jonetta rose barras: Battling the local and federal hits to health care in DC

Oct. 1, 2025, may go down as some sort of health care D-Day in DC. By some estimates more than 50,000 residents who are currently enrolled in Medicaid, the DC Health Care Alliance or below-market Affordable Care Act coverage through the DC Health Benefit Exchange Authority could experience reductions in benefits, an increase in costs or the complete loss of insurance, according to government and private sector experts with whom I spoke this week.

Republicans in the U.S. House of Representatives — mostly President Donald Trump sycophants masquerading as elected officials concerned about American citizens — have already voted to change eligibility standards for Medicaid and impose an hourly work threshold for retaining benefits. They are also moving to restrict the ability of many lawfully present immigrants to obtain health care coverage and penalize any states that assist undocumented immigrants. 

DC residents may have been prepared for the GOP chainsaw. However, many were unprepared for the news that Mayor Muriel Bowser and her deputy mayor for health and human services, Wayne Turnage, delivered last week during a presentation of their proposed fiscal year 2026 budget and financial plan. Hoping to rein in spending, they announced that the city intends to tighten Medicaid eligibility, resulting in 25,575 residents being kicked out of the program effective Sept. 30. According to published reports, another 27,000 residents could also be shifted from the Healthcare Alliance. 

It’s unclear what exactly will happen in terms of alternative coverage for the Alliance members, many of whom are undocumented workers. However, the DC Health Benefit Exchange Authority is moving to create a Basic Health Plan for the displaced Medicaid recipients.

Who knew?

“We found out about this when everyone else did when the budget was released Tuesday,” said Adrian Jordan, president and chief executive officer of Amerigroup DC, one of three managed care organizations in the city under contract with the District government to work with Medicaid recipients and others. Residents receive care through the networks of health and wellness providers arranged by the MCOs, which are principally insurance companies.

“Worst-case scenario, [Medicaid recipients] could lose coverage or be dropped by one of the managed care organizations,” explained Jordan. “For some, it could mean that if they want to have health insurance, the only insurance they would be able to get will be through their employers.”

The District of Columbia Hospital Association likewise didn’t receive advance warning, a spokesperson told me during a telephone interview. He said that the group’s “priority is making sure care is being provided to District of Columbia residents.” 

“We continue to evaluate the [mayor’s] policy proposal and expect more information about the Basic Health Plan and how that works,” the spokesperson added.

If major contractors and providers were unaware of upcoming changes, it’s fair to say the more than 280,000 participants in DC’s various subsidized insurance programs were also left in the dark. Why the secrecy?

Mila Kofman, executive director of the DC Health Benefit Exchange Authority, told me earlier this week that she and her team began their work as early as March in consultation with Bowser and Turnage. “We started to figure out what the best possible option is, understanding that these folks are moderate-income wage earners and traditional commercial products are not the best for this income level because of premiums and because of out-of-pocket costs for care, like deductibles and copayments and coinsurance,” she said during our extensive interview.

Under the Affordable Care Act, states have the option to create a Basic Health Plan — with the federal government picking up most of the tab, at least under current rules. As Kofman considered whether a BHP was the best route for DC, she assessed the experience of other states. Simultaneously, she engaged her technology expert, who was a “principal developer for our DC Health Link system.”

“We engaged in those conversations very early, because if you wait too long to start figuring out what IT changes you need and start building them, then you won’t be able to get things done on time,” continued Kofman, taking me through the process of trying to construct a rescue hatch for nearly 26,000 “childless adults and adult caregivers who are at between 138% and 200% of the federal poverty level,” many of whom likely do not have steady employment or whose jobs do not include health benefits.

I have committed to following how the city addresses the needs of those residents who are kicked off the only health insurance they’ve been able to afford. Kofman has a deadline of Oct. 1 — a feat that seems impossible to many people, including myself.

“The exchange is no stranger to doing hard things,” said Jordan. “But there is not a lot of time to have a seamless process.”

Kofman said she is up for the task. However, known and unknown obstacles await her. The DC Council is just beginning budget deliberations. Will any of its decisions affect her work?

The U.S. House of Representatives has already voted on its reconciliation bill, which incorporated significant changes to Medicaid. A day before the May 22 vote, Kofman and others from the state marketplaces sent a letter to Speaker Mike Johnson and Minority Leader Hakeem Jeffries warning of dire impacts: “The legislation under consideration in the House … will make for a sicker, less financially secure American public and strain hospitals and health care providers by increasing uncompensated care.”

The “risk is further compounded by proposed cuts to Medicaid and the impending expiration of Enhanced Premium Tax Credits,” wrote the 18 signers from Maryland, Virginia, Colorado, Idaho, Pennsylvania and New Jersey, among others.

Those premium credits have made it possible for lower-income families and individuals to afford insurance on the commercial market. The legislation that authorized them is set to expire at the end of this year, said Kofman. 

Johnson and his Republican caucus ignored the concerns raised by Kofman and her colleagues, the same way they dismissed Bowser when she pleaded with them to vote on a Senate-approved fix to the Continuing Resolution that imposed a $1.1 billion cut on DC in the middle of this fiscal year.

The Senate has not finished its budget deliberations. Many people hope its actions will be less severe. Don’t be shocked, however, when Republicans in the upper chamber also slash programs critical to the survival of average Americans.

Nevertheless, Kofman seemed confident her office could reach its goal. “We have a successful record of standing up very complex programs. We built the exchange in nine months. There was no blueprint. No one in the world had done it. And we were the last to start our IT build-out. [Still], we were one of four to open on time.”

She also noted that “when the Massachusetts Health Connector for Business, which is their exchange, went looking for someone to replace their IT system and support their operational side for their exchange for business, they didn’t go with a private sector [entity] or any other state — they went with us.” That was in 2017. 

In the week and a half since Bowser released her budget proposal, finally exposing to the public her health care intentions, Kofman has begun putting her show on the road. “People didn’t know anything about it . … My deputy and I started to have those conversations.

“We reached out to stakeholders. … I reached out to all three MCOs to have at least a preliminary conversation with each of them. I also reached out to our two carriers on the individual market side to make sure they were aware that this was happening,” Kofman continued. 

“If people oppose [this] because change is hard, that’s just not good enough, right? We’re in this together, and we need to get to the best possible place we can get to for everyone involved — our residents, our providers, the medical community,” she added during our virtual interview at 8 a.m. Monday. 

By late afternoon, Kofman was hosting the first meeting of her advisory council composed of health care experts, providers, nonprofit managers and community advocates. It’s led by Linda Elam, a former director of DC’s state Medicaid office and a former chief executive officer of Amerigroup. 

“We don’t have all the answers,” Kofman said. “We need to rely on experts on the ground. We need to rely on advocates. And we need to understand physician issues, carrier issues, broker issues [and], in some cases, job-based employer issues. 

“It can be challenging,” Kofman added. 

That may be speaking in understatement. Her next major task will be working with federal officials to ensure what the exchange is doing is “aligned.”

Then the team will have to create a “blueprint” of DC’s Basic Health Plan, including the scope of coverage, which Kofman said “would have to be like Affordable Care Act benefits” — meaning that, unlike Medicaid plans, there would be no guarantee of adult dental or vision coverage. There is also a “difference in how behavioral health is covered.”

Kofman said the feds require the blueprint to be posted for 30 days for public comment. “We like to get a lot of feedback, so we are asking our new advisory council for feedback before we post the draft for public comment. Our advisory council has expert and community voices, and they will help inform the draft blueprint.”

That process will begin as soon as next week, according to Kofman. “We will review public comments and modify, as necessary.” Then, the document will be presented to the feds.

Knowing the nest of incompetents leading federal agencies under the current administration and getting in the way of seasoned professionals trying to do their jobs, I do not share Kofman’s optimism. A couple of members of her advisory committee, including Patricia Quinn, wondered more about local DC agencies, however.

Medicaid transitions haven’t always gone smoothly here, Quinn said. She’s right: I have certainly written about contract debacles and sagas during which well-articulated plans were upended by incompetence or politics. But I won’t rehash all of that.

Even as Kofman tried to persuade her advisory council members, I kept thinking of something she said during our earlier conversation: “The Basic Health Plan standards are on the private market side. As you’re thinking about potential risks on the public insurance side, keep in mind that our potential risks are actually whatever is done on the [Affordable Care Act] side.“

For example, immigrants who are in the country legally — on a visa or having been granted asylum — currently qualify for lower premiums through the ACA. However, the bill recently approved by the House changes that. 

Unless the Senate rejects that section of the measure, those individuals will no longer qualify for the lower premiums, explained Kofman.

“We looked at our enrollment. Currently, there are about 300 people who get lower premiums, who will no longer qualify if the Senate passes [the House] version,” she said.

DC’s Medicaid program doesn’t include undocumented immigrants, per long-standing federal rules. Still Kofman’s example makes clear that with Trump Republicans in charge and the District in fiscal crisis, trying to construct a truly effective rescue hatch for nearly 26,000 lower- and moderate-income residents may turn out to be a fool’s errand.

jonetta rose barras is an author and DC-based freelance journalist, covering national and local issues. She can be reached at thebarrasreport@gmail.com.