Amy Bredeson hears the question but waits to answer until she moves out of earshot of her 11-year-old daughter, Chloe.
Then, in a lowered voice, the 40-year-old Bluffton resident explains what she fears will happen if Congress passes a proposed rollback of federal spending on Medicaid, the program that provides insurance primarily to the poor and disabled.
“If we took her off the drug, the brain tumor could grow back very quickly,” Bredeson says of a $15,000-a-month pill Chloe takes each morning, which also prevents seizures. “The cysts on her kidneys could start growing again, and she could need a transplant a lot sooner.
“I think things would go downhill quickly for her.”
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Bredeson is one of more than 1 million S.C. residents who depend on Medicaid – in her case, to pay for Chloe’s expensive treatment for a pair of life-threatening diseases.
Many of those South Carolinians will watch anxiously as the U.S. Senate returns Monday to consider a proposal to repeal and replace the Affordable Care Act, also known as Obamacare. That plan is expected to cut rising Medicaid costs by $772 billion over a decade, according to the nonpartisan Congressional Budget Office.
But not everyone is sounding the alarm about the potential Medicaid cuts.
U.S. Sen. Tim Scott, R-North Charleston, says the plan will not affect S.C. residents who depend on Medicaid because South Carolina was one of 19 states that did not expand health care coverage after Obama’s signature health-care law passed.
“If you’re currently on Medicaid, I can’t think of any scenario as a South Carolina resident that you would lose coverage, because Medicaid coverage won’t change,” Scott told The State newspaper.
However, some national experts, S.C. health care professionals and state legislators say the proposal will hurt.
The plan eventually would leave 22 million more people without health insurance nationally – and 215,000 more in South Carolina, including 49,000 children, according to estimates.
A key change in the Senate plan is a cap on Medicaid contributions to states. That would force state lawmakers across the country to make tough decisions about where those limited health care dollars flow, threatening services South Carolina now chooses to provide to families.
Programs that could be in danger include one that makes children with severe disabilities – like Chloe – eligible for Medicaid despite their parents’ income.
S.C. lawmakers “would be asked to make some horrendous choices” about whether to extend those programs “for patients with the most challenging medical issues,” said state Sen. Brad Hutto, an Orangeburg Democrat and a member of the state Senate’s Medical Affairs Committee.
Capping federal contributions to states could force some of them to pay less to health care providers, Hutto said. That could lead physicians and other providers to refuse Medicaid patients, leaving those patients to rely instead on costly emergency room visits, Hutto said.
The Senate’s proposal also would hurt S.C. hospitals – especially in poor, rural areas – that rely on Medicaid reimbursements to stay afloat, S.C. Hospital Association spokesman Schipp Ames said.
States could make up the lost funding by raiding other government services, such as education or public safety, said Robert Hartwig, an insurance expert at the University of South Carolina’s Darla Moore School of Business.
Or, he said, they could raise taxes to pay for Medicaid, but that proposal would “go over like a lead balloon in very conservative states” like South Carolina.
Before the Senate takes up the hotly contested proposal, here is a look at other ways the plan would affect S.C. residents:
Spending caps threaten SC’s most vulnerable
Cuts to Medicaid would affect South Carolina’s children, seniors and people with disabilities.
Roughly 70,000 of the more than 1 million Medicaid recipients in South Carolina are elderly, according to the S.C. Department of Health and Human Services.
Medicaid covers long-term care for low-income residents of nursing homes or assisted living facilities after Medicare’s coverage period of 100 days ends. Medicare is the federal health insurance program for seniors.
The state’s youngest residents – 650,000 of whom are on Medicaid – also will lose out, according to estimates.
Under the GOP plan, 49,000 S.C. children would lose insurance by 2022, doubling the number of uninsured children from 1 in 20 to 1 in 10 in South Carolina, according to the Urban Institute, a think-tank in Washington, D.C.
Limiting Medicaid spending also could impact the nearly 30,000 S.C. residents with disabilities who receive treatment through Medicaid programs that the state chooses to provide.
If Medicaid spending is limited, those programs, which the state offers voluntarily through its disabilities and Medicaid agencies, could be cut.
The programs already are in high demand. As of June 1, more than 8,000 S.C. residents were waiting for services through Disabilities and Special Needs alone.
Some taxpayers win
The GOP plan includes good news for some S.C. taxpayers.
Those without health insurance would no longer would suffer penalties.
The Senate’s “Better Care Reconciliation Act” would eliminate Obamacare’s individual mandates to purchase health insurance.
In 2014, about 122,750 S.C. taxpayers paid a combined $24 million in federal penalties for not having health insurance. The average payment was $197.
The GOP plan also offers tax credits to help with the cost of health insurance. But South Carolina will receive far less in 2022 under the GOP plan than it would under current law.
The Urban Institute estimates federal spending on tax credits will drop to $215 million in South Carolina under the GOP Senate bill in 2022. Under current law, S.C. enrollees would receive $1.1 billion in tax credits and other cost-sharing reductions.
Higher-income households also would see big tax breaks.
Individuals who make $200,000 a year or couples who earn $250,000 would get a tax break. The GOP plan would roll back Obama-era Medicare tax increases on wages and investment income.
Pre-existing conditions could cost more
Roughly 1 in 6 South Carolinians – 822,000 – has a pre-existing condition that, under the Affordable Care Act, could not be grounds for denying health insurance coverage or for charging them far more than healthier people for the same coverage.
Under the GOP plan, South Carolinians with pre-existing conditions still could not be denied coverage. They also could not be charged higher premiums because of their health status.
However, states could ask permission to allow insurance companies to provide fewer benefits in their plans, passing on the cost of treatments to patients. Reducing covered health-care services could make it difficult or impossible for people with pre-existing conditions to afford their treatment, according to experts who analyzed the bill.
Working families, whites biggest losers
Whites and working families would be impacted the most.
Under the Senate GOP bill, the number of S.C. whites under age 65 without insurance would climb from 272,000 in 2022 under current law to 425,000.
That would leave 18 percent of white S.C. residents without coverage by then, up from the 11 percent projected under current law, according the Urban Institute.
By comparison, 17 percent of S.C. blacks – 188,000 – would be uninsured in 2022, up from 153,000, or 14 percent, projected under current law to be uninsured by then.
Working class families also would take a hit, experts say.
The GOP bill would increase by 192,000 the number of uninsured S.C. residents with a full-time worker in their family to 594,000.
About 23,000 South Carolinians with no full-time workers in the family would lose insurance, bringing their ranks to 225,000.
‘Bravest little girl’
Bredeson, a part-time freelance writer who home-schools her son, says her family can’t afford for Chloe to lose coverage.
Chloe needs the expensive medicine to fend off the growths and seizures that led doctors in 2010 to diagnose her with two serious diseases, tuberous sclerosis complex and polycystic kidney disease.
Medicaid covers that medicine and Chloe’s periodic visits to see a lineup of specialists from Charleston to Memphis, Tenn., who monitor her growths and her blood pressure. Bredeson estimates Chloe’s treatment by now would have cost millions without insurance. Bredeson expects her daughter will take the medicine for life.
Nowadays, Chloe can live a mostly normal life. She has not had a seizure in four years, and the growths seem to be shrinking.
An honor roll student last year, she is heading to sixth grade in the fall.
She doesn’t stop smiling, even during medical tests. She rarely stops singing, and she enjoys dancing with the children’s worship team at her church. Her mother calls her the "bravest little girl you'll ever meet.”
But Bredeson worries about congressional Republicans’ plans for Medicaid. She says she has left messages with the offices of both S.C. senators — Scott and Lindsey Graham — once crying over the phone as she explained Chloe’s conditions and how heavily her family depends on the federal entitlement program.
“I know they don’t want to take away coverage from a little girl who needs it to stay alive.”
SOURCES: Urban Institute, Kaiser Family Foundation, S.C. Department of Health and Human Services and Department of Disabilities and Special Needs, and the Congressional Budget Office
Staff writers Cassie Cope and Bristow Marchant contributed to this story.