The House GOP budget bill screws Medicaid expansion enrollees twice; do I hear three times??

Welp. House Republicans did indeed follow through with passing their horrific (and disgustingly-titled) "One Big Beautiful Bill" Act which will effectively repeal the bulk of the ACA without officially repealing it, and that's just for starters.

The final vote was 215 - 214, with every Republican except a handful voting for it (and the two who voted against it openly admitted to the NY Times that they would have voted for it if their votes had been needed), and every Democrat voting against it. There were 2 Republican "no" votes...but both of those were only because they wanted the final bill to be even more draconian.

The Congressional Budget Office projected the bill, if enacted, will result in at least 13.7 million more Americans losing healthcare coverage (and that was based on a prior version of the bill; the new version is even more extreme).

There's so many awful things included in the bill, many of which are of course healthcare-related, and it would take hundreds of blog entries to discuss them all...but I want to focus on one in particular.

Much has been written by myself and others about the so-called "work reporting requirements" which ~20 million Americans enrolled in Medicaid via ACA expansion would be forced to comply with on a monthly basis in order to remain on the program.

But what happens to those who aren't able to comply for any number of reasons (which will likely be at least several million people)?

Well, by definition these folks would earn less than 138% of the Federal Poverty Level (FPL), so they would fall into two groups: Those who earn less than 100% FPL and those who earn 100 - 138% FPL.

Those who earn 0 - 100% FPL would presumably fall into the same "Medicaid Gap" which nearly 1.4 million people are already in across 9 of the 10 states which haven't expanded Medicaid under the ACA in the first place: They'd no longer be eligible for Medicaid...but neither would they be eligible for federal subsidies via an ACA exchange plan.

That sucks to be sure...but what about those who earn between 100 - 138% FPL? Surely they should be eligible for heavily-subsidized ACA exchange plans, right?

Well...not so much. As explained by Sabrina Corlette, Karen Davenport, and Stacey Pogue at CHIRblog (the Center on Health Insurance Reforms):

The E&C bill cuts $715 billion from Medicaid and Marketplace coverage, including through Medicaid “work requirements” as outlined by our CCF colleagues here. It also extends those work requirements to the Marketplaces, by denying eligibility for premium tax credits to anyone who is kicked off Medicaid because of a work requirement. Denying affordable coverage to such people is cruel in its absurdity. Families must have at least some income (a minimum of $15,650/year for an individual, $26,650 for a family of 3) to qualify for premium tax credits, so anyone who qualifies is in a working household. This means that if they were disqualified from Medicaid because of a work requirement, yet have sufficient income to qualify for Marketplace coverage, it’s not because they weren’t working, it’s because they couldn’t navigate the red tape required to prove they were working.

Let's say you're a single adult working 100 hours/month (well over the House GOP's reporting requirement minimum of 80 hours/month) in, say, Massachusetts, where the minimum wage is $15/hour. That's $1,500/month, or $18,000/year...around 115% FPL.

If Massachusetts was a non-expansion state, you wouldn't be eligible for Medicaid, but you would be eligible for a heavily-subsidized ACA exchange plan (fully subsidized this year; mostly subsidized next year, assuming Republicans let the IRA subsidies expire, which is virtually guaranteed at this point).

However, since Massachusetts has expanded Medicaid, you're eligible for that instead...unless you screw up your monthly work reporting requirement (or there's a glitch in the system) and you get kicked off.

Under the House Republican bill, not only are you no longer enrolled in Medicaid, you also aren't eligible for ACA subsidies, because technically speaking, you're still "eligible" for Medicaid...even though you were just kicked off of the program.

This seems to be the section of the bill which makes this the case (h/t to Louise Norris for finding the legislative text):

B) Other provisions.--For purposes of section 36B(c)(2)(B) of the Internal Revenue Code of 1986, an individual shall be deemed to be eligible for minimum essential coverage described in section 5000A(f)(1)(A)(ii) of such Code for a month if such individual would have been eligible for medical assistance under a State plan (or a waiver of such plan) under this title but for a failure to meet the requirement to demonstrate community engagement under paragraph (1).

The second part is clearly referring to people who get kicked off of Medicaid expansion for not meeting the reporting requirements.

The first part is admittedly a bit murky. Section 36B(c)(2)(B), which is all about the Advance Premium Tax Credit (APTC) formula & eligibility, says this:

(B) Exception for minimum essential coverage

(i) In general: The term “coverage month” shall not include any month with respect to an individual if for such month the individual is eligible for minimum essential coverage other than eligibility for coverage described in section 5000A(f)(1)(C) (relating to coverage in the individual market).

In other words...assuming I'm interpreting this correctly...you're not eligible for APTC subsidies if you're eligible for Medicaid...even if you were kicked off of Medicaid.

In other, other words, under the House Republican bill, expansion state enrollees who earn more than 100% but less than 138% FPL could be in a worse predicament than if they live in a non-expansion state.

Let that roll around in your head for a moment.

But I also want to address a third potential disaster which might be faced by low-income residents of several states in particular: California, Massachusetts, Rhode Island, New Jersey as well as the District of Columbia.

You see, while the federal "shared responsibility provision" (aka the ACA's "individual coverage mandate penalty") was zeroed out more than five years ago, CA, MA, RI, NJ & DC still have their own state-level versions of it in place.

• California
• District of Columbia
• Massachusetts
• New Jersey
• Rhode Island

The specifics vary in each, but as an example, here's the details for California:

Starting in 2020, California residents must either:

• Have qualifying health insurance coverage, or
• Pay a penalty when filing a state tax return, or
• Get an exemption from the requirement to have coverage.

The penalty for not having coverage the entire year will be at least $900 per adult and $450 per dependent child under 18 in the household when you file your 2023 state income tax return in 2024. A family of four that goes uninsured for the whole year would face a penalty of at least $2,700.

The penalty will be applied by the California Franchise Tax Board. For information about the penalty, including the amount your family could owe for not having coverage, visit the Franchise Tax Board’s website and use their Penalty Estimator Tool.

Now, my guess is that someone in the situation I describe above would qualify for one of these exemptions:

• Income below the state tax filing threshold (you may still choose to file taxes and are required to if you received financial help to lower your monthly premium payment).
• A short coverage gap of three consecutive months or fewer.
• Health insurance is unaffordable, based on actual income reported on your state income tax return when filing taxes.
  • Cost of the lowest-cost Bronze plan through Covered California or the lowest-cost employer-sponsored employee-only plan is more than 8.17 percent for the tax year 2023, 7.97 percent for tax year 2024, and 7.28 percent for tax year 2025.
• General Hardship
• Affordability Hardship

...but even if that's the case, it still adds more paperwork, more red tape and more opportunities for denials, misunderstandings, computer glitches and other types of screw-ups to occur...right as you've just lost your healthcare coverage and are scrambling to find some way of paying your medical bills.