With Trump win, GOP eyes Med­i­caid

The Washington Times Daily - - POLITICS - BY CHRISTINA A. CAS­SIDY

AT­LANTA | When Pres­i­dent-elect Don­ald Trump takes of­fice in Jan­uary, Repub­li­cans will have the op­por­tu­nity to pull off some­thing they have wanted to do for years — over­haul Med­i­caid, the pro­gram that pro­vides health care to tens of mil­lions of low­er­in­come and dis­abled Amer­i­cans.

Any changes to the $500 bil­lion-plus pro­gram hold enor­mous con­se­quences not only for re­cip­i­ents but also for the states, which share in the cost.

Mr. Trump ini­tially said dur­ing the cam­paign that he would not cut Med­i­caid, but later ex­pressed sup­port for an idea pushed for years by Repub­li­cans in Congress — send­ing a fixed amount of money each year to the states in the form of block grants. Back­ers say such a change in the Med­i­caid for­mula is one of the best ways to rein in spend­ing, but crit­ics say big cuts would fol­low.

Cur­rently, the fed­eral gov­ern­ment pays an agreedupon per­cent­age of each state’s Med­i­caid costs, no mat­ter how much they rise in any given year.

Repub­li­cans have ar­gued that states have lit­tle in­cen­tive to keep ex­penses un­der con­trol, be­cause no state pays more than half the to­tal cost. Both House Speaker Paul D. Ryan and Mr. Trump’s pick for sec­re­tary of health and hu­man ser­vices, Ge­or­gia Rep. Tom Price, want to switch to block grants.

Key ques­tions fac­ing Repub­li­cans will be how the fund­ing is struc­tured and how much flex­i­bil­ity will be given to the states.

“It’s ex­cit­ing be­cause you know it’s not go­ing to be the same as it was, and it’s nerve-wrack­ing be­cause you know it’s not go­ing to be the same as it was,” said Terry Eng­land, a Repub­li­can state law­maker who chairs the House bud­get com­mit­tee in Ge­or­gia.

Repub­li­can con­trol of Congress and the pres­i­dency means the GOP can act on its long-held pri­or­i­ties of rein­ing in en­ti­tle­ment pro­grams and re­peal­ing Pres­i­dent Obama’s health care law, which al­lowed states to ex­pand the num­ber of peo­ple eli­gi­ble for Med­i­caid. Thirty-one states have opted for the ex­pan­sion.

It is not clear what the GOP’s re­place­ment plan will look like. Democrats have warned of dire con­se­quences, and any pro­posed changes are likely to trig­ger a fight in Congress.

Last week, the Demo­cratic Gov­er­nors As­so­ci­a­tion warned that re­peal­ing the Af­ford­able Care Act would end health cov­er­age for mil­lions of peo­ple and shift the fi­nan­cial bur­den onto the states, cost­ing them $68.5 bil­lion in un­com­pen­sated care over the next decade. The group said the Med­i­caid ex­pan­sion alone has pro­vided cov­er­age for mil­lions of Amer­i­cans who lacked in­sur­ance and that it had been a crit­i­cal tool for states in com­bat­ing the opi­oid epi­demic.

In 2012, a plan by Mr. Ryan to re­duce the fed­eral deficit in­cluded a pro­posal to con­vert Med­i­caid fund­ing into block grants with a cap on the amount the fed­eral gov­ern­ment would pro­vide. Ad­vo­cacy groups warned that that ap­proach would ul­ti­mately lead to fewer peo­ple re­ceiv­ing cov­er­age.

The Con­gres­sional Bud­get Of­fice con­cluded that un­der Mr. Ryan’s pro­posal, “states would need to in­crease their spend­ing on these pro­grams, make con­sid­er­able cut­backs in them, or both.”

Ear­lier this year, Mr. Ryan and other Repub­li­can lead­ers of­fered an­other, more flex­i­ble op­tion: States would re­ceive a fixed amount from Washington for each per­son en­rolled. That ap­proach would al­low fed­eral pay­ments to grow if, for ex­am­ple, a re­ces­sion forced more peo­ple onto Med­i­caid.

More than 70 mil­lion are on Med­i­caid, nearly 10 mil­lion of them cov­ered as a re­sult of the ex­pan­sion.

GOP bud­get doc­u­ments say fed­eral spend­ing on Med­i­caid has in­creased 200 per­cent in the past 15 years, and the Con­gres­sional Bud­get Of­fice projects it will climb 68 per­cent over the next decade to $642 bil­lion. In ad­di­tion, to­tal state spend­ing on Med­i­caid is ex­pected to rise from about $216 bil­lion in fis­cal year 2015 to more than $337 bil­lion in 2023.

How the GOP over­haul is ul­ti­mately struc­tured will be crit­i­cal, said Matt Salo, ex­ec­u­tive di­rec­tor of the Na­tional As­so­ci­a­tion of Med­i­caid Di­rec­tors.

“Some of my mem­bers are look­ing at this and say­ing if this isn’t done right, if the money doesn’t match what needs to be done, this is po­ten­tially the great­est in­ter­gov­ern­men­tal trans­fer of fi­nan­cial risk in the coun­try’s his­tory,” Mr. Salo said.

States, many of them strug­gling with bud­get short­falls, could end up cov­er­ing fewer pro­ce­dures or med­i­ca­tions, in­sti­tut­ing work re­quire­ments or re­quir­ing co-pays or pre­mi­ums. Those that opted to ex­pand Med­i­caid could de­cide it’s no longer sus­tain­able.


House Speaker Paul D. Ryan wants to over­haul Med­i­caid, in­clud­ing send­ing a fixed amount of money each year to the states as block grants.

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