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Explaining Medicaid’s Starring Role in the U.S. Health Debate

The biggest single change called for by the Republican health-care bill that may be voted on by the U.S. Senate this week is its reduction in federal spending on Medicaid, the program for poor and disabled Americans. The bill is being championed by Majority Leader Mitch McConnell and backed by U.S. President Donald Trump as a way to "repeal and replace” the Affordable Care Act, also known as Obamacare. The Senate bill, like one passed in May by the House of Representatives, would roll back Obamacare’s expansion of Medicaid and make other far-reaching changes to the program as well.

1. Who does Medicaid serve?

It’s the biggest health insurer in the U.S., providing benefits to about one in four Americans. It covers almost half of all births, almost two-thirds of people in nursing homes, almost 40 percent of all children and almost a third of adults with disabilities. Total Medicaid spending was $552 billion in the 2015 fiscal year, 17 percent of overall health spending. Along with education, Medicaid is one of the two largest components of spending by state governments, which administer the program and fund it in partnership with the federal government.

2. How did Obamacare change Medicaid?

It expanded Medicaid to cover those who were unable to afford private insurance but didn’t have incomes low enough to qualify for Medicaid before. After a Supreme Court ruling made the expansion optional, 31 states and the District of Columbia used the financial incentives offered under the Obamacare law to add about 12 million people to the Medicaid rolls. To congressional Republicans’ ire, the expansion was funded in part by tax increases on higher-income people. The federal government pays more than 90 percent of the cost of the Medicaid expansion.

3. What would the Republican bills do?

Reverse the expansion of Medicaid, at different paces. The House bill would wind down funding for the expansion starting in 2020. The Senate bill would phase out the expansion’s funding between 2021 and 2024.

4. How else would they change Medicaid?

Currently, the federal government generally reimburses states for a fixed percentage of Medicaid expenditures, regardless of total spending or number of people enrolled. The Republican bills would impose a per-person limit on Medicaid reimbursement that would increase over time at a rate linked to inflation. The Congressional Budget Office said that under the House bill, which uses the rate of medical inflation to set the pace of spending, federal Medicaid spending would decrease by $834 billion between 2017 and 2026. The Senate bill would set a lower growth rate starting in 2025 by using the general inflation rate as a benchmark for much of Medicaid’s spending, rather than the medical inflation rate.

5. What would the impact be?

The Congressional Budget Office estimates that between 2017 and 2026, 15 million fewer people would be covered by Medicaid under the Senate bill, and 14 million fewer under the House bill, than under Obamacare. In both cases, Medicaid would account for about two-thirds of the increase in the number of uninsured projected by the CBO.

6. How else could poor people get coverage?

The House and Senate bills would make them eligible for subsidies for individual insurance policies, meaning people who are dropped from Medicaid could use the subsidies to buy their own coverage. Critics say the bill would make those policies unaffordable to low-income people by increasing deductibles.

7. What’s the debate about the bills like?

Democrats are unanimously against both bills and are highly critical of their Medicaid cuts. One Republican senator, Dean Heller of Nevada, has come out against the bill because of its Medicaid cuts, and a number of other Republican senators have expressed serious reservations. Governors from both parties say the cuts could crunch state budgets. Hospitals, insurers and other medical associations say the changes would damage the safety net. Republican supporters of the bills say that the cuts will be paired with steps to give states greater flexibility in fashioning improvements to the program, including the option of requiring that non-disabled adults find a job. McConnell has also left open the option of revising the bill, potentially by increasing funds set aside to address problems like treating opioid addiction that are now addressed by Medicaid.

8. What’s Trump’s position?

During the 2016 campaign, Trump said that unlike other Republican candidates he would not cut Medicaid, Medicare or Social Security. But he did support the House health-care bill. After McConnell introduced a draft version of his bill, Sean Spicer, the White House spokesman, said that Trump was "very supportive” of the bill but was "committed” to making sure that people currently on Medicaid didn’t lose their coverage.

The Reference Shelf

  • The Congressional Budget Office analysis of the House and Senate bills.
  • A Medicaid overview from the Center on Budget and Policy Priorities.
  • A report from the Centers for Medicare and Medicaid Services on expansion of coverage.
  • A Medicaid financing overview from the Kaiser Family Foundation.
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