Medicaid exposes GOP rifts on ACA

As congressional Republicans move from talking points to details of how to abolish the Affordable Care Act, behind-the-scenes jockeying over the future of Medicaid demonstrates the delicate trade-offs the GOP faces in trying to steer health policy in a more conservative direction.

For years, many Republicans have railed against the ACA’s expansion of Medicaid, which has extended coverage to about 11 million people. But now that they have the political power to reverse those gains, internal disagreements have emerged.

Some lawmakers want to preserve the federal money their states are getting under the expansion. Others argue that part of that money should be shifted to states that did not broaden their programs — or used for other purposes.

Drew Altman, president and chief executive of the Henry J. Kaiser Family Foundation, said Republicans are “between a rock and a hard place, unless they want to spend more money to preserve the expansion and pay off the non-expansion Republican states who feel like they have toed the party line.”

Some of that intraparty debate spilled into public view Thursday at a Senate confirmation hearing for health-care consultant Seema Verma to lead the Centers for Medicare and Medicaid Services, an agency that oversees $1 trillion in federal spending within the Department of Health and Human Services.

Two GOP senators whose states have expanded Medicaid pressed Verma for her views. She often deflected their questions.

The divide over Medicaid’s future is a legacy of a 2012 Supreme Court decision giving states the choice of whether to embrace the ACA provision that for the first three years has paid the entire cost of covering Medicaid-expansion beneficiaries — adults earning up to 138 percent of the federal poverty level, or about $16,000 a year.

Thirty-one states and the District of Columbia decided to do so, and the law steered roughly $79 billion in new federal funds to them in just the first 18 months, according to a Kaiser Family Foundation analysis.