SAN JUAN COUNTY, Wash. — Dr. Amy Harley, a public health physician, told the San Juan County Board of Health on July 16 that recent federal changes to Medicaid contained in the Budget Reconciliation Act could sharply reduce federal support for state Medicaid programs and lead to coverage losses locally.

Harley said the act’s combination of more frequent eligibility checks, new work or community engagement reporting, limits on tools states use to shore up provider payments, and higher enrollee cost-sharing together are projected to cut federal Medicaid funding nationally by about $1 trillion over 10 years and to reduce coverage for an estimated 12 million people nationwide.

Why it matters: Harley said Washington state is expected to lose roughly $3 billion a year under current projections and that approximately 329,000 people in Washington could lose coverage — a scale she said the state could not realistically backfill entirely from its own budget. Harley told the board that the federal estimates translate to an expected roughly 500 people in San Juan County who could lose Apple Health (Washington’s Medicaid) coverage if the projected dislocations occur.

Key details discussed
- Major provisions highlighted by Harley included increased frequency of eligibility checks for Affordable Care Act expansion adults (from annual to every six months), a possible 80-hour-per-month work/school/community engagement requirement for some enrollees, new restrictions on state mechanisms (provider taxes and directed payments) used to increase provider reimbursement, and added cost-sharing for some low-income enrollees. Harley said such administrative and policy changes have been shown in other states to reduce enrollment and provider participation without improving employment outcomes.
- Harley gave three illustrative examples of how Medicaid coverage supports families and seniors — a working single parent who relies on Home and Community Based Services for a child with developmental disabilities, an older adult who avoids nursing home placement because of in-home supports, and a man whose enrollment enabled access to medication-assisted treatment and housing support after an overdose. She used those examples to underscore that many services often labeled “optional” at the federal/state level are nonetheless essential in practice.
- Timing: Harley noted many provisions are phased in or delayed and that the most consequential changes are projected to begin in 2027. That delay gives counties time to plan but complicates clear public messaging because local effects may not appear immediately after passage.

Local numbers cited
- Harley reported roughly 3,500 Apple Health clients in San Juan County, with about 1,300 children, 1,800 working-age adults and 338 adults 65 or older who are dually eligible for Medicare and Medicaid.
- She reported the federal bill’s national projection of 12 million people losing coverage, 329,000 in Washington state, and an estimated ~500 in San Juan County.

Board response and next steps
Board members and county staff asked how the county can prepare. Harley proposed local planning actions: coordinate with providers and managed-care organizations to monitor enrollment and access; track changes in utilization and health outcomes; support local navigation and enrollment services to help residents meet new reporting requirements; and consider redeploying local funds to protect critical safety-net services most likely to be affected (seniors, people with disabilities, behavioral health, low-income working adults).

"Health coverage saves lives, protects economic stability, and, promotes equity in our community," Harley told the board when describing the stakes of coverage loss.

Harley closed by urging local leaders to begin inventorying which services are locally essential, to monitor state-level decisions about which eligibility groups and optional benefits Washington might change, and to gather local stories that document real-world effects if coverage is reduced.

What the county will watch next: Harley said the county will monitor state-level budgeting decisions and program design, and encouraged local agencies to document case examples so the county can show legislators concrete impacts.