Expect Medicaid to Change, but Not Shrivel, Under Donald Trump

By Robert Pear, November 15, 2016

Picture are President-elect Trump, his wife, Speker Ryan and Vice Pesident-elect Pence seated at a table with a row of American flgs behind them..

From left, Melania Trump, President-elect Donald J. Trump, Speaker
Paul D. Ryan and Vice President-elect Mike Pence on Thursday on
Capitol Hill. Mr. Ryan has proposed rolling back an expansion of Medicaid,
but Mr. Pence is proud of the Medicaid growth he engineered
as Indiana’s governor. (Photo by Al Drago/The New York Times)

Without even waiting for legislation, the Trump administration is almost certain to give states more leeway to run their Medicaid programs as they wish, federal and state officials say.

A number of states have already proposed co-payments and work requirements for people on Medicaid.

In an effort to protect beneficiaries, the Obama administration has limited the use of co-payments and has not allowed work requirements. But state officials say that such changes are likely to be allowed in some form in a Trump administration.

Cindy Gillespie, the director of the Arkansas Department of Human Services, said that with the election of Mr. Trump, she saw “a real chance for states to take back a bit of control over Medicaid and other safety net programs.”

Darin Gordon, who stepped down in June after 10 years as the director of Tennessee’s Medicaid program, predicted that “there will be greater receptivity in the new administration to state proposals that were shut down by the Obama administration.”

Cindy Mann, the top federal Medicaid official from 2009 to January 2015, said it was entirely possible that a Trump administration would “make different judgments” about Medicaid waivers, the vehicle for a wide range of state innovations and experiments. The federal government has broad discretion to approve state demonstration projects if the secretary of health and human services finds they are “likely to assist in promoting the objectives” of the Medicaid program.

On Nov. 1, the Obama administration rejected a waiver request from New Hampshire, which wanted to impose a work requirement and more stringent standards for Medicaid beneficiaries to show they were United States citizens and residents of the state. The requirements “could undermine access, efficiency and quality of care,” the administration said.

New Hampshire will have a Republican governor for the first time in 12 years and could submit similar proposals to the Trump administration.

In September, the Obama administration approved a waiver allowing Arizona to charge premiums to people with incomes above the poverty level ($20,160 a year for a family of three). But federal officials refused to allow work requirements or a time limit on coverage, and they said the state could not charge premiums to people below the poverty level.

The Obama administration also rejected Ohio’s request for a waiver to charge premiums and suspend coverage for people who failed to pay them, a policy it said would jeopardize coverage for more than 125,000 people.

In Kentucky, where more than 400,000 people have gained coverage because of the expansion of Medicaid, Gov. Matt Bevin, an outspoken Republican critic of the health law, is seeking federal approval for a waiver allowing work requirements, premiums and co-payments.

Negotiations over a proposed Medicaid block grant would need to answer difficult questions: How is the amount of the initial federal allotment determined? Will this amount be adjusted to reflect population growth, the effect of an economic downturn, or increases in the cost of medical care or in consumer prices generally? Will it be adjusted to reflect the advent of costly but effective drugs like those to treat hepatitis C? Will states have to continue spending their own money on Medicaid? Will Medicaid beneficiaries still have a legally enforceable right — an entitlement — to coverage and care if they meet eligibility criteria set by the federal government and states?

Medicaid block grants have been a favorite of Republicans in Washington, proposed in various forms by President Ronald Reagan in 1981, congressional Republicans in 1995 and President George W. Bush in 2003.

The House Republicans’ “Better Way” agenda, unveiled in June, would give states a choice of a fixed allotment for each Medicaid beneficiary or a block grant for Medicaid. Either way, states would get less money than they expect to receive under current law.

Under the proposal for a per-capita allotment, states that had not expanded eligibility as of January 2016 would not be able to do so. The enhanced federal payments that states now receive for newly eligible Medicaid beneficiaries would be reduced, and many states would have difficulty making up the difference.

Under the Affordable Care Act, the federal government is scheduled to pay 93 percent of Medicaid costs for newly eligible beneficiaries in 2019. Under the House Republican plan, the federal share would be pared back to its regular levels — now, for example, 70 percent in Arkansas, 62 percent in Ohio and 50 percent in New Jersey.

The budget bill pushed through Congress by Republicans but vetoed by Mr. Obama in January would have repealed the expansion of eligibility.

Appearing on Sunday on the CNN program “State of the Union,” Mr. Ryan said House Republicans wanted to replace the expansion of Medicaid with “refundable tax credits for people to buy affordable health care insurance.”


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