Cassidy-Graham is the Latest Attempt to Take Away Healthcare Coverage from Thousands of West Virginians

The latest attempt to repeal the Affordable Care Act, the Cassidy-Graham bill, would cut West Virginia’s funding for Medicaid by $2.0 billion by 2027. This would undermine health coverage for tens of thousands of West Virginian’s and threaten the state’s historic gains in health coverage stemming from the Affordable Care Act.

The Cassidy-Graham bill cuts health coverage in two main ways.

Block Grants are no replacement for ACA provisions.

The biggest cuts in the Cassidy-Graham bill come from converting the ACA’s Medicaid expansion and marketplace subsidies with smaller, temporary block grants. According to the bill’s sponsors, this block grant would give states “flexibility,” allowing them to maintain the coverage available under the ACA, if they wanted to do so while enabling other states to experiment with alternative approaches. In reality, however, states would not be able to maintain their coverage gains made under the ACA, because the block grant funding would be an insufficient amount to maintain coverage levels equivalent to the ACA. The block grant would provide $239 billion less between 2020 and 2026 than projected federal spending for the Medicaid expansion and marketplace subsidies under current law.

In 2026, this funding would completely go away, leaving states with 100 percent of the cost for the people covered under these programs. This cut would almost certainly leave states no choice but to discontinue these kinds of coverage. The result is that, beginning in 2027, Cassidy-Graham would be virtually identical to a repeal-without-replace bill — except for its additional Medicaid cuts through the per capita cap, described below. The non-partisan Congressional Budget Office (CBO) estimated that the repeal-without-replace approach would ultimately leave 32 million more people uninsured. The Cassidy-Graham bill would presumably result in even deeper coverage losses than that in the second decade.

A permanent and ongoing cut to traditional Medicaid

Like prior House and Senate Republican repeal bills, the Graham-Cassidy bill would radically restructure and cut the rest of Medicaid, outside of the ACA’s Medicaid expansion. It would end the federal-state financial partnership under which the federal government pays a fixed percentage of a state’s Medicaid costs. It would instead impose a per capita cap, under which federal Medicaid funding would be capped at a set amount per beneficiary, irrespective of states’ actual costs, and would grow each year more slowly than the projected growth in state Medicaid costs per beneficiary.

The result would be deep cuts to federal Medicaid spending for seniors, people with disabilities, families with children, and other adults (apart from those affected by the bill’s elimination of the Medicaid expansion). Notably, these per capita cap cuts would come on top of the cuts to Medicaid expansion funding and marketplace subsidies under the block grant discussed above.

Starting in 2025, the annual adjustment of per capita caps is reduced to an even lower level, creating even deeper cuts to Medicaid. In 2027, after the block grants disappear and Medicaid per capita caps are further reduced,  combined would result in a $2.042 billion federal funding cut for West Virginia.

Cassidy-Graham's Large Cuts to Federal Health Care Funding Grow Even Larger Starting in 2027

Disruptions to the individual markets

In addition to hurting healthcare coverage through major Medicaid cuts, Cassidy-Graham would also disrupt the individual market. The Cassidy-Graham bill would immediately eliminate the individual mandate requiring everyone to have some kind insurance coverage or else pay a fine, which the Congressional Budget Office estimated would result in 15 million more uninsured in the following year.

The bill’s elimination of the ACA marketplace subsidies and start of a block grant in 2020 would cause massive additional disruption. States would lack guidance, standards, or administrative infrastructure for creating their own coverage programs, and insurers would have no idea how the individual market would operate, including what their risk pools would look like. Insurers would most almost certainly impose large premium rate increases to account for uncertainty; some would likely exit the market altogether.

Then in 2027, when the block grant disappeared entirely, insurers would face a market without an individual mandate or any funding for subsidies to purchase coverage in the individual market. Yet they would still be subject to the ACA’s prohibition against denying coverage to people with pre-existing conditions or charging people higher premiums based on their health status. Many insurers would likely respond by withdrawing from the market, leaving a large share of the population living in states with no insurers, as CBO has warned about previous repeal-without-replace bills.


Senate Health Bill (BCRA) Would Hit West Virginia Hardest

While it is unclear what version of the legislation the U.S. Senate will plan to take up on Tuesday (7/25) when they vote to proceed to repeal and replace the Affordable Care Act (ACA), the revised version of the Better Care Reconciliation Act (BCRA) would be particularly harmful to West Virginians.

An updated report from the national Center on Budget and Policy Priorities shows that West Virginia would be among the hardest hit states in the nation. Not only would the number of uninsured West Virginians grow by nearly 300 percent – the largest increase in the nation (See Map) – but it would reduce federal Medicaid/CHIP spending by half or $1.8 billion by 2022. Last-ditch efforts by Senate leadership to offer more money to Medicaid expansion states won’t fix this bill either. Below is a quick summary of BCRA’s impact on West Virginia and here’s a one-page fact sheet.

West Virginia Would Sustain Huge Coverage Losses

  • 211,000 West Virginians would lose coverage by 2022 if BCRA is passed.
  • The BCRA would increase West Virginia’s non-elderly uninsured rate from five percent to over 19 percent, a 299 percent increase, more than any other state.
  • 1 out-of-seven non-elderly West Virginians who would have coverage under the ACA would lose it because of the BCRA.

West Virginia’s Medicaid and CHIP Programs Would Be Cut in Half

  • The BCRA would cut West Virginia’s CHIP program by 47 percent by 2022 (compared to 26 percent nationally)
  • The number of people enrolled in Medicaid would fall by more than half by 2022, or 263,000 people.

 BCRA Would Drastically Increase West Virginia’s Costs to Maintain Medicaid Expansion

  • The state’s cost to maintain expansion would rise by 50 percent by 2021, 100 percent by 2022, and 150 percent by 2023.

 BCRA Would Make Access to Substance Use Disorder Treatment Less Available

  • West Virginia has the highest drug overdose death rate in 2015.
  • The share of West Virginians with substance use or mental health disorders who were hospitalized but uninsured fell from 23 percent in 2013 to five percent in 2014.
  • Rolling back expansion would roll back coverage for the 33 percent of West Virginia expansion enrollees who used mental health or substance use disorder services in 2014.


Senate Health Care Bill Cuts Medicaid to Pay for Tax Cuts for the Rich – UPDATED

The Better Care Reconciliation Act (BCRA), the latest Republican plan to repeal and replace the Affordable Care Act (ACA), was introduced in the U.S. Senate on June 22, 2017, and is awaiting a vote. In its current form, the bill would eliminate most of the provisions of the ACA, including its tax provisions, and drastically cut Medicaid, essentially ending Medicaid expansion and instituting per capita caps. The end result of these changes for West Virginia would be a large tax cut for a small number of the wealthiest individuals in the state, while tens of thousands would lose Medicaid coverage.

The two largest tax provisions that would be repealed are the  Additional Medicare Tax, which is a 3.8 percent tax on wages for taxpayers with wages exceeding $200,000 ($250,000 for married earners), and the Net Investment Tax, which is a 3.8 percent tax on investment income for taxpayers with income exceeding $200,000 ($250,000 for married couples). Repealing these two taxes would cost over $31 billion, with 85 percent of the benefit going to the top 1 percent of Americans.

According to the Institute on Taxation and Economic Policy, only 11,100 West Virginians would benefit from the repeal of these two taxes, or only 1.2 percent of taxpayers in the state. The tax cut would be worth $46 million for West Virginia, with 96 percent of the savings going to the wealthiest 1 percent in the state, or those earning more than $346,000/year.

On the health care coverage side, federal funding for Medicaid would be $102.2 billion lower in 2022 under the BCRA than under the ACA, a 26.4 percent decline. Federal funding for premium tax credits and cost-sharing reductions would also fall by $38.2 billion, an 84 percent decrease. West Virginia would lose $1.8 billion in federal spending, a 48.9 percent decrease compared to current law.

The decrease in funding would force West Virginia to end Medicaid expansion, and make further restrictions to Medicaid eligibility. According to the Urban Institute, 264,000 West Virginians would lose their Medicaid coverage due to the loss of federal funding. Overall, 218,000 West Virginians would lose health insurance coverage, quadrupling the state’s uninsured rate.


The cost to give 11,100 of the wealthiest West Virginians millions in tax cuts is 218,000 uninsured West Virginians. The “savings” from the cuts to Medicaid are poured directly into tax cuts which overwhelmingly benefit the wealthy. Overall, for every West Virginian who would benefit from the tax cuts in the Senate health care bill, 24 would lose their Medicaid coverage. The core of the BCRA is taking away health care from millions of people in order to pay for a tax cut for the rich.



New numbers from the Urban Institute provide estimates for the number of children affected by the Senate’s health care bill. In West Virginia, the number of uninsured children would increase by 19,000 by 2022 under the Senate health care bill, a 475% increase. The uninsured rate for children in West Virginia would increase from 1.1% to 6.2%. West Virginia would have the largest increase in the share of its children who are uninsured in the country.

How Many Jobs Could the AHCA Cost West Virginia?

A recent report from the Economic Policy Institute looks at how many jobs could be lost in each state under the Republican health bill – the American Health Care Act. The AHCA – which would repeal the Affordable Care Act (ACA) – is like a zombie – it just does not seem to quite die.

Yet every attempt to bring it forward for a vote in the House has failed as many moderate Republicans remain nervous about the impact the legislation will have back home. And for good reason. Nonetheless, an effort by leadership and President Trump to regroup and hold a vote in the house over the next month in underway.

The Republican repeal will strip away the Medicaid expansion in West Virginia, reduce and cap federal Medicaid funding, and roll back the marketplace premium and cost-sharing subsidies for private insurance. Not only would many more West Virginians go back to being uninsured, the Republican repeal bill will strike a devastating blow to West Virginia’s struggling economy.

What would the Republican repeal bill mean for health insurance coverage in West Virginia?

– More than 800,000 West Virginians would be at risk of losing their health insurance coverage or face exorbitant premiums for a plan that does not cover pre-existing conditions.

– West Virginia would face a $4 billion cut in federal funding for the Medicaid program over 10 years (2019 to 2028), effectively shifting those costs to the state.

Federal cuts of this magnitude will force West Virginia to cut children, seniors, people who need long-term care, people with disabilities, and struggling low-income workers from the Medicaid program, as well as cut critical health services, and cut payments to hospitals, doctors, and other providers.

What would the bill mean for jobs in West Virginia? Nearly 23,000 jobs would be at risk in West Virginia by 2022. West Virginia would be in the top five states with the largest reduction in job growth as a share of the total employed population – a 1.45 percent average annual job less.

– 7,436 jobs in District 1 (Representative McKinley)
– 6,778 jobs in District 2 (Representative Mooney)
– 8, 701 jobs in District 3 (Representative Jenkins)

The Affordable Care Act resulted in billions of federal dollars flowing into West Virginia. With the ACA Medicaid expansion in 2014, the new federal dollars constitute the single most important economic stimulus package for this state in recent memory, creating jobs, boosting our economy, and supporting our rural hospitals and health-care providers. The health-care sector is one of the few sectors in West Virginia that has seen job growth in the last five years.

These health and economic security gains of West Virginia families would be at risk if Washington revives an ACA repeal effort. No state has more to lose than West Virginia if this zombie bill arises again.


Wealthiest 1% of West Virginians Gain from Tax Cuts in Health Care Repeal

The House proposal to repeal the federal Affordable Care Act (ACA) and replace it with the American Health Care Act (AHCA), provides only a tiny fraction of very wealthy West Virginians tax cuts while reducing the number of Americans with health coverage by an estimated 24 million. The two big tax cuts included in the AHCA are the repeal of taxes on investment income and earned income, both of which only apply only to people who make over $200,000 a year. These taxes were enacted to pay for the ACA’s health care expansions, including Medicaid in West Virginia that has provided insurance to over 170,000 West Virginians.

In West Virginia, 96 percent of the benefit from repealing these two taxes would go to the wealthy top 1 percent of West Virginians. Only 11,063 West Virginians, or 1.2 percent of taxpayers in the state, according to a recent analysis by the Institute on Taxation and Economic Policy (ITEP), would benefit from cutting these taxes. The average tax cut in West Virginia for the estimated 11,063 taxpayers impacted would be $5,239. The other 922,000 taxpayers in the state would receive no benefit.

Nationwide, the tax cuts would total $31.5 billion. Of that, only 0.15 percent would go to taxpayers in West Virginia, roughly $46 million.

Below are the state-by-state figures for more information on who benefits from these proposed tax cuts:

184,000 West Virginians Could Lose Coverage with Partial Repeal of Affordable Care Act

With the new Trump Administration’s promise to repeal and replace the Affordable Care Act (ACA or Obamacare), Congress is now considering partial repeal through the budget reconciliation process, to avoid a filibuster. The repeal maybe phased in over time, but no replacement plan has been defined. The budget reconciliation process only allows changes to components of the law with federal budget implications, which would allow for the elimination of the Medicaid expansion, the federal financial assistance for Marketplace coverage (premium tax credits and cost-sharing reductions), and the individual and employer mandates. It is unclear if the January vote to repeal without replace will pass. Some Republican Senators (such as Lamar Alexander R-TN and Susan Collins R-ME) have publicly expressed concern about voting to repeal in the blind without any replacement plan identified.

The Urban Institute has done an analysis of healthcare coverage and spending if the ACA is partially repealed through the reconciliation process, similar to the one passed last summer and vetoed by President Obama.

The Urban Institute projects that 184,000 West Virginians would lose healthcare coverage in 2019 under a ACA repeal, a 208% increase in the number of uninsured. This includes low-wage working West VIrginans would lose Medicaid coverage due to the elimination of Medicaid expansion, those for whom coverage becomes unaffordable due to the loss of premium tax credits, and healthy individuals who can afford coverage but are no longer required to purchase it. Without insurance, many West Virginians will put off seeking care until their condition is serious or even life threatening, and more expensive to treat. The ACA repeal could cause a growing number of medical bill bankruptcies that leave West Virginia families destitute.



While the number of uninsured West Virginians would dramatically increase with the ACA repeal, a much smaller share of the uninsured would be eligible for financial assistance.  Under a partial repeal through reconciliation,  only 13 percent of the 272,000 uninsured West Virginians would be eligible for any financial assistance (all under Medicaid or CHIP), because of  the elimination of both the Marketplace tax credits and the Medicaid eligibility expansion. In contrast, under the ACA, 71 percent of the remaining 88,000 uninsured would be eligible for either Medicaid/CHIP or tax credits through the
ACA’s Marketplaces in 2019.


West Virginia would also stand to lose billions in federal funding with the repeal of the ACA. Under the ACA the federal government is projected to spend $35 billion from 2019-2028 funding West Virginia’s Medicaid/CHIP program, and $2 billion on premium tax credits for West Virginians. The a partial repeal of the ACA, federal funding for Medicaid would fall to $23 billion over that time frame, and the premium credits would be eliminated, a loss of $14 billion in federal funding. This loss of federal funding would threaten the state’s healthcare infrastructure and likely destroy jobs across the state.


In addition, as the number of uninsured increases, the amount of uncompensated care – the cost of health care for the uninsured and underinsured –  would increase. Uncompensated care is paid for in a variety, some of it is financed by the federal government, some by state and local governments, some by the healthcare providers, and some of it is passed on to insured patients through higher costs. While the ACA reduced uncompensated care through coverage expansion, its repeal would dramatically increase the costs of uncompensated care for the healthcare system. Under current law, uncompensated care is projected to cost the healthcare system $656 billion over the next 10 years, with the federal government spending $262 billion, state and local governments spending $164 billion, and providers spending $230 billion. With a repeal of the ACA, uncompensated care costs would increase by $1.1 trillion over the next 10 years. However, federal programs must be increased to cover the additional costs above the current levels, which previous ACA repeal bills have not done. If no federal action is taken, state and local governments and providers would have to $1.1 trillion uncompensated care increase themselves.

The ACA, while not perfect, has become a foundation of health security for thousands of West Virginia families. Its repeal will have a significant impact on the state, as will any replacement plan, when it is defined. But as of now, tens of thousands of West Virginians stand to lose their healthcare coverage, while the state and the healthcare industry must prepare to lose billions in federal funding.

Census Data Shows Thousands Gaining Health Insurance, But Many Still in Poverty

The Census Bureau released the 2014 American Community Survey (ACS) this week, which contains data on poverty, income, and health insurance coverage for all 50 states. For West Virginia, the data release had both some really good and some not-so-good news.

First the good news. The 2014 ACS release was to first to have data on health insurance coverage with the Affordable Care Act in full effect, including the expansion of Medicaid. And, as one of the states that opted to expand Medicaid, West Virginia saw a major decline in its uninsured population. The number of West Virginians without health insurance coverage fell by nearly 100,000, from 14% of the population, to just 8.6%, the third biggest decline in the country. The decline in the number of uninsured was more than 10 times bigger than any previous year’s change. Now over 91% of West Virginia’s population has health insurance.


The Affordable Care Act is largely responsible for the decline in West Virginia’s uninsured population. As part of the Affordable Care Act, Medicaid was expanded to people making up to just $32,500 per year for a family of four (138 percent of the federal poverty rate). The Supreme Court, however, left it up to the states to decide whether to extend their benefits to these families and accept the federal funding to do so. In May of 2013, Governor Tomblin decided to expand West Virginia’s Medicaid program, and as of June 2015, more than 164,000 newly eligible West Virginians are receiving health insurance through expansion.

Other provisions of health care reform are also helping reduce the number of West Virginians without health insurance. 33,000 West Virginians have enrolled in health care plans through the state’s new health insurance marketplace, which allows people to easily compare prices and benefits of health care plans. Many of these people receive federal subsidies to help them pay their premiums and reduce their out-of-pocket health costs.

The expansion of health insurance largely benefits low-income working families. Children under 18 and West Virginians participating in the labor force made up more than 2/3rds of the decline in the uninsured population.

It wasn’t all good news for West Virginia from the Census Bureau, however. While the data release from the ACS showed significant progress in insurance coverage, the state is not seeing any progress in reducing poverty. The state’s poverty rate in 2014 was 18.3%, essentially unchanged from 2013 and still above its pre-recession levels. One in four children in West Virginia lives in poverty. In addition, the state’s median household income hasn’t budged since the recession, and at $41,059, is the 2nd lowest among the 50 states.

But just like policies such as the Affordable Care Act made a difference in the state’s uninsured rate, theyy can make a difference when it comes to poverty. Enacting a pro-work state earned income tax credit would open the doors of opportunity for people at low-wage jobs by letting them keep more of what they earn to help pay for things that allow them to keep working, such as child care and transportation. This will help build a more secure future for these families – including their kids – while boosting local economies across the state. In contrast, proposals to cut taxes for the wealthy and businesses would close the doors of opportunity, taking away resources from services families rely on every day without boosting the economy or creating jobs.

A state earned income tax credit, set at 15% of the federal credit, would supplement the existing federal earned income tax credit and benefit 158,000 working West Virginia families. It would provide an average credit of $332 a year to those families and put $52 million back into local economies in West Virginia. Twenty-six other states and the District of Columbia already have a state earned income tax credit.

 state eitc infographic

Supreme Court Upholds Obamacare Subsidies for 25,000 West Virginians

The Supreme Court upheld a key provision of the Affordable Care Act today, protecting subsidies that make health insurance affordable for millions of Americans, and tens of thousands of West Virginians.

In a 6-3 ruling, the Court found that premium subsidies should be available both in states that have set up their own health insurance exchanges, and in states that use the federal exchange, like West Virginia.

The plaintiffs in King vs Burwell case contended that the under the law, premium subsidies should only be available in states with their own exchanges, not to those enrolled through the federal exchange. This argument was supported by a number of conservative politicians, including West Virginia’s Attorney General Patrick Morrisey.

However, the Court rejected that argument, making subsidies available in all states, marking the second time the Supreme Court has upheld a key Affordable Care Act Provision.

West Virginia is one of 36 states using the federal exchange rather than setting up its own exchange. Had the Supreme Court’s ruling gone the other way, West Virginians in the federal exchange would have lost their premium subsidies, in some cases tripling the cost of health insurance.

The are approximately 33,000 people enrolled in health insurance plans through the exchange in West Virginia, with about 25,000 qualified for premium subsidies. In 2014, those with subsidized exchange plans in West Virginia saw their monthly premiums reduced from $415 to just $113, meaning that 78% of premium costs are covered by subsidies. At that rate, in 2016 the subsidies could save low and moderate income West Virginians over $185 million.

Since the enactment of the Affordable Care Act, West Virginia’s uninsured rate has plummeted from 17% to 6.6%, almost entirely due to the law. With the Supreme Court’s ruling today, that progress in insuring West Virginia’s population has been protected and the destabilization of the individual market has been prevented, and West Virginia remains one of the biggest Affordable Care Act success stories.

Let’s Not Go Backwards on Paying Social Workers

Last week, the State Senate passed a bill (SB 559) that would except DHHR social workers from the requirement to be licensed by the West Virginia Board of Social Work. According to the West Virginia Department of Health and Human Services, this bill aims to get more people to apply for positions within Child Protective Services (CPS). While CPS has suffered from retention problems and high levels of caseloads, eliminating licensure could put vulnerable children at risk and remove important accountability standards. Furthermore, this proposal neglects to deal with one of the central underlying problems, which is low pay. As former State Senator Donald Cook pointed out about CPS workers: “They’re underpaid.  They’re overworked.” 

According to the Bureau of Labor Statistics (OES), social workers in West Virginia are paid less than their counterparts in almost every state. In 2013, the average salary for child social workers that worked with children was just $31,700 – ranking last in the country.  Mental health and substance abuse social workers where paid even less in West Virginia on average, just $30,300 per year – also ranking last in the nation. While the average salary of healthcare social workers was $42,780 in 2013, this was lower than all but two states.

social workers pay child

Social worker pay 2

Social Workers Pay 3

While it’s good that DHHR is concerned about staffing shortages, eliminating accountability standards for social workers is not going to solve the problem and could make employee turnover worse. Let’s hope the House makes major changes to the bill and that we take concrete steps in the future to ensure that all DHHR social workers get paid a decent wage for their hard and important work. Instead of a race to the bottom, we need a race to the top. Our children deserve no less.


Want to Help Stop Flu Outbreak? Let More Workers Have Paid Sick Time

Just a month into peak flu season, the CDC has already declared a national epidemic due to the flu’s widespread activity and the deadly nature of this year’s virus. West Virginia is no exception. The outbreak is considered widespread across our state, as you can see from the the map below. While preventing the spread of the flu means staying home from work, a large chunk of workers do not have access to a single paid sick day.


As flu activity is increasing, providers are seeing more flu hospitalizations and flu deaths. Part of the reason the flu is so widespread this year is because most of the flu strains circulating are different from those included in the flu vaccine. In order to combat the outbreak the CDC is strongly advising people to stay at home when sick. Health providers in the state have offered to write doctors’ notes for patients who are diagnosed with the flu or flu-like illness so they can begin to use their available sick time. The problem with this recommendation is that over 225,000 West Virginia workers do not have access to a single paid sick day. A doctor’s note does not help low-wage workers who cannot risk losing a paycheck or their job when they are ill.

DHHRFLUTK  Source: West Virginia Department of Health and Human Resources, “Current Influenza Surveillance Data”, updated January 5, 2015, accessed January 6, 2015. 

Almost half of workers who do not receive paid sick time have reported going to work when they are ill, according to a study published in the journal Vaccine. Outbreaks spread further and last longer in workplaces that are less likely to have sick days, according a study of the 2009 H1N1 flu pandemic by the Institute for Women’s Policy and Research. With around two-thirds of service workers in West Virginia lacking access to sick time, the risk doesn’t stop at the workplace. These workers perform services, such as preparing food, and the general public’s health is at risk when a worker cannot afford to stay home ill.  

The WV Department of Education has joined with WV DHHR to create a pledge for students to fill out when they return to school this week, promising to help prevent the spread of flu by washing their hands and covering their mouths when they cough. I am sure many health officials wish that students could easily pledge to stay home from school to avoid spreading the flu. Unfortunately, when low-income parents do not have access to paid sick days, staying home to care for a sick child is not an option. This is because three-and-a-half days of missed work is the equivalent of an entire monthly grocery budget for a low-income family, according to the Economic Policy Institute. According to the CDC, adults are contagious for 5-7 days after they become sick with the flu and children may be considered contagious for even longer periods. 

Establishing a minimum standard for paid sick time will not only help protect workers and help families be healthier and productive, but it could help mitigate the risk of contracting and spreading deadly viruses like the flu at our workplaces and schools.