Category Archives: Medicaid

What Will the Trump Administration Mean for Medicaid?

After a long and highly contentious presidential election lasting more than a year, we now know that Donald Trump will be our next president. In the days since the election, Trump has nominated individuals for key posts in his cabinet. With the selection of Rep. Tom Price (R-GA)—an outspoken ACA critic—to head DHHS, and Seema Verma—a consultant who helped design waiver-based Medicaid expansions in conservative states—to head CMS, Trump’s intention to significantly overhaul Obamacare seems apparent. Indeed, recent commentaries from Jonathan Oberlander and Gail Wilensky make clear that Trump’s victory is not good news for Obamacare supporters and those benefiting from the law.

Repealing and replacing Obamacare entirely is unlikely, because Republicans lack the 60 Senate seats needed for cloture. Thus, the most likely path forward is through budget reconciliation, which requires only a simple majority. Unfortunately, that means the Medicaid program is a vulnerable target, which raises the question: What will the Trump Administration mean for Medicaid? There is not a simple answer to that question. Trump himself has offered conflicting views. While he campaigned on the idea of repealing Obamacare and block granting Medicaid, he also went on Dr. Oz and expressed support for ensuring that low-income individuals continue to have Medicaid coverage.

As I see it, there are four possibilities for the future of Medicaid. First, Congress and the Trump administration may repeal the Medicaid expansion. While both President-elect Trump and Speaker of the House Paul Ryan (R-WI) have advocated for repeal, doing so may prove politically unpopular. Matt Bevin mounted a successful campaign to become Governor of Kentucky, promising to end the state’s Medicaid expansion. However, once he entered office, the stark reality of taking coverage away from some 425,000 Kentuckians led Gov. Bevin to amend his position and pursue changes to the program instead.

Thus, a second possibility is that the Medicaid expansion continues, but that beneficiaries face new, more stringent eligibility requirements. For example, Speaker Ryan’s “A Better Way” proposal outlines the possibility of introducing work or education requirements, and enforceable premiums into Medicaid. His plan also precludes states from expanding Medicaid after January 1, 2016, permanently establishing the disparity in coverage between expansion and non-expansion states. Moreover, beginning in 2019, Speaker Ryan’s plan would slowly phase down the enhanced federal matching rate for the expansion population to normal levels. This reduction in federal funding may prompt states to reverse their decision to cover the expansion population.

A third possibility is that Congress and the Trump administration will limit federal Medicaid spending through a combination of per capita allotments and block grants. Under the per capita allotment approach, states would receive a fixed amount of federal funding for each Medicaid enrollee, based on the state’s federal matching rate. This means total federal funding would increase or decrease as enrollment increases or decreases, but the per capita amount would remain constant. Alternatively, states could opt to receive a Medicaid block grant—a lump sum based on enrollment and utilization projections.

In his “A Better Way” proposal, Speaker Ryan envisions this giving states “more flexibility to adapt their Medicaid programs, to better design benefit packages in a way that better meets the needs of their state populations, [and] promotes personal responsibility and healthy behaviors…”  Yet, as Colleen Grogan writes, states already enjoy tremendous flexibility in the design of their Medicaid programs. While proponents of Medicaid block grants suggest that they will free states to make their Medicaid programs more efficient, Jeanne Lambrew found that previous block grant proposals failed to predict actual patterns of Medicaid costs. In some cases, that meant that the federal government would have overspent in its attempt to control costs, while in other cases, it meant that state Medicaid programs would have been severely underfunded. Moreover, evidence from both Rhode Island and Puerto Rico fails to support any link between federal funding caps and Medicaid program efficiency.

Finally, there is the possibility that nothing changes. While such a scenario is unlikely, there are two ways it could happen. First, Republican governors in Medicaid expansion states—including Jan Brewer in Arizona and Rick Snyder in Michigan—may oppose efforts to repeal the expansion or implement a block grant because they have seen the expansion work well in their states, and want to avoid the political fallout of rescinding coverage. Second, the courts might preserve the program. Sara Rosenbaum suggests that capping federal Medicaid spending may be viewed as unduly coercive in the wake of the Supreme Court’s ruling in NFIB v. Sebelius, because states agreed to participate in Medicaid with the expectation of an ongoing federal match, not a fixed sum of federal dollars. Thus, the Supreme Court might rule that forcing states to accept Medicaid block grants is unconstitutional, and—just like the Medicaid expansion—might make the block grant optional for states.

While the future of the Medicaid program under the Trump Administration is unclear, the potential implications of serious disruptions to Medicaid for tens of millions of vulnerable Americans are frightening. In a blog post from March 17, 2015, Edwin Park of the Center on Budget and Policy Priorities wrote, “House Budget Committee Chairman Tom Price’s budget plan proposes to radically restructure Medicaid by converting it to a block grant and cutting federal funding for it steeply, by $913 billion over the next decade.” The cuts would put Medicaid spending in 2025 almost 34% below where it would be expected under current law. That certainly saves money, but at what cost?

Note: This piece first appeared at Public Health Post.

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Posted by on December 19, 2016 in Medicaid


Mental Health Loses Funding As Government Continues Shutdown




Budget Cuts









Everyone Benefits




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President Obama Fails To Explain Tech Glitches And Solutions In ACA Speech

Monday at 11:30am EST, President Obama spoke in the Rose Garden about the recent troubles with health insurance exchange enrollment and websites. With a team of young people standing behind him and Janice Baker at his side, the first person in the state of Delaware to successfully enroll in the exchange, President Obama said he was speaking to every American wanting to get affordable health insurance. He claimed that in the last three weeks, despite the horrific technological problems with the websites, that “half a million consumers across the country have submitted application through federal and state marketplaces.” He further touted that the “federal site alone has been visited 20,000,000 times” in the last three weeks. Unfortunately for those American’s who are really interested in signing up on the exchange sites, he glossed over the depth and breadth of the current troubles, giving a speech that sounded more like a State of the Union address with small-business examples and reading letters written to the White House.

President Obama also alleged that no one wants to see the exchange sites improve more than the federal government, noting that, “the website has been to slow, and people have been getting stuck during the process.” He also said that it is the mission of the administration to make them “more better,” with visible cringing from the audience, but claimed failures were due to response rates. He said the public response was “overwhelming, which has aggravated the underlying problems.”

However, he failed to go any further to explain what those other underlying problems were or when specifically they will be fixed. He did say that while HHS and contractors such as CGI Federal are working out the “kinks,” American’s should be patient. He claimed that “if the product is good, [American people] are willing to be patient,” suggesting that there will not be a delay for the individual mandate.

Nevertheless, he followed this by assuring the public that unlike Black Friday sales, the insurance plans will not run out like purchasing a new PlayStation – adding to the list of items the administration has compared exchange sites to, including iPhones and travel websites.

Despite his promises of improvements and putting the “best and brightest” on the job, CNN and other sites have insisted that the inherent technological and platform problems with will not be resolved anytime soon. This begs the question, that if the federal government is now searching for the best and brightest to correct the estimated 5,000-5,000,000+ lines of coding that need to be fixed on the federal site alone, who was working on the original platforms?

As he continued his speech, the President reminded the American public that although the websites for enrollment are not as, “quick, consistent or efficient as we want,” that the exchange sites are far more than “just a website.” He noted that many pieces of the Affordable Care Act (ACA) are already in place and being utilized by millions of Americans. He addressed pre-existing conditions, youth under the age of 26 and several other provisions that are already being rolled out by federal law, and the successes they have seen there.

He noted more examples of ACA triumph in Oregon, where he maintained that the exchange, “has cut the number of uninsured people by 10% in three week,” which is about “56,000 more Americans” with health insurance coverage.

During the speech, President Obama also tried to clarify the exchanges or marketplaces by describing them to the public as becoming part of a “big group plan… that bargains on your behalf for the best deal in health care.” He said that by doing so, insurance companies have created new products and options that strengthen market forces, leading to better deals.

He went on to say that without a doubt, “prices have come down,” further claiming that “when you add the next tax credits (those not yet implemented)… then the prices come down even further.”

The President rounded out his talk by noting the Republican party’s opposition to the ACA and how willing they were to “shut down the global economy” to fight against the ACA. A move, he claimed, that shows just how unwilling Republicans are to negotiate on legislation intended to, “free families from the pervasive fear that one illness one injury will cost you everything.”

While that may be the goal of the Affordable Care Act, the underlying technological and coding problems may prove to make that impossible.


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Closing Racial And Ethnic Disparity Gaps: Implications Of The Affordable Care Act






For those looking to Massachusetts, data does support a slight improvement in overall access to care by showing that Whites, Blacks and Hispanics all had increases in the number of insured, and further that the percentage of the state’s population that had “any doctor visit in prior year” between 2006 and 2009 rose by more than five percent.

Unfortunately, as many have argued, those for and against health reform, Massachusetts is not necessarily a good representation of other US states or populations, as anyone who has been to Massachusetts knows that the state population looks and behaves very differently from places such as southern California or the Southside of Chicago. Furthermore, even in Massachusetts the number of Blacks and Hispanics that remain uninsured is two and three times that of Whites, respectively.

Many of those who will be left uninsured will be Blacks, immigrants and Hispanics, who will continue to use Emergency Departments for critical care or, worse, go untreated.






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How the Supreme Court’s Decision Saves Money, Leaves People Uninsured






Deconstructing Conservative Excuses For Not Expanding Medicaid







4. There are hidden costs to this expansion.







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Posted by on August 3, 2012 in Medicaid


Medicaid and Red State Governors: A Love/Hate Relationship

In addition to the much discussed individual mandate, a central element of the Affordable Care Act designed to increase insurance coverage is the expansion of the Medicaid program to cover anyone with an income up to 138% of the federal poverty level. To put that into context for those who might not know, Medicaid eligibility currently has two requirements: income eligibility and categorical eligibility. Income eligibility means that your income has to fall below a certain level, which varies by state within certain federal guidelines. Categorical eligibility, which also varies somewhat by state, means that you have to be a certain “type” of person. For example, pregnant women and children are typically eligible for Medicaid, whereas very few childless adults are eligible. The Affordable Care Act changes that, making anyone who is low-income (again, 138% of poverty, or $30,843 a year for a family of four) eligible regardless of what other “category” they might belong to.

The odd thing about the ACA, though, is that it will actually be more generous to conservative states that have not previously established more generous Medicaid limits. Here’s why: Starting in 2014, the federal government will pay 100% of the difference between what states are currently covering and the new 133% of poverty threshold. This amount is gradually reduced over time, reaching 90% by 2020, where it is slated to remain indefinitely. While Medicaid is currently jointly financed by the federal and state governments, this new arrangement has the feds picking up the bulk of the costs of the new coverage. The thing is, some states, like Massachusetts, are already providing coverage of parents up to 133% of poverty. These states that are already quite generous will not receive much in the way of new federal money. By contrast, other states, like Texas, only provide coverage for parents up to 26% of poverty (that’s less than $3,000 a year). When they opt-in to the Medicaid expansion, the federal government will pay the full difference in cost of expanding eligibility up to 138% of poverty. That’s a lot of federal money to states like Texas. Generally, the more conservative states are the ones with the most uninsured persons and the strictest Medicaid eligibility requirements. Therefore, they are also the ones who will gain the most under the ACA.

Of course, this depends on their willingness to participate in the Medicaid expansion, which is optional. The ACA did include a provision that said that if states didn’t participate in the Medicaid expansion, the federal government could also withdraw their funding for the existing Medicaid program. The Supreme Court, however, said that this was coercive and unconstitutional. The result is that states are free to participate in the program or not, without fear of repercussions. Politically, republican governors are adamant about resisting implementation of the Affordable Care Act. Louisiana’s Bobby Jindal has already proclaimed that his state, whose health statistics place it squarely in the bottom of the country (50th in 2008, rising to 49th by 2011), will not be creating an insurance exchange and will not be participating in the Medicaid expansion. It’s unfortunate, because the people in these states are the ones who desperately need help the most.

Of course, the politically-motivated decision not to play ball will only hurt these states further, as they walk away from literally billions of dollars in federal assistance that would boost their economies and improve the health of their residents. There will also be pressure from organized health care interests to participate, because that money will reduce their uncompensated care costs. So, I’m not sure if the rhetoric we’re hearing today will hold true in the end. If it does, though, it will be a great example of bad politics dominating good policy, and the people it will hurt the most are the ones who are already wounded.

Update: As Nicole points out in the comments, the actual threshold is even higher than I originally stated. Medicaid eligibility goes up to 138% of poverty, not 133% as I had written. I have updated the text to indicate this.

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