美国国家公共电台 NPR Repeal Of Health Law Could Force Tough Decisions For Arizona Republicans（在线收听）

DAVID GREENE, HOST:

States are already preparing for changes that might come if the Republican replacement for the Affordable Care Act passes. That replacement bill, known as the American Health Care Act, is still working its way through Congress. And for one thing, there are huge implications for states that expanded Medicaid under Obamacare. Will Stone of member station KJZZ in Phoenix reports.

WILL STONE, BYLINE: Connie Dotts is a big fan of her insurance.

CONNIE DOTTS: I like that we can choose our own doctors. They also have extensive mental health coverage.

STONE: Dotts, who's 60 and lives east of Phoenix, isn't on some pricey plan, either. She's on Medicaid. Her eight prescriptions are cheap. She has no co-pays or premiums. And that's allowed her to stay on top of her emphysema, depression and osteoarthritis.

DOTTS: I have torn ligaments in my ankles. And I can't take the time off from work to go to physical therapy or have surgery.

STONE: Dotts works retail and says without Medicaid, seeing a doctor would be too expensive.

DOTTS: It's just barely above what they consider livable income. Any extensive medical issues would put an excessive burden on me.

STONE: That's the situation for many of the 400,000-plus people who are now covered by Medicaid because of the Affordable Care Act. Arizona was one of the Republican-led states that expanded Medicaid. But the GOP's proposed replacement rolls back that expansion funding after 2020. And while it will still pay higher expansion rates for people already in Medicaid like Dotts, that's only if her income stays about the same, says Swapna Reddy with Arizona State University.

SWAPNA REDDY: What we know about the Medicaid population is that they kind of fall in and out of eligibility on a regular basis.

STONE: That's because how much money they make tends to fluctuate.

REDDY: So it has the real potential of eradicating Medicaid expansion over a period of time.

STONE: And the bill, championed by Speaker Paul Ryan, does more than pare back Medicaid's growth under the ACA. It fundamentally transforms the funding model. Instead of an open-ended entitlement, it would be capped so the federal government only gives the state a certain amount of money. And Reddy says that likely won't keep up with the growing cost of covering people.

REDDY: The states will have to come up with the remaining money to cover these folks. And if they're not willing to do it, then it really shifts the way that we look at the safety net.

STONE: The Republican legislation would eventually cost Arizona nearly half a billion dollars a year just to keep the group of adults with the lowest income covered. During the recession, that kind of financial pressure led state lawmakers to freeze enrollment. And there's another broader risk about overhauling Medicaid, says Tom Betlach, who leads the program in Arizona. The state already spends as little as it can, so getting locked in at the current funding rates gives other states a leg up.

TOM BETLACH: If they're able to achieve improved outcomes and reduced costs, they're able to capture those savings versus we actually get penalized for being a good steward of taxpayer funds.

STONE: All of this puts the state's Republican governor, Doug Ducey, in a tricky situation. He would like the ACA repealed but has said he doesn't want hundreds of thousands of people to lose coverage. He's expressed concern the GOP bill doesn't give the state enough flexibility. And it wasn't on his watch that Arizona expanded Medicaid, either. It was actually Trump ally and former Governor Jan Brewer. Just last month outside a court hearing on Medicaid expansion, she defended that decision.

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JAN BREWER: I think it was the right thing to do. It saved lives. It insured more people. It brought money into the state. It kept rural hospitals from being closed down. And today, there are tens of thousands of people that are very, very grateful.

STONE: To pull off the expansion, Brewer had to band with Democrats and buck her fellow Republicans like state Senator Debbie Lesko, who says she thought the day might come when the feds would go back on their promise.

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DEBBIE LESKO: I voted against Medicaid expansion not because, you know, I don't want people to get health coverage but because I'm a realist. And I know how much we can afford in our budget.

STONE: It's a reality that dozens of states and their legislatures could soon face as Washington tightens the purse strings of the country's largest insurer. For NPR News, I'm Will Stone in Phoenix.

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GREENE: And Will's story is part of a reporting partnership with NPR, KJZZ and Kaiser Health News.

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