A Republican tax and spending bill headed to President Donald Trump’s desk includes unprecedented Medicaid cuts that could threaten health coverage and services for thousands of rural Marylanders, advocates and elected officials warn.
The House voted 218-214 to pass the measure Thursday afternoon. It could slash about $1 trillion from Medicaid, a government health program for low-income Americans that insures 1.5 million Marylanders, in order to fund tax cuts tilted toward the wealthy. With Trump’s signature, it would become the largest reduction to the country’s social safety net in history.
Medicaid has served as an especially critical lifeline for many rural patients and providers. In Maryland, the program covers 20% of people in rural communities, a slightly higher share than in urban areas, including 36% of children, 18% of working-age adults and 11% of seniors.
In turn, Medicaid provides a pot of revenue for rural hospitals, clinics, community health centers and nursing homes.
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The Republican bill cuts Medicaid primarily by imposing work requirements and eligibility checks that could push people off coverage, and by capping how states can raise money through provider taxes. GOP leaders contend the changes will reduce waste, fraud and abuse in the system while ensuring that recipients work in return for government benefits.
In rural Maryland, the measure would mean 11,000 fewer Medicaid enrollees and $1 billion less in federal Medicaid spending over 10 years, according to analyses by the health policy research and news organization KFF.
Jonathan Dayton, executive director of the Maryland Rural Health Association, said, without sufficient funding, rural providers who are already operating on fragile margins could face serious threats.
“Rural hospitals may even close,” Dayton said during a recent conference call with reporters. “They may even shrink. And, at the heart of it, rural Maryland families will suffer.”
U.S. Rep. April McClain Delaney, a Democrat who represents rural Western Maryland and northern Montgomery County, estimated that 32,000 people in her district could lose health coverage under the Republican bill. She said Medicaid supports a range of her constituents, including children with disabilities, cancer patients, people with chronic diseases and veterans.
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McClain Delaney warned that a provision to slash hundreds of billions from the Supplemental Nutrition Assistance Program, also known as food stamps, would hit rural communities hard. She said states were not equipped to fill the gap.
“I keep saying: It’s a tsunami that is headed towards rural America,” McClain Delaney said. “States, fundamentally, can handle one or two things, but when they have so many things hitting them at once, they’re just not going to be able to step in to fill that void.”
Because hospitals are among the largest employers in many rural counties, Medicaid cuts will affect not only access to health care but jobs and the broader economy, McClain Delaney said.
Even before Republicans proposed sweeping Medicaid cuts, the rural health care system was struggling with staffing shortages, transportation barriers and long emergency room waits, Dayton said.
Since 2010, 88 rural hospitals around the country have closed, while another 65 stopped providing inpatient services, according to researchers at the University of North Carolina. The Republican bill puts hundreds more rural facilities at risk, the same group found.
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Thus far, Maryland has largely avoided rural hospital closures, thanks in part to its decades-old all-payer rate-setting model. The system requires public and private insurers to reimburse hospitals at the same rate for a given procedure, helping keep afloat rural hospitals that serve many Medicaid and uninsured patients.
But the all-payer model works only if people have health insurance, said Alice Burns, a Medicaid expert at KFF.
“It doesn’t really matter if you’re using all-payer rates. If people don’t have coverage, they are not going to be accessing as much health care, and providers are not going to be getting paid as much,” Burns said.
Republicans sought to blunt the impact of Medicaid cuts, scrambling to add a $50 billion fund for rural hospitals ahead of a Senate vote Tuesday. Because states would split a portion of the money evenly, those with smaller rural populations, including Maryland, stand to receive a disproportionately large share.
But the National Rural Health Association said the fund was too small. And an analysis by KFF estimated the fund was over $100 billion short of offsetting cuts to federal Medicaid spending.
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Democrats said, rather than applying a Band-Aid, Republicans should have left Medicaid alone.
“It’s a drop in the bucket,” McClain Delaney said of the fund. “I don’t think that is at all enough money to even be able to touch the amount of hurt that is going to be unfurled across America.”
Baltimore Banner reporter Meredith Cohn contributed reporting.
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