If the U.S. Senate agrees with Congress to repeal and replace the Affordable Care Act,  San Francisco health care providers said their current practice of serving everyone would become unsustainable and in the long run, and services could be cut.

Representatives from three local healthcare providers all said that the Congress’s health care plan would likely result in thousands of San Franciscans losing coverage that they gained through the Obama-era Medicare expansion. Though they would continue to offer services to anyone who needs them, the institutions would be reimbursed for less of the care that they provide.

“In San Francisco alone, the ACA resulted in more than 130,000 people getting health insurance who hadn’t had it before, and that’s extremely meaningful,” said Dr. Susan Ehrlich, CEO of Zuckerberg San Francisco General Hospital referring to the Affordable Care Act. “Before ACA,  about 40 percent of our patients were uninsured, and now only about three percent are.”

President Donald Trump is proposing a major cut to Medicaid (known as MediCal in California) in his budget in support of the healthcare bill House Republicans approved.

Around half of the General Hospital’s revenue comes from MediCal, Ehrlich said.

The House bill, Ehrlich said, “could be devastating for us in terms of jeopardizing our revenue flow.”

“We would look for private philanthropy, we would look for grants, we would look for revenue wherever we could get it, but it’s such a large amount of money it would be difficult to recover all of it,” said Ehrlich, though she added that it’s unclear how much exactly would be cut under the Senate’s version of the bill, or if the Senate will even approve one.

At the Mission Neighborhood Health Center, 20 percent of the patients were able to get insurance through Medicaid, according to said Brenda Storey, the executive director. Statewide roughly a third of residents are covered by Medicaid, known as Medi-Cal in California.

There are layers of setbacks associated with a decrease in Medicaid coverage, health administrators said.  One of them is that the Republican proposal includes funding Medicaid on a per-capita basis, rather than basing it on the proportion of the population that needs it.

The new proposal, said Storey, talks about Medicaid on a per capita basis.

“There’s some disincentives there already,” Storey said. “One of the things…that you don’t have is the flexibility to say the population in need of Medicaid increases so the funding increases.”

What’s more, for those who enrolled in Medicaid during the Obamacare expansion, the proposal would require the state to redetermine eligibility every six months. Inevitably, income fluctuations and administrative hurdles would result in lapses in coverage.

“If we had to renew our license every six months I’m sure we would lapse too,” Storey said.

It’s not just a lapse in coverage, however.  Costs will go up.

Obamacare’s Medicare expansion upped funding to allow for a 90 percent reimbursement of costs for patients enrolled through the Medicaid expansion. The rest of California’s Medi-Cal patients, those who did not enroll through the expansion, are subject to just 50 percent reimbursement.

Under the proposed Trumpcare plan, the lower reimbursement rate would also apply to anyone who enrolls in Medi-Cal as of 2020. Those whose coverage lapsed would return at the new, lower reimbursement rates, Storey said.

What’s also at stake is coverage for the most vulnerable. Tax credits, one of the ways the new bill proposes to help people pay for health insurance plans, would be calculated by age rather than income.

Plus, “In order to benefit from a tax credit you have to have income,” said Ehrlich of General Hospital. “A lot of patients don’t have enough income to benefit from a tax credit. And they also have a lot of things going on in their lives like homelessness, illness, substance abuse that make it difficult for them to access [services].”

Inevitably, the hardest hit will be those who are already struggling. According to Miriam Gerace, communications director at Planned Parenthood of Northern California, more than 90 percent of the 11,000 people Planned Parenthood serves in San Francisco every year earn at or below twice the federal poverty level. That’s about $24,000 for an individual, and $40,000 a year for a three-member household.

“Imagine in San Francisco trying to live on $40,000 with a family of three,” Gerace said.

She, too, mentioned the state’s reimbursement rates, calling them “very low.” The result Gerace has observed is that some providers do not accept Medicare patients because they cannot function without sufficient reimbursement.

All three of those Mission Local spoke with said they will continue to keep their doors open to anyone regardless of insurance or immigration status. But with reimbursements reduced, that would cost them.

“We will certainly continue to serve the community. I think it will be over the long term, if we have less people who end up being on Medi-Cal then that’s less funding coming into the Health Center,” Storey said. “We will try to fundraise the difference try to advocate at the state level for funding and at the local level also.”

Gerace at Planned Parenthood, however, sees the crisis as already impending.

Planned Parenthood faces a different problem: Under the bill passed by Republicans, the provider would be barred entirely from getting any Medicaid reimbursements for a year, because of Republican refusal to allow federal dollars to go to an institution that in some cases provides abortions (though the Hyde Amendment already bars federal funding from being used specifically for abortion).

“As far as we’re concerned, the crisis is already here, we already needed to shore up our funding even before the federal funding was threatened,” Gerace said. “If it were to happen, it would be a significant hit. And what I want to emphasize is that it wouldn’t be on us as an organization, it would be on our patients, and that’s why we’re going to fight with everything we’ve got to make sure that doesn’t happen.”

In order for the new healthcare bill to pass it will need Senate approval, but significant adjustments are expected before a vote, and a vote date has not yet been set.