Unpacking the Health Impacts of Republicans’ ‘Big Beautiful Bill’

Dan Gorenstein (DG): Hey, it’s Dan. This week, we’re doing something a little different: Tradeoffs, live!

Last Wednesday, June 18 I moderated a virtual event about what’s shaping up to be one of the most consequential health care stories in the last decade.

News Montage: Lawmakers are one step closer to delivering on President Trump’s agenda… // It’s crunch time in Congress as Republican Senate leaders try to shape the president’s so-called “Big Beautiful Bill.”

DG: The legislation, currently working its way through the U.S. Senate, would cut nearly $1 trillion in health spending over the next decade and leave millions of people uninsured. New research predicts that this package of health policies would lead to some 51,000 preventable deaths each year.

We brought together a panel of leading doctors and economists to help us unpack these eye-popping estimates, and we found it so useful that we wanted to share it with you.

Today, why experts believe Republicans’ big bill could cause so many people to lose their insurance — and why that could be deadly. From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: The conversation you’re about to hear was recorded live and has been edited lightly for length, clarity and sound quality.

Thank you for joining us. I’m Dan Gorenstein, the founder and executive editor of Tradeoffs. If you’re new to Tradeoffs, we’re a nonprofit newsroom that covers health care’s toughest choices. 

All year long, policy change under the Trump administration and Republican Congress has moved at a breakneck pace and with a massive scope. At times, it’s been hard to make sense [of] — let alone to assess — the consequences of the news. That’s why we’ve partnered with our friends at the Leonard Davis Institute of Health Economics at the University of Pennsylvania for a series of conversations called Decoding the Moment. 

LDI is Penn’s hub for research on health care delivery, health policy and population health. They have more than 500 research fellows who are national experts and thought leaders on health and health care in America. 

One of the most consequential health policy things happening in Washington right now, of course, is the debate over the Republicans so-called Big Beautiful Bill. The legislation, currently working its way through the Senate, would cut nearly $1 trillion in health care spending over the next decade. And the nonpartisan Congressional Budget Office estimates it will push some 11 million people off their health insurance. On top of that, Republicans in Congress so far have not included an extension of the enhanced subsidies for Obamacare plans. Those are set to expire at the end of the year. The CBO says that will put another 5 million people off of their private health insurance.

16 million people becoming uninsured over the next decade would be an unprecedented shock to the health care system, impacting states, hospitals, insurers and, of course, people. And I’ll just note, as many of you know, the Senate this week proposed making even deeper health care cuts. This is obviously moving quickly, and our conversation today will be based largely on the bill that was passed by the House earlier in the month. 

We asked for your questions in advance, and nearly 100 of you submitted them with your registration. Thank you so much for that. And it speaks to the deep, deep interest here and the stakes. We’ll hit a handful of them over the next 40 minutes. And please talk up the other folks in the chat. We know that there’s a lot of expertise on the call, and we hope that part of what we can do through these events is to help you all connect and learn from each other. To initiate that, I’d like everyone to jump into the chat now to introduce yourself with your name, what you do and maybe what you’re hoping to learn today. While you do that, I’m going to ask our three panelists to introduce themselves and talk for a second about their expertise. Rachel, please kick us off.

Rachel Werner (RW): Hey Dan, great to see you. Here I am Rachel Werner. I am the executive director of the Leonard Davis Institute of Health Economics. I’m also a professor of medicine and a physician here at Penn.

DG: Thanks, Rachel. Eric and Aditi, please introduce yourselves.

Eric Roberts (ER): Hi, Dan. Hi, Rachel. Thanks very much for having us. My name is Eric Roberts. I’m faculty in the Division of General Internal Medicine at Penn and a health economist by training. Much of my research focuses on Medicare and Medicaid policy issues, and in particular, coverage for people who have both known as dual eligibles.

Aditi Vasan (AV): I’m Aditi Vasan. I’m a pediatrician and health services researcher by training and an assistant professor of pediatrics here at Penn. Much of my research focuses on administrative burdens or the logistical challenges that can make it harder for folks to access benefit programs.

DG: Thank you all for joining us for this very important, consequential conversation. So as I understand the bill, the bulk of the federal savings comes from fewer people having health insurance — Medicaid in particular. Before we get into the research, Eric and Rachel, you guys have done estimating the deaths those changes could lead to, let’s talk a minute about why we think people will lose their Medicaid in the first place. Now, Republicans have framed this legislation as a way to rid Medicaid and to some extent, the ACA, of waste, fraud and abuse. So you’ve got one provision, for example, that sounds perfectly benign: more frequent eligibility checks.

Aditi, this is your area of expertise. Can you walk us through why, based on the evidence, a wonky reform like this will almost certainly push some people off of Medicaid?

AV: Yes, thanks for that question, Dan. I think the evidence on this is clear. More frequent eligibility checks for a program like Medicaid create paperwork barriers that push folks off coverage. Studies have found that about 1 in 10 Medicaid enrollees experience coverage gaps where they lose coverage and then regain their coverage within a year. And it’s estimated that 70 to 90% of coverage gaps — or churn — in benefit programs happens at the time of recertification. That’s because recertification can be a really confusing process for beneficiaries. 

People who are still eligible for Medicaid can lose coverage because they don’t know how the renewal process works. They don’t get a renewal notice in the mail, or they don’t respond to their renewal notice and complete all the needed paperwork in the required time frame, which can be as short as 10 days. If you’ve ever had a stressful period in your life when it’s taken you more than ten days to pay a bill, or you’ve accidentally lost something in a stack of mail, you see how easy it can be for these folks to lose access to Medicaid. 

The COVID-19 pandemic provided a sort of natural experiment that actually let us study how we might reduce churn. And we saw that when Medicaid recertification was paused due to the pandemic and those administrative hurdles were removed, more children and adults stayed covered. We’ve also learned a little bit about the downstream benefits of staying continuously covered. In a recent study, my colleagues and I found that continuous coverage during the pandemic was associated with a decrease in unmet health care needs among publicly insured kids in particular. So, as you said, Dan, although House Republicans have framed the bill in terms of reducing waste, fraud and abuse, the evidence really doesn’t support that claim. Most people who lose Medicaid at the time of recertification are still eligible for the program, and so conducting eligibility checks every six months is unlikely to reduce fraud or abuse, and is in fact, very likely to both increase paperwork burdens for states who will have to process this recertification paperwork much more often and result in coverage loss for administrative reasons.

DG: And Aditi, how clear is the evidence on this?

AV: I think the evidence is clear. We know, again, churn happens to 1 in 10 Medicaid beneficiaries every year, and much of that happens at the time of recertification. So it stands to reason that if you double the frequency at which folks have to recertify, that’s going to be many more folks churning on and off of benefits.

DG: Okay. Please.

RW: Sorry to interrupt. I just wanted to sort of emphasize the excellent framework that Aditi laid out and say, like, the problem currently without even these proposed changes is a real one, and it really prevents people from getting care that they need. 

And so just to give you an anecdote, there was a patient admitted to the hospital a few years ago who was uninsured. Over the course of their hospitalization, it came to light that the person had metastatic cancer. And what that person really wanted to do was to go home and get hospice at home and sit in their backyard and feel the grass on their feet. 

But in order to get that, that person needed to be enrolled in Medicaid. In order to be enrolled in Medicaid, they had to prove their income eligibility. In order to do that, they had to find their pay stubs. But the patient at this point was confused because of their metastatic cancer, [and] was unable to tell their family members and their friends where the pay stubs were, and so was unable to get onto Medicaid. And so this is a real burden for people often at their most vulnerable point when they need care the most. And we’re really preventing people from not only getting the care that they want and need, but also it’s wasteful in this particular case [because we’re] requiring this person to stay in the hospital until he passed away.

DG: Right. And so that’s interesting, Rachel. So what you’re saying is, rather than this person being able to go to hospice, and be at home — feet on the lawn — they ended up being in the hospital — a much greater cost to the federal government than being on hospice.

RW: Yeah. I mean, we could debate who paid for that cost when he was in the hospital because they were uninsured and that, you know, gets into probably another conversation, but yes, [it’s] a greater cost to society. 

DG: Okay, great. Very good. Thanks for that anecdote. And everybody — speaking to the audience here — I asked Eric and Rachel and Aditi for anytime they’ve got an anecdote to jump in. We’re going to get really wonky in this conversation — and I’m sure many of you are here for that — but I also want to say it’s these stories sometimes that really can be very powerful for folks. So thanks for that, Rachel. A+.

So Aditi, I want to talk about work requirements with you [and] what may happen as a result of work requirements. Under the legislation, many millions of people would have to either work or look for work, be in school or volunteer 80 hours per month to be eligible for Medicaid. A few states have tried this, including Arkansas in 2018. In just six months in that state, 18,000 people more lost their Medicaid coverage. What do we know about why people lost their coverage?

AV: Yeah, we know that for most of those 18,000 people — so about 85 to 90% of the folks who lost coverage — coverage loss was actually due to administrative or paperwork burdens, and not because they weren’t meeting work requirements. Almost half of all beneficiaries in survey studies said they didn’t know about the work requirement, and many of those who did know actually had trouble navigating the really complex online system that the state had set up for reporting their work hours. 

This system required broadband internet access. It wasn’t mobile friendly, and it actually had limited hours of operation, so you could only access it during the day and not on nights or weekends. So there were a lot of hurdles that folks had to jump through just to report their work hours. Studies found that most people who lost coverage either were already working but couldn’t navigate the reporting system, or should have been exempt from the work requirement — for example, because they were the only caregiver of a severely disabled child or because they were disabled themselves — but they couldn’t navigate the system to get an exemption. And Tradeoffs actually recently shared this really heartbreaking story of Adrian McGonigal, who was a 40-year-old worker at a chicken plant in Arkansas and lost Medicaid coverage despite having a full-time job because he only logged his work hours once. He knew he had to log his work hours; he managed to navigate the system and reported them; but he didn’t realize that he had to keep going through that process every single month.

And after he failed to log his hours, he actually lost his Medicaid coverage. And when he lost coverage, he lost access to medications he needed and he started to get sick more often. He, in fact, got sick so often that he lost his job and became unemployed. And just a few years later, he died of a heart attack at the age of 46. 

This is a death that potentially could have been prevented if he had had consistent access to insurance and been able to get the health care he needed. So I think those stories really put this in context. These are real people who are working and are doing all the right things, but are losing coverage for administrative reasons. I think it’s also important to stress that we learned from Arkansas’s experience that work requirements didn’t increase employment. The data shows that about 92% of Medicaid insured adults are either working or qualify for exemptions like caregiving responsibilities, illness or disability. So imposing work requirements adds burdens that can be really devastating for patients’ health and access to care without the benefit of actually increasing workforce participation.

DG: Thanks for the plug of the story but also, more importantly, thanks for covering so much ground in your answer, Aditi. I think that sometimes it can be easy to focus on one side of the equal sign when the debate is over work requirements — and that is should people work or should they not work? And as you pointed out, the evidence shows overwhelmingly many of these people are already working. But the piece that gets forgotten that you alluded to at the top of your answer is the reason people lose their coverage is not because of failure to work, but because of these administrative burdens. And just to sort of put a finer point on that, when we talk about administrative burdens, the states need to have a kind of infrastructure that makes it easy enough, intuitive enough, for people to actually sign up. Can you speak to how that might sound easy, but can you speak to [how] that’s actually a challenge for states?

AV: Yeah, that’s exactly right. So states essentially have to set up a whole new system that allows people to report their work hours, not just once, but at the required frequency, whether that’s weekly or monthly. Folks have to log into the system. They have to be able to report and prove their work hours. And then states have to have someone at the other end in charge of processing this reporting, identifying errors, and then either following up with the beneficiary to tell them you need to report your hours differently or cutting off their coverage if it turns out they don’t meet the requirements. 

So that’s a huge amount of information that states aren’t currently receiving or processing that they quickly have to develop a system for receiving, processing and then translating to changes in benefits. And so I focused on the burden for patients, which is immense. But this is also essentially an unfunded mandate to states to put together complex administrative systems to gather and act on this data.

DG: Thanks for calling that out — the unfunded mandate. Okay, next question here. 

The bill also makes some changes that would make it harder for people to enroll or stay enrolled in private insurance through the Obamacare marketplaces — things like shortening enrollment periods, limiting automatic re-enrollment, narrowing eligibility for subsidies for lawfully present immigrants. Julius Wool in our audience is curious about these changes, which again conservatives say are necessary to curb fraud. Aditi, are the same principles you talked about in Medicaid why researchers expect 3.5 to 4 million people to lose ACA coverage if this bill was passed?

AV: Yeah, patients covered through ACA marketplace plans face many of the same administrative burdens as Medicaid beneficiaries. But I’ll highlight that there are actually sometimes added complexities for them to navigate when accessing coverage. 

So, if you lose your Medicaid coverage despite still being eligible, you can re-enroll at any time during the year. For ACA plans, though, there are these very brief annual open enrollment plans when you’re supposed to sign up. Right now, that’s about 10 weeks of the year, and the bill actually would shorten that to only six weeks. And so beneficiaries who lose coverage might have to miss these open enrollment windows and then navigate a more complicated process to re-enroll. Or they might face really significant premium increases or changes in their subsidies when they try to enroll. And that all makes it more likely that they’ll transition from a marketplace plan to uninsured, and lose their access to care entirely.

DG When we come back, two of our panelists explain why they’re estimating that this bill could lead to 51,000 preventable deaths a year — and how they landed on that number. 

MIDROLL

D: Welcome back. You’re listening to a live conversation that I moderated on June 18 with University of Pennsylvania experts Rachel Werner, Eric Roberts and Aditi Vasan about the likely health impacts of Republicans’ so-called Big Beautiful Bill. 

The nonpartisan Congressional Budget Office estimates that this legislation would leave 11 million people uninsured over the next decade.

DG: So, Rachel, you and Eric looked at what’s going to happen as a result of some of these people losing their coverage. You all worked with folks at Penn and at Yale looking at a couple of provisions in the bill looking at the potential mortality impacts. Let’s start by talking about the people who would end up uninsured. Between provisions in this bill and not extending the Obamacare subsidies, you estimate we’ll see some 20,000 preventable deaths each year. Before we talk about how you got those numbers, just a quick definition, Rachel — what does preventable deaths mean?

RW: Sure. Thanks, Dan. So, I think it means what it sounds like, which is, you know, we all are going to die. That’s sort of a uniform thing that we face. Some deaths are preventable if people get the right care, medical care at the right time. When that happens, we can prevent death or, you know, at least delay death. Other deaths are not preventable. And so what we were interested in the work that Eric and I did with our colleagues here and at Yale was to try and estimate not all deaths, but just the ones that could be prevented from Medicaid or other types of insurance.

DG: Great. Thank you for that definition. So now, at a high level, can you describe — no weeds, Rachel, no weeds — can you describe how you got to these numbers?

RW: Yes. You can anytime you see a weed, just stop me.

DG: Will do.

RW: Okay, so let me just back up and say, right now, there are over 70 million people enrolled in Medicaid, approximately. This bill that was passed by the House would decrease enrollment in Medicaid by around 7.7 million people. That’s one group. We know from all of the things that Aditi talked about — including increased administrative burden, making it harder to get on and stay on Medicaid and also decreased funding for Medicaid — that 7.7 million people approximately would lose coverage. 

We also know a lot about the relationship between having insurance coverage through Medicaid and how likely you are to die. And so there’s been a lot of research, a preponderance of evidence, I would say, that insurance — particularly Medicaid insurance — saves lives. And there’s a lot of different estimates out there and they range, but Medicaid saves for every 1000 people, somewhere between 1 and 4 lives per year. So, we basically just did the math. We said, okay, if 7.7 million people — this is actually Yale that did this math — are going to lose coverage and we approximately know how much that is associated with death, that’s going to result in around 11,000 deaths. 11,300 deaths per year. 

Then there’s another piece of it. You said around 20,000 deaths and so that’s only 11,000 deaths. The additional piece was that it’s not just about what is in this bill and the cuts to the Medicaid program they’re going to make. They’ve also left out some things from the bill that are very important…

So just to give a little bit of background, in 2020, Congress provided subsidies for health insurance that’s purchased through Obamacare. This made health insurance much more affordable for many low-income adults in this country, and it increased the number of people that are insured by probably around 15 million or so. Just to give you like a little bit of a snapshot of how important this was, it used to be that if you bought your coverage through Obamacare, only about one-third of those people were able to get coverage for less than $10 a month. Now, with this subsidy that’s currently in place, about 80% — so over three quarters of people — can get coverage for less than $10 a month. So that really made a big difference. A lot more people were able to buy coverage through Obamacare than would have been without these subsidies. These subsidies have been extended once already. They are currently set to expire this year in 2025. And this bill that we’re talking about did not include another extension of these subsidies. 

So the expected result of not extending these subsidies would be another 5 million people will lose coverage on top of the 7.7 million people I already talked about. And so when you add the deaths expected from those 5 million people, it’s an additional 8,800 deaths and so you get to this number of 20,000 deaths approximately.

DG: Great. Thank you for walking us…

Eric Roberts (ER): Dan, could I just jump in really quickly? I just wanted to add a little bit of context here. So Rachel is alluding to sort of 1 to 4 fewer deaths per 1000 people. That sounds like a small number, but on a baseline mortality rate of 2 or 3% in this population, if we were to remove coverage for people, that would lead to — in relative terms — a 15 to 20% increase in deaths that would have been prevented by giving people insurance. [That] is a really large number when you think about the scale of the population that’s covered by these programs. 

The other thing I would just point out here is that in 2024, there were about 25 million Americans who were uninsured. So if you add up all of the pieces of this bill, including the failure to extend the enhanced marketplace subsidies that Rachel alluded to, and you add 16 more million people to the uninsured population in the U.S., that’s a 60% increase in the number of people who are uninsured in the U.S.

DG: Thank you. Thanks for that number, Eric. And just a quick follow-up on that: Math can be really tricky for a lot of folks, so when you say 60% what does that — in layman’s terms — mean to you?

ER: Yeah. So that means that your family member who may be working a part-time job or a job that doesn’t offer employer-sponsored insurance has to make the painful choice between paying a much higher premium or going without insurance. Going without insurance may mean they go without seeing their doctor or their dentist. It may mean that for those of us who are struggling with substance use disorders like opioid use disorder, it’s not getting treatment for that disorder and potentially risking, you know, health complications and ultimately mortality from that. It could even be children who are affected. We know there’s good evidence from research that when parents don’t have access to health insurance and health care, their children are more likely to go without — even if those children have health insurance. This is sort of an ecosystem, and if you pull health insurance out from parts of it, there can be waterfall effects that are felt throughout families and communities.

DG: Thank you for that. Rachel, I just want to follow up. I mean, a lot of the work that you all have done is based on the estimate  — nothing untoward here — but it’s based on the estimates that you’ve gotten from the Congressional Budget Office of how many people are going to lose insurance. Estimates are a fancy word for guesses — educated guesses but guesses. And some experts, particularly conservatives, have pointed out that the CBO can get things wrong — as one would expect from projecting impacts of complex legislation. How confident are you in these estimates from not the CBO estimates, but your own estimates, knowing that they’re built on these estimates from the CBO? How should we think about them? How should we take them both with a grain of salt and take them seriously in your own mind as a researcher?

RW: Yeah. I mean, so as you said, these are just estimates and sometimes we call these back of the envelope calculations because we’re quickly trying to understand how to put the numbers together to provide a summary number. I am pretty confident that we are in the ballpark. And there’s a few reasons that I am confident. 

One is that there have been other groups that have done the same sort of exercise we have, but using a different approach and slightly different numbers that have come up with very similar estimates of the number of people who will die when disenrolled in from Medicaid. And so, for example, there’s an article that just came out on Monday in the Annals of Internal Medicine that through the same basic exercise. They found a range of estimates from about 8,000 to 24,000 so we’re at the low end of that range, which is reassuring to us. 

The other thing I think about is that, as you said, the CBO numbers are imperfect. They are also estimates. And there’s a lot of things you have to assume to make those estimates. I think that the CBO may be underestimating the number of people who are losing insurance. There [are] a couple of reasons I think that. 

One is that the work that they’ve done showing the number of people losing insurance through the work requirements — I think among people who are experts in work requirements, people think that those are very low end numbers — and so we might expect even more people to lose coverage when work requirements are implemented. The other thing the CBO does, which is a reasonable thing to do, but they have to make some sort of guess about how much if the federal government pulls back on funding of Medicaid, they have to make some guess of how much states are going to make up that funding because right now Medicaid is funded partly through the federal government and partly through states. The CBO sort of took a mid-range estimate and said states are going to make up about half of that money. I think that that is a long shot. States budgets are very tight right now. Some states may be able to make up half of what they lose from the federal government, but I think it’s not a stretch to say most states can’t. And so if the funding that’s available for Medicaid goes down more than the CBO estimated, more people are going to lose access to coverage. So I think that I’m pretty confident that we are at the low end of the right ballpark.

DG: Okay, thank you for walking us through that and showing your work. I think that in this moment when there’s so much information, I think you all explaining your work and your process helps lay things out and demystify it. So I really appreciate how open you all have been to actually breaking it down like this.

When you put your research, Eric and Rachel, when you put your research together — the coverage losses and other elements of the bill that we’ll get into shortly — you estimate in total, 51,000 people will suffer preventable deaths each year as a result of this legislation. I know we’ve been talking about 20,000, but there’s some other provisions here. 

To put that 51,000 into context, that’s about the same number of people who died of COVID in 2023. It’s 7 or 8% the number of people who die every year from heart disease and cancer. I’ve let you guys wonk out a lot here. We’ve talked about a lot of numbers here, but I want to talk to you as individuals, but particularly you, Rachel, I know you’ve spent a good chunk of your career thinking about policy and policy implications — why was it important to you as a person, as a researcher, to quantify how many people could die based on what Congress is considering?

RW: Yeah. I mean, Dan and I were having a text exchange about this this morning, and he asked me that question and I said, “Well, I’m a doctor.” And I think preventing deaths is what we are interested in as humans and also as doctors. And somebody put in the chat, “One preventable death is enough.” You know, you said that this is 7 or 8% of all deaths related to heart disease and cancer — the way I think about this number is that it’s equivalent to the number of people who die from colon cancer every year in this country. Those are deaths that we can’t prevent. Often those are deaths that we throw the best treatments, the most state of the art technology at people, and we still can’t save their lives. The 50,000 deaths that we’re estimating here, actually, there’s a very simple solution to prevent them. And I think that is to give people insurance. And I think that the reason that Eric and I and our colleagues wanted to use deaths to understand the impact of this bill is because it’s a really salient thing. Everybody understands that preventable deaths should be prevented. And there’s a very simple solution to it, which is Medicaid.

DG: And how about you, Eric? Why did you want to do this? Why did you want to talk about the mortality effects?

ER: Similar to Rachel, it’s a salient outcome, but it’s also one where if you think about although death is ultimately unavoidable, deaths that occur in early or middle life or even into one’s 60s mean that there are years of potentially productive, valuable life that individuals are not enjoying and not contributing to society to their families. We think about sort of the dollar and cents costs of health coverage, but there’s also a social cost to losing individuals too early who can’t engage in society and contribute meaningfully. And there’s good evidence even from Medicaid that when you give coverage especially earlier in life to individuals, not only do they live longer, but they engage more productively in education and in work and other things — and so society is losing something when we lose individuals prematurely.

DG: Great. Thank you for that. And Eric, a question for you. We’ve talked to conservative health economists in our reporting over the past several months who question the value of Medicaid for improving health and even say that we lack good evidence that having health insurance improves people’s health. They point to the famous Oregon Medicaid experiment, which found that people who received Medicaid did not have better health outcomes compared to similar people who did not have Medicaid. At its core, your analysis relies on the idea that going without insurance can be deadly. Can you give us a short history of how the research has evolved since Amy Finkelstein and Kate Baicker released that paper however many years ago?

ER: Yeah, so we’re coming up on probably the 12th anniversary of the Oregon Health Insurance Study. And I think if you had polled health economists around that time or in a window of that time, the consensus would have been that maybe health insurance improves health but the jury was still out. Now, the answer is an unequivocal yes. And the unequivocal yes arises from a body of evidence that has built up from multiple independent studies that have looked at the Affordable Care Act Medicaid expansion as a natural experiment, efforts to enroll people in marketplace coverage [and] effects of gaining Medicare when people turn 65. The consistent theme across these studies that has developed in the last 15 years is that health insurance has widespread benefits for health and saves lives. 

The reasons are pretty intuitive and are borne out in the evidence. Getting someone insurance allows them to get screened for diseases like cancer. It’s a major source of providing people with treatment for the opioid epidemic that this country has wrestled with. It allows people to get medications to manage their chronic conditions. And so if you suddenly pull back all those resources that have been allowing people to get the care they need, the evidence is very clear now that we will lose lives.

DG: Thank you. So let’s move on to the second provision that you all looked at, which was how this bill could have deadly consequences for people who keep their coverage, or at least some of it. There are lots of headlines now making the rounds talking about President Trump saying he wouldn’t touch Medicare, but now he is touching Medicare. What we’re about to get into will help give people some more context for this. 

Several folks in the audience, including Judy Strait-Jones, asked how the bill could impact Medicare. Here’s the background that’s helpful. So, Eric, you looked at the 13 million Americans who are eligible for both Medicare and Medicaid. These are people who have low incomes and are also either disabled or over 65. Some of those 13 million people check all three of those boxes. These folks are called the duals or the duly eligible because they are enrolled in both federal programs, Medicare and Medicaid. 

And those people — the duals — get extra help [through] Medicaid to pay for their prescriptions — about $6,000 a year on average. I realize you guys are sticking with me here, and I’m talking to you in the audience here. I know the panelists are with me. The Biden administration now passed a rule that was intended to make it easier for people on Medicare to sign up for Medicaid. Eric, not talking about your research, just talking about the Biden administration move here: What was the problem the administration was trying to solve with this fix?

ER: The problem was red tape. In its essence, older adults and people with disabilities had an onerous Medicaid application and renewal process. So, unlike working-age adults who needed to just show proof of income, older adults needed to go through a more complex income and asset test, and it requires individuals to itemize their assets. I have a family member who is a duly eligible individual, and I looked at his Medicaid re-enrollment form and it was 17 pages long. You can imagine that for older adults who may lack social support or other resources — many of whom might be suffering from memory decline — this kind of application complexity just makes it harder for people to enroll in Medicaid benefits that they actually qualify for. And we know from research that only about half of low-income Medicare beneficiaries who qualify for Medicaid actually are enrolled. And so the point of these rules was to lessen that burden so that more eligible people could receive benefits for which they’re eligible.

DG: Thank you. And one of the small changes nestled into the massive bill is a provision that would delay implementing that rule that you just outlined until 2035. The CBO estimates that will lead to 1.3-plus million people — fewer Medicare beneficiaries being able to access Medicaid. Based on your research, what’s the fallout from that 1.3 million fewer Medicare beneficiaries being able to access Medicaid?

ER: Yeah, so there’s a number of consequences. First is that those individuals are likely to have much higher out-of-pocket costs when they go to get services covered by Medicare. For dually eligible individuals, Medicaid covers copays when you go to the doctor or the hospital, and so a doctor’s office visit that you normally wouldn’t have to pay for with =Medicaid, you might have a $20 or $30 copay. For an individual in this population where most have incomes less than $15,000 per year, these kind of copays add up and they’re financially burdensome. 

Another consequence of losing Medicaid or going without is that individuals don’t get help with their prescription drug costs. And in recent research that Rachel and I did, we found that individuals who don’t get help with their drug costs because they don’t have Medicaid are more likely to die. And that increase in deaths ranged in our estimates from about 4 to 22%, depending on the sickness of individuals and the types of drugs they were using. 

And I just really want to be concrete about this so we sort of get to sort of the personal level and away from sort of the abstract level. Think about an individual who is taking an inhaler to manage their asthma or chronic obstructive pulmonary disease. About 1 in 6 people on Medicare has a chronic lung disease, so this is pretty common. The typical out-of-pocket cost for an inhaler can range from $30 to upwards of $100 each time someone fills that prescription. When they get help with their drug costs, that out-of-pocket cost is capped at no more than $10 per fill. So imagine a person going to the pharmacy used to paying $10 to refill a medication, and now they’re being asked to pay $100 to fill an inhaler. It’s very likely that this person is not going to be able to afford to make this copay and so they face this kind of heartbreaking choice, potentially, between filling medications they need or going without to pay for other necessities. And this is one of the reasons why we find really strong and sizable mortality effects of not having Medicaid coverage in this population.

DG: Thanks, Eric, and Rachel, did you want to jump in?

RW: I wanted to add one thing about Eric’s research and why it’s so important, which is that you brought up the conservative voices who doubt the relationship between insurance and mortality and I think part of what Eric’s research does is explains why there is a strong relationship between insurance mortality. It’s because when people don’t have access to their drug coverage or their drugs, they die. And so I think it’s really important in part because it just helps us explain why Medicaid is so important.

DG: Right. What you’re saying, I think, Rachel, is it’s not only just sort of this idea that insurance is important, but it shows us more of almost a causal link. 

RW: Yeah. 

DG: And would you say, Rachel, in your mind, since the Oregon Medicaid experiment, that it’s becoming clearer [and] we’re understanding the mechanism of why this is working?

RW: Yeah. I mean, I would say that I am super confident about the relationship between mortality and insurance, and that insurance prevents death. I think we are starting to understand more about why that is true. Part of it’s medications, part of it’s sort of the economic spillovers of having these benefits — I was about to get very wonky on you, so I’ll just leave it there.

DG: Thank you for catching yourself. So there are two final questions. I know we have about two minutes left. We’re going to get to both of these questions and I hope most of you all stick around. This has been an amazing conversation. 

Rachel, there’s a last piece of this analysis that you and Eric did that looks at another delayed Biden rule. This one more people probably know about. It’s a rule that would increase the required staffing at nursing homes. The Republican bill would also delay this from going into effect until 2035. You estimated that this would lead to 13,000 extra deaths a year. Quickly, can you explain why?

RW: Yeah. So this was work I did with Norma Coe. There has been a long body of evidence showing that nursing home staff save lives. We have chronically had a nursing home system that has had many prominent examples of quality concerns. One of the approaches to fixing it is to improve increased nurse staffing levels. The Biden administration issued a rule to increase the minimum staffing levels. 

When the pushback started, which was almost immediately about a year ago, Norma and I wanted to help the public understand why this was so important. So given the current level of staffing within the United States and the known relationship between staffing and mortality, in a similar way we were able to estimate the number of people who would die if this mandate wasn’t put in place.

DG: Thank you. That was very quick. Final question to all of you. There’s been so much conversation about this legislation, much of it very politically charged of course. As health care researchers, what’s the most important thing you want people to hold on to as they think about what’s at stake in this bill? Aditi, let’s start with you.

AV: I’ll highlight that these changes aren’t eligibility reforms. They’re really barriers to coverage for people who are eligible. And the impacts that we’re talking about aren’t theoretical. We actually have good data from Arkansas and other states showing that administrative burdens and not actual eligibility are often what drive coverage loss. 

I’ll also highlight that while we focused our conversation today on Medicaid, the Republican bill will also impose significant administrative burdens on families accessing other programs like the Supplemental Nutrition Assistance Program or food stamps. And so working adults and working families with children are going to be hit really hard by administrative burdens across multiple sectors. There’s a lot at stake here for working families.

DG: Eric?

ER: I’ll just say quickly that this is not some sort of other population that’s being affected. As Rachel said, more than 70 million people are covered by Medicaid, [and] 20 million by marketplaces. They are our community members, our colleagues, in some cases, our family. And so, given the scope of these programs and the size of the changes being contemplated, the effects are going to be felt extensively and across communities and in many individual families.

DG: And, Rachel.

RW: So I would just like plus-one on both Eric and Aditi’s points. Medicaid touches millions of people in the United States. Two-thirds of people report knowing someone who has received benefits through Medicaid. Half of the people in the country — 1 or 2 people — have a family member or themselves who have received Medicaid. And so these administrative burdens, which the administration is selling as no major changes to the Medicaid program, create real barriers to enrollment. And it’s not just the dollars and cents that they’re trying to save. It’s really going to cost human lives at the end of the day. And so I think that is the take home.

DG: Thanks for sticking with us and giving this long, ‘live album’ like podcast format a try. If you’ve got feedback, we’re always happy to hear it at tradeoffs.org.

That’s also where you can subscribe to our weekly newsletter to learn about live events like this one and stay on top of all the health policy news coming out of Washington. Again, that’s tradeoffs.org

Thanks once more to the Leonard Davis Institute of Health Economics at the University of Pennsylvania for their partnership on today’s show. 

I’m Dan Gorenstein. This is Tradeoffs.