Just weeks after lambasting the Affordable Care Act repeal and replacement efforts as "terrible" and "mean," President Trump is now calling for something even meaner: repealing the ACA entirely and replacing it at a later date.
Repealing the ACA without replacing it would leave 32 million more uninsured by 2026.
Though delayed, the Better Care Reconciliation Act, the Senate version of the repeal, survives. It empowers states to apply for waivers to opt out of offering essential health benefits, defunds abortion providers like Planned Parenthood for one year, and offers smaller subsidies. Perhaps most devastatingly, the plan discontinues the Medicaid expansion and caps the Medicaid funding distributed to states to deprive the program of nearly $800 billion over the next decade.
Repealing and replacing the ACA with the Better Care Reconciliation Act would lead to an estimated 22 million more uninsured Americans by 2026, according to the Congressional Budget Office.
Withdrawing funding from abortion providers almost ensures that low-income Medicaid recipients will receive less medical care and be at heightened risk for unplanned pregnancies. Although the Senate bill offers more generous subsidies to poor Americans than those included by the House, the subsidies are still lower than those provided by the Affordable Care Act and are based on a less generous "benchmark plan" than that established by the ACA. As a result, Americans will pay more for less coverage.
Without the funding necessary to maintain the expansion, states will have no incentive to maintain the enhanced levels of participation and certainly no incentive to further expand their eligibility settings for Medicaid candidates. Additionally, the capped Medicaid funding per person would only be permitted to grow along with the medical component of the Consumer Price Index. The Center on Budget and Policy Priorities has indicated that the actual Medicaid costs will likely outpace those accounted for by the medical consumer price index (CPI) calculation. By 2025, the capped funding would grow only in accordance with the general CPI. Actual Medicaid costs far outpace those accounted for by the general CPI, amounting to major cuts to the program.
On top of all this, the Trump administration has separately proposed $610 billion cuts to Medicaid.
If congressional Republicans have begun to take a hammer to the social safety net, the Trump administration has complemented their work with a hatchet. The administration's budget calls for $191 billion in reductions to the Supplemental Nutrition Assistance Program, colloquially referred to as food stamps, and $21 billion in cuts to Temporary Assistance for Needy Families over the next decade under the guise of fiscal responsibility. The reality is that such reductions wouldn't even make a dent in the deficit: In fiscal year 2015, only around 10 percent of the federal budget went toward financing SNAP, TANF and other social safety net programs.
When it comes to sustaining the social safety net, every dollar is critical. In the absence of sufficient funding for SNAP and TANF, states will be forced to either tighten their eligibility standards, rendering currently eligible families and individuals ineligible, or reduce their benefit packages. The administration has already laid the foundation for such adjustments: The budget intends to limit SNAP benefits provided to families exceeding six members to those offered to families of six. As a result, a family of nine would be forced to live off of a little over $3 per day per person.
A number of Republicans have offered unrealistic advice to poor Americans in preparing for these drastic reductions. Representative Jason Chaffetz framed the situation as a matter of choices: "And so maybe rather than getting that new iPhone that they just love… maybe they should invest in their own health care." Such comments betray a misunderstanding of the nature of the health care landscape. Cell phones cost a few hundred dollars. Health care costs can run into the hundreds of thousands, potentially bankrupting families without insurance.
There exists a vast network of nonprofit service providers across the country that supports low-income Americans in their times of hardship. Charitable support for the vulnerable is a part of a long American tradition that dates back to the country's founding. Almshouses offered refuge for poor, homeless, elderly and physically and mentally disabled Americans well into the 20th century. Bread lines and soup kitchens stretched across the country to aid those ravaged by the Great Depression. The New Deal and the Great Society developed and reinforced the welfare state, respectively, building off the charitable work begun by private organizations. By the middle of the 20th century, public welfare had become a fully entrenched responsibility of the federal government.
However, the services of nonprofit providers can only supplement the social safety net, not replace it. Speaker Paul Ryan warned of the social safety net's potential to become "a hammock that lulls able-bodied people into lives of dependency and complacency, that drains them of their will and their incentive to make the most of their lives" as compared to the dignity afforded to those either gainfully employed or who only ask for help when contending with truly dire straits. Senator Mike Lee alluded to the existence of this network of service providers in his calls for "a voluntary civil society" to temper the excesses of "big government."
Alicia Wilson, executive director of La Clinica Del Pueblo, called the idea of asking charities to replace government funding "laughable." For nonprofit service providers like La Clinica Del Pueblo, DC Central Kitchen and Martha's Table that are already at or near capacity, accommodating a flood of people newly deprived of the critical benefits that keep their families afloat will be difficult if not impossible.
Anticipating the Cuts: When Demand Exceeds Supply
Access to nutritious food is the orienting principle of DC Central Kitchen, which distributes 7,300 meals every day to poor children, delivers locally sourced, freshly prepared food to corner stores in DC's low-income food deserts and converts food that would have otherwise been wasted into healthy meals for homeless shelters, halfway houses and other nonprofits. The nonprofit provides these supplemental food services in addition to operating a job training program that prepares adults with histories of job instability, mental health challenges, homelessness, and incarceration for employment in the culinary industry. Alexander Moore, DC Central Kitchen's chief development officer, estimates that the organization serves 6,000 school children and corner store consumers, all of whom struggle with food scarcity and food insecurity.
SNAP figures critically into DC Central Kitchen's mission of providing nutritious meals to those who need them the most. DC Central Kitchen works with a local SNAP office to identify candidates for its job training program, and in kind, to refer eligible trainees to access SNAP benefits. Furthermore, the program empowers participants in DC Central Kitchen's corner store program to afford healthy food options that otherwise would be out of reach.
DC Central Kitchen views SNAP as a "critical lifeline." The organization, according to Moore, is proud to work with SNAP to help vulnerable Americans "get back to work and earn a living wage" and cautions that cuts to SNAP would pose a serious challenge to DC Central Kitchen and its clients. DC Central Kitchen's programs are at capacity now. It regularly gets between 60 and 80 applications for its job training program which only has 25 spots. Meals are served daily in 15 schools and distributed to 80 partner organizations throughout the District. Physical limitations to the organization's infrastructure make a major increase in demand for services impossible to satisfy.
DC Central Kitchen and Martha's Table work with communities in Wards 7 and 8 in Washington, DC, where three grocery stores feed 150,000 people, an arrangement that gives new meaning to the term food desert. Lack of access to fresh, healthy food can have devastating effects on families, especially children. To this end, Martha's Table offers a continuum of services to support children, including early childhood education, after-school programming and arts and technology workshops. Martha's Table has a well-established presence out in the community as well: The organization operates a thrift store and a no-cost shopping program at a Martha's Outlet. McKenna's Wagon, the organization's daily mobile food truck, serves meals at Martha's Table and then makes different stops throughout the area to feed between 315 and 400 people every day. An emergency grocery market opens every day to support families in need. During the 2015-'16 school year, Martha's Table distributed more than 550,000 pounds of food to 24,000 families. The organization estimated that its food programs served a total of 1.1 million meals in this same span of time.
Ryan Palmer, director of external relations at Martha's Table, struck an optimistic tone. Should the cuts be implemented, Martha's Table plans on learning from and listening to the families that live them. The Joyful Food market, for one, was the result of families telling Martha's Table that there were few places to get fresh food. As it stands, however, the organization has seen a 25 percent increase in demand for its lobby market between the first half of 2016 and the first half of 2017.
Uplifting the Needs of Families
La Clinica Del Pueblo functions as a multipurpose community health center that offers primary and special care, mental health and substance abuse care, language access services, HIV counseling and testing, nutrition workshops, and healthy eating and lifestyle training workshops in partnership with other community-based organizations. According to Alicia Wilson, the organization serves patients who are mostly members of the Latino community in Washington, DC, and Maryland, specifically immigrants and their first-generation children. These patients are well represented among the denizens of the working poor: Wilson estimates that 50 percent of those serviced by LCDP are at or below the federal poverty level with 90 percent of that population living below 200 percent of the federal poverty level. Seventy percent of La Clinica Del Pueblo's clients are insured; 10 percent are insured through the Affordable Care Act, 20 percent have insurance via a program unique to the District called the DC Healthcare Alliance for Americans regardless of their immigration status (immigrants are barred from accessing public benefits for five years), and between 25 and 30 percent are Medicaid enrollees.
La Clinica Del Pueblo provides long-term primary care to almost 4,200 patients every year. Patients currently on the organization's roster are well taken care of, but the possibility for expansion is limited. Ideally, according to Wilson, La Clinica Del Pueblo wants to supply care to residents of seven zip codes in the Washington, DC, Metropolitan area. There are 40,000 residents in these zip codes without any primary care providers. Even with a recently opened location in Hyattsville, Maryland, La Clinica Del Pueblo is not able to make a dent in addressing that care gap: The facility only has the means to support 1,000 patients.
Kicking people off of Medicaid, Wilson cautioned, does not mean that they have other sources to turn to for health care. Clinics like La Clinica Del Pueblo rely on Medicaid reimbursements to fund their operations. But even with these reimbursements, La Clinica Del Pueblo has reached capacity and is often forced to refer new patients to other organizations. Without Medicaid funding, La Clinica Del Pueblo's capacity for growth will be diminished, thus reducing the availability of its services. Turned away from Medicaid and charitable clinics, many will seek help from emergency care centers, but only when they need it the most. Some hospitals, Wilson predicted, will go under because of the loss of Medicaid reimbursements, and as a result, some patients will die.
When asked how she would respond to those who suggest clinics simply find other sources of funding, Wilson offered this choice word: naïve. La Clinica Del Pueblo searched for every dollar it could find and stretched every dollar to its maximum potential in the days before it received reimbursements from Medicaid and the DC Healthcare Alliance. Once those investments started coming in, the positive effects were tangible: When buttressed by the power of the government social safety net, the clinic observed a multiplier effect through which it was able to provide more care.
"Harder" to Realize the American Dream
Reflecting on the impact of the proposed cuts, both DC Central Kitchen's Moore and La Clinica's Wilson painted a picture of families engaged in a struggle for survival. Many families in America "are struggling to do everything right," according to Moore -- everything from satisfying "the needs of their children" to working grueling hours to fighting "to break the cycle of intergenerational poverty." Federal benefits like SNAP, TANF and Medicaid factor significantly into empowering these families to face daily obstacles.
Without health insurance, Wilson argued, families live in fear with toxic levels of stress and uncertainty looming over them. Their lives are characterized by tradeoffs that are neither socially nor economically fair. They're forced to choose between paying out-of-pocket for pricey doctor's appointments or hoping that their illness or pain goes away on its own.
Budget cuts that force families to go without, Moore argued, "will make it that much harder for [them] to achieve the American dream."
To be sure, nonprofit service providers go a long way in helping families begin to realize the American dream. Martha's Table helped increase food security among the families that visited its Joyful Food Markets from 29.5 percent to 74 percent during the 2015- '16 school year. Last year, DC Central Kitchen delivered 1.8 million meals to its nonprofit partners and one million meals to low-income students, while boasting an 88 percent job placement rate among graduates of its culinary job training program. La Clinica Del Pueblo provides 35,000 services to thousands of patients each year.
Such impactful service is a testament to these nonprofits' years of dedication and sheer will. But their work can only reinforce the social safety net. These benefits, in Moore's words, "need to be available for people who need them when they need them."