Last week, House Republicans in Congress moved their replacement plan for the Affordable Care Act through the Ways and Means Committee, finally providing some details after years of pledges to repeal former President Obama’s signature legislation.

Because they’re hoping to use the budget reconciliation process to pass the bill, which requires that every provision have a direct impact on the federal budget, the Republicans’ plan does not address many of the point-of-service concerns doctors have expressed about the ACA, such as burdensome documentation requirements for insurance reimbursement.

While local and state health care leaders are still waiting to see estimates from the Congressional Budget Office to assess the impact on tax credits and how many people would be affected, they are already concerned about the ways Medicaid would change under the American Health Care Act, as the replacement plan is called.

“Clearly there were things that needed to get fixed — that’s always the case in large-scale industry reform. Small businesses were suffering; people were struggling with high-deductible plans,” said Mary Kay Clunies-Ross, vice president for membership and communication at the Washington State Hospital Association. “We want any fix that’s going to make the health care system work better. But we don’t think that the proposal that was put forward is going to do that.”

Under the GOP proposal, federal funding for the Medicaid expansion that allowed low-income people earning up to 138 percent of the federal poverty level (about $33,600 per year for a family of four) to access free health care would be rolled back starting in 2020.

Washington is one of 31 states that expanded Medicaid, providing coverage to some 600,000 people. Under the GOP plan, those people would stay covered by federal funding, but the state couldn’t add any new people from the expansion population and anyone who lost eligibility couldn’t re-enroll.

“We’re most concerned about the number of folks who are on Medicaid and their ability to continue to be covered by Medicaid in the future,” said Jennifer Hanscom, Washington State Medical Association executive director. “And by the federal government scaling back its financial commitment to Medicaid in the future, what does that mean in terms of funding that comes into our state, and our ability in Olympia to make up that difference?”

It could have a huge impact on the state budget, she said.

“We recognize that there are challenges with the ACA and areas where it can be improved. We just want to make sure that any modification to it doesn’t result in more people losing access to medical care,” said Dr. Shane Macaulay, Medical Association president.

If the GOP rolls back the Medicaid expansion without providing an alternative option for coverage for those patients, it will result in a drop in coverage for millions of people, he said. “The concern would be, the refundable tax credits in (the bill) would not be sufficient to keep up with the restrictions in coverage.”

The other significant change to Medicaid would be federal funding on a per capita basis, instead of the percent share the feds currently pay to supplement each state’s program.

That could put states in a bind if medical costs unexpectedly go up, while the per capita or “block grant” amount stays the same.

“If our state has a recession, or if costs were to rise because of expensive new medicines on the market, or a public health crisis happened — now, a state would get more money,” said Anita Monoian, CEO of Yakima Neighborhood Health Services, the lead agency in Yakima and Kittitas counties for helping people sign up for Obamacare. “But under the (GOP) proposal ... it would be the same amount of money and the state would have to figure it out on their own.”

That would likely result in cutting services, she said.

In recent years, the cost of curative drugs for hepatitis C presented that exact scenario, challenging state Medicaid programs to find a way to pay for treatment with a list price of nearly $100,000 per person.

If large swaths of the population lose access to coverage, the ripple effect would be felt across the health care industry and affect the health of communities overall, Clunies-Ross said.

“When you have huge numbers of uninsured people, their ability to access the health care system is dramatically different – they don’t have access to primary care, they don’t have access to maintenance for chronic diseases, and they end up in the emergency room,” she said.

More uninsured people also creates greater uncertainty for health systems wondering what services to invest in, if they don’t know whether patients will be able to access or pay for them anyway, she said.

“We don’t see a way forward to a more affordable and effective health care system if large sections of the community can’t access health care at all,” she said. “What we’re seeing ... is that this reduces the amount of covered individuals in our communities, and that’s the wrong direction.”

Health leaders will continue to watch and read as more details emerge in the coming days.

“Once the CBO numbers come out, then we can really start crunching locally and statewide what we believe would be the impact,” Monoian said. “Until then, it’s all just an assumption and a lot of white noise.”

Molly Rosbach can be reached at 509-577-7728 or

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