid program and will have adevastating impact not only on
access to abortion, but also onaccess to other sexual and
reproductive health services aswell.
This law also makes changes toMedicaid financing, making cuts
(15:04):
and imposing restrictions thatwill impact states' abilities to
finance their own share ofMedicaid funding because
Medicaid is a federal and statepartnership.
And so, both the federalgovernment and state governments
are responsible for putting upshares of total Medicaid
spending in each state.
(15:24):
And in order to cut federalMedicaid spending through sort
of a backdoor approach, Congressdecided to restrict states'
abilities to raise funds.
And some of these levers havespecifically allowed states to
increase reimbursement rates,for example, for family planning
(15:47):
services in states such asWashington and California.
These are policies calledstate-directed payments.
And there are really severerestrictions going forward on
state-directed payments as wellas provider taxes as a result of
this bill, which will result inincreasing, as with all of
(16:07):
these cuts, increasing budgetholes for states that they're
just not going to be able tomake up.
It's worth noting that overOBBBA's Medicaid cuts may force
states to drop optional sexualand reproductive health benefits
and eligibility categoriesbeyond what is in the law.
Federal Medicaid fundingcomprises the largest source of
(16:30):
federal funding for states.
It finances just underone-fifth of states' total
spending.
The amount of federal Medicaidfunding that states receive
hinges on actual programexpenditures.
So if states cover fewerpeople, say, because of the
largest eligibility cuts in UShistory for the Medicaid
(16:51):
program, then they're going toreceive less funding from the
federal government.
And coverage losses frompolicies such as work
requirements, retroactiveeligibility, the cuts to
immigrant eligibility, and othercuts in this law will cut the
federal funding that statesreceive by hundreds of billions
(17:13):
of dollars nationwide.
States aren't going to be ableto fill such a
gaping hole in their budgets as I said before. And many may pursue state-level Medicaid cuts in order to make up the difference.
And so, this is one of thereasons, you know, a lot of
states are convening speciallegislative sessions right now
to figure out how they're goingto deal with these budget
(17:33):
shortfalls.
And it's really important thatsexual and reproductive health
advocates have eyes on thosespecial sessions to watch what's
happening and engage.
Such cuts could directly orindirectly impact sexual
and reproductive healthcare accessfor Medicaid beneficiaries,
including not just thoseenrolled in some of the
(17:54):
eligibility categories we'vetalked about, such as Medicaid
expansion, but states may alsochoose to make up these
shortfalls by dropping optionalcategories, such as pregnancy
coverage extensions, familyplanning coverage expansions.
The Immigrant Children's HealthImprovement Act has options to
cover lawfully residingimmigrants who are pregnant or
(18:14):
children, which many states haveadopted.
All states have adoptedoptional coverage under the
Breast and Cervical CancerTreatment Program.
Some states may go as far toreverse Medicaid expansions
altogether.
And as well, states may pursuebenefit cuts or waivers of
benefit protections underfederal law.
(18:36):
For example, they may drop orplace limits on optional
benefits such as prescriptiondrugs, which are critical for a
wide range of sexual andreproductive health needs.
All 50 States currently coverprescription drugs, but that's
not a requirement.
It's optional.
States may drop doula coverage,which we've seen a great
increase in recent years, butit's not required.
(18:58):
They may drop state-fundedcoverage of abortion beyond the
Hyde Amendment's exception.
17 states cover abortionsbeyond Hyde exceptions for
Medicaid beneficiaries through atotally state-funded separate
program.
We may see states pursuewaivers of federal requirements,
(19:21):
such as the reallycomprehensive benefit for
children and youth that providesaccess to a lot of sexual and
reproductive health services, orprotections such as the
mandatory non-emergency medicaltransportation benefit, which
helps beneficiaries who facetransportation barriers access
(19:42):
sexual and reproductive healthcare.
So all of this is to say thatbeyond the specific cuts that
are in the bill, there are alsogoing to be downstream budgetary
impacts that could spiral toonly cause barriers to sexual
and reproductive health care forMedicaid beneficiaries and
entire communities to justreally soar.
Jennie (20:05):
Okay, so before we talked, I knew it was terrible
and that the cuts to Medicaidwere really bad and going to
have really severe impacts.
Somehow it was so much worsethan I thought.
There were definitely partsthat I hadn't necessarily heard
about.
Again, I'm not in the weeds onMedicaid, so there were
(20:26):
definitely areas that I was notas familiar with that we could
see impacts on.
Unfortunately, there is so muchthat is bad in this bill
related to health that we can'tdig deeper on multiple areas,
but let's talk about workrequirements.
I think that is one of thoseareas that the right is so good
(20:47):
at framing where they don'tsound like they are heavy lifts
or like aren't aren't going tobe devastating and you can have
those really basic I mean we'rejust asking people to work and
so if you don't know all thedetails or get deeper into it it
may seem reasonable so let'stalk about why this is such a
problem.
Madeline (21:07):
Yeah, so you know, work requirements have existed
in other public benefit programsfor decades now.
We've also seen workrequirements tested during the
first Trump administration inArkansas.
This is a reality.
Nationwide Medicaid workrequirements is a reality that
advocates have fought to preventfor years.
(21:27):
These, like I said, are trulyMedicaid cuts by another name.
And I mentioned this before,but these mandatory nationwide
non-wavable work requirementswill apply to Medicaid extension
beneficiaries 19 to 64 and alsopeople with partial Medicaid
expansion coverage under awaiver in states such as Georgia
(21:49):
and Wisconsin.
States have to implement thesework requirements by January
1st, 2027, notably aftermidterms.
And they may implement themearlier if they receive approval
from the Centers for Medicareand Medicaid Services or no
later than January 1st, 2028 ifthey request and CMS grants them
(22:13):
a one-time extension.
So, decades of researchdemonstrate that public benefit
work requirements do not improveemployment outcomes, their
purported purpose.
Most Medicaid beneficiaries whocan work already do so.
Instead, these are Medicaidcuts by design.
They force people to overcome alitany of barriers to show that
(22:34):
they're already working orqualify for an exemption.
The Congressional Budget Officeestimated that nationwide
Medicaid work requirements willaccount for OBBBA's largest
Medicaid cut, both in terms offederal funding cuts and also
increases to the number ofuninsured individuals.
Again, just this cut willincrease the number of uninsured
(22:58):
individuals nationwide by 5.3million people.
Under the new workrequirements, applicable
individuals will have to provethat they complete 80 hours of
qualifying work-relatedactivities per month, which is
quite high, or meet exemptioncriteria in order to enroll in
and maintain their Medicaidcoverage.
(23:20):
The law does not permit statesto waive these requirements, and
many people will be unable tomeet the monthly minimums due to
no fault of their own.
Low wage workers' hours areinfamously variable and out of
their own control.
My brother works for a grocerystore, and he is now a full-time
(23:45):
employee, but it took him yearsto get there.
And for years, he just wouldn'tget the hours he needed because
the manager didn't want to paymore full-time employees
benefits and so would purposelykeep hours low.
And this is a reality that somany working class people face
(24:08):
across the country.
Numerous studies on publicbenefit work requirements show
disproportionate sanctions,These are things like
termination of benefits forBlack people and people with
physical and mental healthconditions.
And at a minimum, states haveto verify these qualifying
activities or exemptions duringboth the month before
(24:30):
application and at least onemonth between eligibility
redetermination.
So at least every six months,but they can impose more onerous
verifications.
Just to really stress what thisdoes, like the
TLDR is that (24:46):
the way that this is structured is it actually shuts the front door on coverage. So, you need to prove that you’re already meeting the requirements before you can enroll. And just to really stress how backwards this is
We're really, really making ithard for people to enroll in
(25:20):
coverage as a result of theserequirements.
The law ostensibly exemptscertain populations from the
work requirements, such aspeople who are eligible for
pregnancy-related Medicaidcoverage or would be if they're
already enrolled in Medicaidexpansion, some people with
disabilities or chronicconditions, and parents,
(25:42):
guardians, or caretakerrelatives of disabled
individuals or dependentchildren 13 or under.
However, nearly three decadesof research on and experience
with public benefits workrequirements has demonstrated
that these exemptionsconsistently fail, sparking
widespread improper eligibilitydenials.
(26:03):
Exemption processes arenotoriously confusing, riddled
with complex paperwork andadministrative requirements, and
poorly publicized.
Oftentimes, the systems we'veseen have held weird hours.
So, you can only accesswebsites at certain hours.
That was true in Arkansas.
(26:23):
And applicants andbeneficiaries also often
experience significant powerdifferentials with program
caseworkers who have a lot ofdiscretion over whether to grant
exemptions and oftenarbitrarily deny them.
And we also have concerns aboutwhether states and the handling
(26:46):
applicant and enrolleesexemption-related data with
regards to, for example,pregnancy.
And that's a major area offocus for my work right now.
These work requirements, inshort, are Medicaid expansion
cuts that are only going toserve to further decimate access
to affordable sexual andreproductive health coverage for
(27:09):
people with low incomes andunderserved communities in the
41 states, including D.C., thathave fully implemented Medicaid
expansion.
It has profoundly improvedsexual and reproductive health
access for millions of peopleduring their reproductive years
and menopause thereafter.
Dozens of studies demonstratethe Medicaid expansion improves
(27:32):
sexual and reproductive healthoutcomes and reduces inequities.
And if Congress allows thesework requirements to go into
effect, millions of peoplenationwide will lose access to
this sexual and reproductivehealth care access lifeline.
Jennie (27:48):
I feel like it's also important.
I feel like we talked aboutthis briefly last time we talked
about Medicaid, but just areminder that a lot of people
may not know they're on Medicaidbecause it gets rebranded at
the state level.
I'm from Wisconsin.
So in Wisconsin, if you're onBadgerCare, that is Medicaid.
And so, there are a lot ofpeople who may not understand
that these cuts are going toimpact them.
Madeline (28:09):
Yeah, that's right.
Medicaid goes by a number ofnames across the country.
That's part of what is soconfusing.
So, when I was in grad school,I was covered by MassHealth.
That's Medicaid.
In Massachusetts, Wisconsin, asyou said, calls Medicaid,
BadgerCare.
Tennessee calls it TennCare.
California calls it Medi-Cal.
(28:30):
And there are otherstate-specific names too.
So if you're not sure, Googlewhat your state calls Medicaid,
because it's very likely thatsomeone, if it's not you that's
covered by Medicaid, somebody inyour circle is.
And it's going to impact them.
Jennie (28:46):
Unfortunately, Medicaid isn't the only area where we're
going to see health impacts inOBBBA.
What else are we going to see?
Madeline (28:53):
Yeah, so we're also going to see a lot of cuts to
affordable private healthinsurance coverage under the
Affordable Care Act.
We expect to see an additional4 million people lose coverage
due to these cuts, theseAffordable Care Act cuts.
(29:14):
We expect to see some of thecuts that are in OBBBA in the
private insurance space, forexample, include removing
eligibility for affordablehealth coverage for lawfully
present immigrants who are underthe federal poverty line.
We see limits on the specialenrollment periods in the
(29:39):
marketplace.
For example, there's alow-income special enrollment
period that helps individualswho turn back and forth between
Medicaid and marketplacecoverage enroll in marketplace
coverage mid-year outside ofopen enrollment if they suddenly
(29:59):
become ineligible for Medicaid.
And that is a really criticalenrollment protection for people
with low incomes.
And there are a number of otherchanges to private insurance
coverage that will impactpeople.
We're also going to see the endof extended premium tax credits
(30:23):
at the end of this year thathave helped millions of people
access affordable coverage.
And so, health insurancecoverage is about to get a lot
less affordable for many, manypeople in the working class
across the United States.
Jennie (30:40):
Well, I'm glad you brought up starting who's going
to be impacted because I thinkthat's a really important
consideration we need to thinkabout is: who is going to be the
most impacted by all of thesechanges?
Madeline (30:51):
Yeah, I want to be perfectly clear that this is an
assault on the working class.
We expect that in the comingyears, 10 million people with
low incomes will lose Medicaidcoverage, that number 4 million
people for marketplace coverage,and with this coverage,
affordable access to sexual andreproductive health care.
(31:14):
And the down effects of losinghealth insurance coverage is
going to cost many members ofthe working class their lives.
A joint Yale School of PublicHealth and University of
Pennsylvania study estimatedthat OBBBA's health care cuts
together to Medicaid and privatehealth insurance access will
(31:35):
cause over 50,000 deaths a yearnationwide once these provisions
are implemented.
And we can expect these impactsto disproportionately impact
low-income care communities ofcolor, people with disabilities,
immigrant communities, andother underserved communities.
And again, I want to beperfectly clear what these cuts
(31:55):
are paying for.
This was not a bill that savedtaxpayers money.
It increased the national debtby trillions by both increasing
the national debt and cuttingthese essential programs in
order to finance tax cuts forthe ultra wealthy, expanded mass
(32:15):
deportations by ICE and otheradministration priorities such
as the federal takeover andmilitarization of DC and other
democratic states that we'reseeing right now.
That's what this bill is reallyabout.
We are also going to see anescalation in sexual and
(32:36):
reproductive health careproviders shutting their doors
due to increases inuncompensated care from this
bill, including hundreds oflabor and delivery units that
have been closing in recentyears.
That number is just going toincrease nationwide as a result
of this law.
(32:57):
Particularly in ruralcommunities, maternal health
care apartheid means that peoplemust drive hours, sometimes
crossing state lines, to accesspregnancy-related care,
intensifying the risk ofcomplications.
Medicaid expansion has had aprotective effect on provider
(33:17):
budgets, helping keep theirdoors open for the communities
that they serve.
And this isn't just, you know,Medicaid beneficiaries, but also
locals in these communitiesthat are served by these health
care institutions.
So if you think like, well, Idon't have Medicaid, I checked
and I'm not covered by Medicaidand I'm not covered by these
(33:40):
affordable subsidies under theACA that are being gut by this
bill, don't think that this billis not going to impact your
healthcare access because byreally attacking the budgets of
sexual and reproductivehealthcare providers, including
labor and delivery units, thisis going to impact your access
(34:01):
as well.
You know, we see that Medicaidexpansion has helped keep doors
open also for individuals inneighboring non-expansion states
who travel across state linesto access care.
So if you're in a non-expansionstate and think this isn't
(34:23):
going to impact me, that's nottrue either, especially if
you're in a rural area,especially if you're near a
state border.
Expansion decreasesuncompensated care.
It increases revenue.
It improves provider operatingmargins, especially for
providers and particularlyhospitals in rural communities.
And all of these cuts, workrequirements and more will
(34:46):
undermine these benefits.
Coverage losses from this bigugly bill are going to drive up
the rates of uncompensated care,narrowing operating margins and
forcing many to shutter theirdoors.
For example, our friends at theNational Partnership for Women
and Families recently found that140 rural labor and delivery
(35:09):
units nationwide are at risk ofclosure or service cutbacks due
to the Medicaid cuts.
So it is a lot.
This law is so far reaching.
I think it's so much worse thanthe vast majority of the public
is aware.
And I would say that's bydesign.
(35:31):
Democrats brought up aresolution to President Trump
and kept saying there are noMedicaid cuts in this bill.
There are no Medicaid cuts inthis bill.
And Democrats raised aresolution and tried to get
Republicans to vote on aresolution agreeing that there
would be no Medicaid cutsthrough this bill.
(35:51):
And out of the other side oftheir mouths, they said, no,
we're not going to do that.
We're not going to vote on thisresolution, but there are no
Medicaid cuts in this bill.
Well, there are $990 billion inMedicaid cuts in this bill.
And that's the reality that nowthe U.S.
public is going to have to livewith.
Jennie (36:11):
Yeah, I really think about, I mean, so much of what
you said but, like, you know,tying it to, like, personal
thinking; I grew up in ruralWisconsin, my mom still lives in
rural Wisconsin, the hospital Igrew up going to is considered
a rural hospital, and thinkingof how much further my mom would
have to go to access care ifthat hospital were to close...
(36:32):
like, these are real impacts onpeople's lives and it gets so
often just gets lost and talkingabout the numbers and stuff is
like these are people who aregoing to struggle to find access
to health care and when theylose their coverage.
Okay, so now that the bill hasbeen passed, people may feel
(36:52):
like there's nothing they cando, but I'm sure that's not
true.
What can our audience do to getinvolved in this?
Madeline (36:58):
There are so many important ways to engage.
One of the ways right now, manystates are convening special
legislative sessions to reallyfigure out what they're going to
do to make up budget shortfallsand start implementing these
And so, keeping an eye on thosesessions and their implications
(37:20):
for sexual and reproductivehealth is really, really
critical.
And engaging in the process isreally, really critical.
If you are a federal advocatelistening in, a lot of these
policies are going to have to gothrough CMS to be implemented.
So, engaging in administrativeadvocacy in the coming years,
(37:45):
Engaging in comment writing,engaging in meetings with the
Office of Management and Budget,and just really fighting as
hard as we can to ensure thatthese provisions are implemented
in the least harmful waypossible.
If you are a state advocateworking with your state Medicaid
(38:06):
agency to mitigate damage,including making sure that some
of the notices that will go tobeneficiaries informing them of
these changes are clear.
Meet federal requirements.
Meet best practices.
That's going to be reallycritical.
Partnering with communityorganizers and across a wide
(38:29):
range of stakeholder groups onoutreach to really get the word
out so that people understandhow they can keep their coverage
if they, in theory, could keeptheir coverage.
If they're going to be kickedout of coverage, it's really
important that people are awarewhen that's going to happen so
(38:51):
that they can go and get theservices they've been putting
off sooner rather than later.
So, outreach really, reallyimportant.
There are also really importantlevers for getting involved in
state Medicaid administrativepolicy.
One of these is the MedicaidAdvisory Committee, which is a
(39:12):
space that advocates can getinvolved to inform state
Medicaid policy.
There are also beneficiaryadvisory committees for Medicaid
beneficiaries to help shapeMedicaid policy in their states.
All of this really, reallyimportant.
And NHELP is committed toensuring that the broader sexual
(39:32):
and reproductive health rightsand justice movement has the
tools it needs to work togetherto really do as much damage
mitigation as we can here.
And so if you are interested ingetting involved, please reach
out.
You can also, if you'relistening in and are interested
(39:54):
in getting involved in advocacyin general, you can learn more
and sign up for and NHELP'slistserv for our advocacy
resources and alerts and alsoaccess pre-existing resources at
www.healthlaw.org.
We also have a landing page forour OBBBA implementation damage
(40:16):
mitigation resources, which isgrowing, including an incredible
chart that one of my colleaguesput together with all of the
implementation dates, becausethese cuts are going to be
hitting at different points.
And that chart is so valuablefor creating a work plan of what
needs to happen in the comingyears in the states and at the
(40:38):
federal level.
Jennie (40:40):
That's going to be so useful to have.
Madeline (40:42):
Yeah.
Jennie (40:42):
Madeline, thank you so much for being here.
today I had so much fun talkingto you about such terrible
things.
Madeline (40:49):
Thank you so much for having me Jennie and holding
space.
I know that you know these cutsare deeply personal to so many
of us and it's a reallyhorrifying reality to face and I
really believe that we have itin us to fight to hold the line
on as much as we can for as longas we can and ensure that these
(41:13):
are implemented in the leastdamaging way to sexual and
reproductive health rights andjustice possible.
Thank you.
Jennie (41:21):
Okay, y'all.
I had a great conversation withMadeline.
I hope you enjoyed it and havea wonderful rest of your week
and I will see everyone nextweek.
[music outro] If you have anyquestions, comments, or topics
you would like us to cover,always feel free to shoot me an
email.
You can reach me at jennie,J-E-N-N-I-E at
reprosfightback.com or you canfind us on social media.
(41:43):
We're at rePROs Fight Back onFacebook and Twitter or
@reprosfb on Instagram.
If you love our podcast andwant to make sure more people
find it, take the time to rateand review us on your favorite
podcast platform.
Or if you want to make sure tosupport the podcast, you can
also donate on our website atreprosfightback.com.
Thanks all.
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