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Conversations in Pulmonary, Critical Care and Sleep Medicine by the American Thoracic Society
Announcement: [00:00:00] You are listening to the ATS Breathe Easy podcast brought to you by the American Thoracic Society.
Erika: Welcome to the American Thoracic Society. Breathe Easy podcast. I'm your host, Dr. Erica Moison of Portland, Oregon and the Air Health R Health Podcast. I am here today with Dr. Sade Afolabi, who is here to talk about the impact of changes to Medicaid funding that we're passed as part of HR one, colloquially known as the one big beautiful bill, which will have significant impacts on Medicaid and children's health insurance funding or chip.
So Dr. Afolabi as a pediatric lung doctor, why don't you go ahead and introduce yourself.
Shade: Hi I'm s Shade Afolabi. I'm a pediatric pulmonologist in Texas and specifically in the Dallas area. And I absolutely love what I do [00:01:00] every single day and I deal with a large Medicaid population. So this is really near and dear to my.
Erika: And can you share with us why Medicaid funding is so important for children in particular?
Shade: So, Medicaid funding accounts for about 80% of children under the poverty line, but Medicaid and chipped together account for about 50 40 to 50% of children's healthcare coverage. And so it's a huge funder of children.
and so that's why it's really important to me. But importantly as well, Medicaid actually covers a very. Important population of adults as well. And and, and they are particularly exposed to some of the changes that that the one big beautiful Bill will
Erika: bring. Absolutely. And speaking about pediatrics, with Medicaid being such a large funder of healthcare for children, what impact might there be on the future pediatric workforce?
Shade: That's a great question and a really [00:02:00] important question. as some may know there's a, a, a paucity of pediatric pulmonologists, and part of the reason why is because funding Medicaid is often not funded to the degree that Medicare is funded and the payment parity doesn't exist and people are less inclined.
To become pediatric pulmonologists and other pediatric subspecialists. And the, the cuts to Medicaid have the potential to impact that even more profoundly. And we have the potential to lose even more medical students who are, who are. Extremely interested in pediatrics and love pediatrics to, to defer that and go into other other fields.
And so it, it makes a big difference. And while no one goes in, no one, that's not true. But while very few people go into pediatrics specifically to be. You know, rich or to make a lot of money, [00:03:00] they definitely need to be able to pay their student loans and they need to be able to do all of those important things.
And those are increasingly more important factors when choosing a specialty. So this is very, very important. And in addition to that, it's very important for rural populations as well. and these catchment areas for rural populations to get access to pediatric, um subspecialists. Challenging and will become even more challenging with these Medicaid cuts.
Erika: Yeah. So these are hitting kids and adults pretty hard. What are the overall estimates and changes to funding for Medicaid in the CHIP program?
Shade: So it's really the biggest changes are for those with medic, those Medicaid expansion states. So Medicaid expansion states are going to lose a, a, a big chunk of their funding and need to now find different innovative ways to be able to.
recoup those [00:04:00] funds. I'm from Texas. We are not a Medicaid expansion state. I think that folks in these, in the small number of states that aren't Medicaid expansion feel that, that they might not be as significantly impacted. But what's important to know is that this is. Over 10 years and Medicaid will not have the ability to expand over 10 years as well.
And that's going to be expansion that's needed. with the advent of new technologies that are very expensive with inflation, um with the cost of living. All of those different things are going to go up over that co over that course of 10 years. And Medicaid is not going to be able to keep up.
So even if they're not on Medicaid, it's. Even if you're living in a non-Medicaid expansion state, you're likely to be significantly impacted. And while children are thought to be fairly well protected because Medicaid expansion really does [00:05:00] apply mostly to adults, as I said before, children are going to be impacted because Medicaid is gonna be unable to expand.
Or to grow. In addition to that there's a lot of administration that goes through Medicaid. There's a ton of administration and that the, the big beautiful bill is really making administration changes, um that make a servicing Medicaid more challenging. And I talk to employees that work for Texas Medicaid all the time in my job, and they really, really try hard to do their jobs well.
and they really want to serve the children of Texas and they want them to get the coverage and the healthcare that they need. But their hands are tied in many ways and will be tied even more. and so I don't want people to think the Medicaid [00:06:00] administrators are the evil folks. they just don't have the resources.
And those resources are going to be cut even more significantly in the future.
Erika: What are the key mechanisms in the bill driving these changes and cuts?
Shade: There's a lot, and it's important to know that many of them don't bec start, many of them don't kick in until after, really after the midterms in 2027.
but There are some administrative, um challenges that are going to happen including things like emergency Medicaid will be impacted retroactive Medicaid. When you say you get sick. You're eligible for Medicaid, you get admitted to the hospital, they apply for Medicaid and retroactively initiate your retro your Medicaid.
That's gonna be limited as well. the the time period [00:07:00] for which you're eligible for Medicaid, which you can, um reapply for your eligibility will be impacted as well. and then there's several other things that are going to be impacted. What I see. That will be more challenging for me to do my job is the retroactive Medicaid.
That's gonna be a, a big challenge. And then in addition to that, the the time period with which you have to apply to Medicaid is shortened. And that's why the administration part really worries me because. What can happen is that you can turn in your paperwork on time, but if the administration doesn't get to your paperwork on time, then you have to restart the process all over again, and then you don't have any insurance in the meantime.
And that's gonna happen for children and adults that, that those changes so far are not restricted to adults alone. And so that, that's gonna be challenging.
Erika: It's just giving me very uncomfortable flashbacks to the days before the a CA where you'd have people admitted and [00:08:00] they were so sick, there's no way they could work to get themselves insurance.
And you're asking people who are sick and unable to work and do anything to, you know, fill out complex paperwork and pay attention to all these deadlines. It just is overwhelming for everybody. It,
Shade: it really is. And then talking about work, the work requirement is new as well. And that's gonna be a big challenge as well.
work requirements. there, there's plenty of studies. I think Oregon has actually done an excellent study that shows that work requirements. Don't help that work. Requirements don't work. and it only increases the burden on those folks that are unable to work. There are some exceptions to the work requirement, but when you look at them, they're very, very stringent and to meet the requirements there's, there's gotta be an administrator to be able to figure out if you meet even those requirements.
So there's so many people that are gonna be eligible that are gonna fall through the cracks as well. [00:09:00] Um and so that's a, that's a big concern, especially for those adults seeking
Erika: Medicaid coverage. Can you talk about those barriers people may now find in accessing the Medicaid benefits, even if they are working?
Shade: So I can't speak on it with a lot of Robust kind of background knowledge on it. But for those that are working, the work requirements are about 80 hours a month. and then for those who are. not working or unable to work, there are still requirements that they may have to be either involved in, they may have to be in school or they may have to do community service work.
And so those are are big challenges as well. And so 80 hours a month to some people doesn't seem like a big deal, but that's, that can [00:10:00] be a very big, um Burden to a very big hurdle for for folks who are disabled and a very, very big hurdle for parents. Right? And so one of the work requirements is that you're required to work if your children are 14 years of age or.
Older and I was, I was thinking 14 years of age. That means that you have to leave your 14-year-old at home by themselves. And, you know, things have changed over the course of, of of, of many years. I was left alone at home when I was 14 years old. There are 14 year olds that are not able to be left, you know, to be left home alone that are and, and, and, you know, there's no provisions for that.
And that's, that's really challenging as well. So there's a lot of different roles. There's a lot of administrative roles that are gonna be challenging for people to meet those hurdles. And then those people who are already working but not able to meet that full work requirement are, are, are gonna be impacted as well.
Erika: Yeah, especially [00:11:00] in today's economy where there's so many gig jobs, there's so many different forms of informal work or informal compensation arrangements that people do just to get by. You know, not everything fits neatly into a time sheet.
Shade: Yeah. Yeah, that's so true. and people are working more than one job.
they're working multiple part-time jobs and that that's a hundred percent true. So, and, and once again, they're gonna have to find a way to prove that they're meeting that requirement When, um there, there's, there's very, it's very opaque about how you're going to actually document that those requirements.
Erika: And then putting so much on these administrators where you're, instead of just paying doctors and hospitals and pediatricians for the healthcare, you're paying all these salaries of people to navigate all these things for people who are barely getting by to begin with. You know, CMS had previously done all this work to try to make the administrative cost of Medicaid lower and to make this whole process of enrollment and administration more [00:12:00] efficient.
But part of this bill was actually to delay all those efficiencies that we had worked so hard with all these studies. To develop over the years. what impact does that expect it to have?
Shade: So I, I can tell you in the state of Texas, I think it's gonna have a significant impact. I think that the, there are many folks that are very worried about what the next steps are going to be.
these, um administrative, um requirements and delays have been, Huge hurdle to overcome, and I think many states aren't quite sure how they're going to be able to do this in an efficient way in order to not, um prevent an a significant number of people to be dropped from the roles in a very, very quick.
Period of time, every state's gonna have to do it very, very differently. every state already ha you know, every [00:13:00] state already has their rules for what they do now, and some are very permissive and some are somewhat restrictive. and I don't think that you can use the more restrictive states as a model because those restrictive states oftentimes have some of the highest.
number of uninsured children, essentially mostly and that are eligible for Medicaid. so I, I'll take Texas as an example. we have the highest number of uninsured children, and when we had our. Medicaid unwinding. Many children that were eligible for Medicaid were were dropped due to regulatory administrative reasons.
but they were, they were eligible and, and those are some children that have never been able to get back on Medicaid or have never been able to consistently stay on Medicaid. One of the big challenges is that. UU usually it takes, most states have a year before you have to re-enroll. [00:14:00] you know, now it's gonna be six months is for adults to have to before they have to re-enroll.
I'm not quite sure what it is for children and that, and that's gonna be a huge burden and a huge challenge.
Erika: Yeah. And is there an increased risk of medical debt with all these changes to Medicaid coverage?
Shade: Of course, yes. There's a definite increase risk of increase in medical debt. and that increase in medical debt is, um not
There aren't enough rules to protect people from medical debt right now. and it has significantly it has, it has put people into poverty and so the potential to put more people under the poverty line as a result of this is is, is very scary. and so it's, it's, it's very, it's [00:15:00] a multifaceted
Chain of events that has the potential to have people who are sick, who need care to really um. l lose a lot of funding and, and kind of, and fall under the, a poverty line. I'll, I'll give you a, a quick story. I grew up without a lot of money and we were, we were Medicaid recipients and when I was in medical school, they were, they were talked, they gave us a scenario and they said, well, what if you lose your home due to medical debt?
And at first I was like. But they have a place to stay. Right? and it was really challenging for me as someone who lived in, um you know, section eight housing and, and, and subsidized housing to really understand what a huge um. Like what a, which, what a huge burden that is what a [00:16:00] huge, um challenge that is, is to lose your home due to due to medical debt.
and that was in the early, um well, let me not say early. That was in, that was in the two thousands. Um and I and I have learned. And seeing how much this affects families every single day. And I was blessed to be a healthy child and this that does not only affect people who are homeowners.
You know, when, when When you're applying for, for some of these funds, having a car is, is, is too much, you know, and people end up losing their, their their modes of transportation and then they lose their jobs. And there there's just a very rapid cascade of consequences. and so we're definitely gonna see more people, um under the poverty level [00:17:00] and more people s suffering due to medical debt due to these changes.
Erika: And how do the changes in the bill affect our immigrant communities?
Shade: Great question. our IMI immigrant communities are going to be affected in many different ways. one component of the big beautiful bill is that some of the funding that's getting cut for Medicaid is going to go to immigrant immigration enforcement.
Right. So that, and, and what does immigration enforcement mean? Right now? It's, it's just a very big, complicated question, but for Funding for, for Medicaid funding for those that are. undocumented. there there's going to be significant, um changes in burden because there are some states that do not cover undocumented individuals at all, but now states that do, will be [00:18:00] significantly hampered in their ability to provide support to that to that patient population.
and I. By hampered they, there will, they will lose their federal funding. if they utilize their state funding in order to help immigrant populations or, or, or undocumented populations. Those documented populations will also have a lot of challenges as well. there are rules that are proposed, but not not necess, not actually enacted yet.
that would be very specific about what populations of documented individuals will be able to be eligible for Medicaid. And those that are seeking citizenship are already wondering if they should even apply to Medicaid because they, they wonder if [00:19:00] that's gonna affect their ability to be citizens.
And so that's already happening now. and that's a big challenge as well.
Erika: And especially with things changing so quickly and the statutes not having the specifics, we need to see how these impacts will happen. There's a large concern that people who find themselves unable to participate in Medicaid may actually also find themselves unable to access healthcare plans through the Affordable Care Act.
And why is that happening, and do we have any idea of what kind of impact or the scale that might have?
Shade: So I don't know as much about the Affordable Care Act, and I'll be very honest about that. I do know that they will, that there are the costs of the Affordable Care Act. the cost of marketplace insurance is going up significantly.
It is what I'm hearing from folks is that it's not necessarily as significant [00:20:00] if you re if you're at a certain, um income level. But, but beyond certain income levels, it people are being impacted already by the Affordable Care Act. And so those that are undocumented, that are documenting their income where they're already.
Starting to track this information. they have the potential to have their confidentiality breached, and that is a huge burden. That's a, that's a huge danger for those that are undocumented. And so I think many are going to be very careful about their decisions to participate in marketplace insurance.
Erika: And I think if the pandemic taught us anything, it's that we're all in this together in terms of keeping our communities healthy. So, you know, thinking about, you know, diseases spreading unchecked or all sorts of things happening that we're just not capturing if we don't have everyone participating in [00:21:00] healthcare is really scary.
Shade: Yes. Yes. And, and you know, to that point. When we talk about those that are undocumented, they, the protections that they have are, are very few. and in certain states their occupational protections are even more limited. And so for, for those folks that are. Working, they're, they're working, contributing to the workforce paying taxes and putting themselves at danger and in danger and not able to get the healthcare that they need is is really unfortunate.
I, I mean, it's worse than unfortunate. It's, it's horrible. and, and we really Have some important ways that we can talk to our legislators about, about our concerns because these rules are not enacted yet. Right. And so there's [00:22:00] still the potential to make some change.
Erika: Yeah. Do you have advice for people listening to this podcast or people who have been on Medicaid or people who are taking care of those on Medicaid for how to speak up to make things better?
Shade: Yes, and talk to your get to know and talk to your legislators, your state legislators, your federal legislators, and you know, it's not as challenging to access them as you think. And yes, you can call, you can send form letters. Calling is really important, and calling is really, really helpful. you can send those form letters, but even two or three sentences that are specific to your concerns sent to a legislator can get, um can get notice.
And sometimes when you approach them, say, I'm really happy to, I'm an expert in X, Y, or Z, and I'm happy to have a conversation with you or one of your staffers [00:23:00] regarding these concerns. And. Plenty of people have actually been contacted, especially when they say I'm an expert and put their references. and that and that can be really helpful and, and people, um and legislators, I think will listen to that, especially if they're you representative in the state or at the federal level.
Erika: Absolutely. Well, I wanna thank you so much in general for being a pediatric pulmonologist because obviously we need more of them and for your service to your community and to everyone trying to help understand the impact of these Medicaid cuts and what they can mean for all of our patients, whether children are adults.
I also wanna be respectful of your time. Is there anything else you wanna add?
Shade: There's a little bit I do wanna add, I think that it's important to know that the American Thoracic Society has always supported and and emphasized that everyone deserves healthcare. and, and I say [00:24:00] always, but you know, since the early nineties, it's been a very long time.
and the American Thoracic Society is working. Really hard with, um with other organizations including the American Academy of Pediatrics in order to help protect, um these vulnerable populations. And while they are very, very. Interested and very, very invested in in, in doing this really, really important work.
They are. Open and want to listen to the voice of the members of the American Thoracic Society. And so speaking to those folks and those individuals within the American Thoracic Society is important as well to tell them how imp important you feel that these things [00:25:00] are. and and, and help with communication with you know, with
Erika: with your legislators as well.
I'm just gonna make a little plug as a member of the council for chapter representatives for ATS members listening to this podcast to find out if their state has a local chapter so they can get involved together in talking to their state representatives at the, and even potentially even more locally, because the more voices are raised because this really is a state's issue, Medicaid is a state program that maybe we can find more solutions locally and community together than is sometimes possible at the national level.
Shade: Absolutely. Absolutely. and I, and I absolutely love what state chapters are doing and how state chapters are powerhouses for the for the American Thoracic Society, and they're growing more and more. So being involved in your state chapter is absolutely impactful and really [00:26:00] you feel like you're, you're.
You're in there, you know, fighting the good fight every day with other folks, fighting the good fight for the respiratory health of adults and children in the United States and and internationally.
Erika: Absolutely. We gotta help the world breathe, right? Yes. Well, I wanna thank everyone for joining us today as especially, oh my God, I'm so sorry.
It's okay. I wanna, oh my gosh, I'm so sorry. Well, I wanna thank everyone for joining us today, especially Dr. Afolabi. I will see you next time on the Breathe Easy podcast.
Speaker: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more a s Breathe Easy podcasts on transistor, YouTube, apple podcasts, and Spotify. Don't forget to, like, comment, and subscribe, so you never miss a show.