The U.S. House is expected to vote on a sweeping budget package this week that would enact the largest cuts to Medicaid and SNAP in program history—even before potential changes that could increase cuts and accelerate the implementation of provisions that will result in health coverage losses. This legislation breaks key promises made by President Trump and members of Congress: it enacts deep cuts to Medicaid and SNAP that will result in eligible people losing those coverage; it will raise grocery prices and health care costs for families; and, despite all that, it increases the deficit. Combined, the health coverage provisions are expected to result in an estimated 65,000 West Virginians losing their health coverage, a catastrophic outcome that could increase the state’s uninsured rate by the largest amount in history. Here’s why.
The Medicaid changes in the reconciliation package are expected to result in approximately 50,000 West Virginians losing health coverage (analysts estimate a coverage loss range of 37,000 to 62,000 based on some uncertainties about how the state would implement the requirements).
One provision, implementing work reporting requirements, would kick some adults off Medicaid if they do not submit proof showing they are working or qualify for an exemption, even though the vast majority of West Virginians do fall under one of those categories and thus, should remain eligible.
We do not have to guess what will happen under this system. Two states have implemented these requirements with deeply harmful results. In Arkansas, one in four people who were subject to the requirements lost coverage within the first year before a federal judge halted the program. Researchers found that nearly all of those who lost coverage were working or should have received an exemption, but they lost coverage anyway because the process was confusing and burdensome. In Georgia, enrollment in the state’s Medicaid expansion has been just 3 percent of those expected to sign up due to these requirements, with fewer than 5,000 Georgians enrolling due to complicated and burdensome reporting rules. And in both cases, enforcing the requirements required expensive technology and administrative capacity to enforce- increasing both bureaucracy and regulatory red tape.
Exemptions do not adequately protect people with disabilities or chronic health conditions. In Georgia, there is a multistep process to prove you have a disability exemption including taking a screening, attesting to your disability online, waiting for a phone call from an eligibility worker, conducting an interview, registering with the state’s rehabilitation agency, verifying with the Medicaid agency that you are registered with the rehab agency, then documenting continued compliance with the rehab agency.
These requirements pose a particular challenge for adults with substance use disorder, for whom being in active treatment is often a prerequisite for them to secure work. And while the legislative proposal instructs that adults who are considered medically frail, which includes having a chronic substance use disorder, should be exempt from these requirements, proving one qualifies for an exemption is a complex multi-step process as highlighted above that often results in eligible people losing coverage. Time spent on reporting compliance takes away from therapy compliance, creating a new barrier to recovery.
Additional provisions in the legislation, increasing the frequency of redeterminations and requiring co-pays to receive health care services, create the same challenges, and could result in more eligible people losing coverage or choosing to forgo needed care due to being unable to afford co-pays.
Expiration of Enhanced ACA Subsidies
As currently drafted, the reconciliation does not include an extension of the enhanced subsidies for ACA Marketplace plans, which are currently set to expire at the end of 2025. If these enhanced subsidies expire, an additional 15,000 West Virginians (with a range of 12,000 to 19,000) are expected to lose their health coverage as they will no longer be able to afford their premiums.
West Virginia would be among the states most impacted by the expiration of enhanced ACA subsidies, given the state’s highest-in-the-nation commercial health care costs. Enhanced ACA subsidies significantly increased enrollment on the marketplace, with 179 percent jump since 2020. Approximately 98 percent of enrollees receive a subsidy to help pay for the cost of health insurance, meaning over 50,000 residents would be impacted by the expiration.
