With Medicaid In Flux, States May Take The Lead On Reform

Overhauling the Medicaid program nationwide would take time, but states won’t have to wait to start making changes.

AP Photo/Alex Brandon
Erin Durkin
Add to Briefcase
Erin Durkin
Jan. 5, 2017, 8 p.m.

Con­gres­sion­al Re­pub­lic­ans could take years to fig­ure out how Medi­caid fits in­to their vis­ion of health care re­form, leav­ing states with a tent­at­ive but wide-open win­dow to ex­per­i­ment with their own pro­grams.

If Re­pub­lic­ans’ plan to re­peal Obama­care mir­rors the one that they man­aged to pass out of Con­gress last year, the law’s Medi­caid ex­pan­sion—and the gen­er­ous bump in fed­er­al fund­ing it provided—will be on the chop­ping block.

It’s not clear how the Medi­caid ex­pan­sion would fit in­to their plan to delay the ef­fects of re­peal for a few years, or wheth­er the pro­cess of re­pla­cing Obama­care would also be a vehicle for a broad­er re­struc­tur­ing of Medi­caid. House Speak­er Paul Ry­an and oth­er GOP law­makers have pro­posed turn­ing the pro­gram in­to a block grant to the states, or im­pos­ing new caps on the pro­gram’s spend­ing.

But amid all that un­cer­tainty, ex­perts say, states can be­gin mak­ing changes on their own—par­tic­u­larly if the Trump ad­min­is­tra­tion is eager to grant waivers that re­lax fed­er­al rules so states can test new mod­els.

“The words ‘block grant’ are simple, [but] it is com­plex to try to im­ple­ment and will have very dif­fer­ent ef­fects across the states and very dif­fer­ent im­pacts de­pend­ing on the level of fund­ing as­so­ci­ated with the block grant … which is why waivers are a safer bet for states,” said Di­ane Row­land, ex­ec­ut­ive vice pres­id­ent of the Kais­er Fam­ily Found­a­tion.

Chris Jac­obs, a con­ser­vat­ive policy ana­lyst and CEO of Ju­ni­per Re­search Group, sug­ges­ted that the next ad­min­is­tra­tion should al­low for blanket waivers, which means the Health and Hu­man Ser­vices De­part­ment would auto­mat­ic­ally ap­prove waivers that meet cer­tain re­quire­ments.

He ad­ded that Trump’s picks for top health care jobs—pick­ing Rep. Tom Price to head HHS and Seema Verma to lead the Cen­ters for Medi­care and Medi­caid Ser­vices—in­dic­ate that the ad­min­is­tra­tion is open to provid­ing such flex­ib­il­ity.

“I think you’ve seen with the Price ap­point­ment and the Verma ap­point­ment that sort of men­tal­ity of, ‘All wis­dom doesn’t em­an­ate from Wash­ing­ton and does not em­an­ate from Se­cur­ity Boulevard in Bal­timore,’” Jac­obs said, re­fer­ring to the CMS headquar­ters. “Let’s give states more free­dom and more flex­ib­il­ity to man­age their pro­grams as they see fit.”

Price would be a strong pro­ponent of in­nov­a­tion at the state level, said Robert Mof­fit, a seni­or fel­low at The Her­it­age Found­a­tion’s Cen­ter for Health Policy Stud­ies. Mof­fit noted that Price had sponsored le­gis­la­tion in the past to provide states with more au­thor­ity over health care pro­grams.

And Verma has sig­ni­fic­ant ex­per­i­ence with re­design­ing Medi­caid pro­grams. She helped se­cure fed­er­al waivers for mod­i­fied ver­sions of Obama­care’s Medi­caid ex­pan­sion, in­clud­ing the “Healthy In­di­ana” plan ad­op­ted by Vice Pres­id­ent-elect Mike Pence as well as pro­grams in Iowa, Ken­tucky, and Ohio.

There is a lot of pent up de­mand from gov­ernors for more flex­ib­il­ity over the Medi­caid pro­gram, said Josh Archam­bault, a seni­or fel­low at the Found­a­tion for Gov­ern­ment Ac­count­ab­il­ity.

Law­makers have already star­ted seek­ing in­put from GOP gov­ernors. In a let­ter last month, Sen­ate Fin­ance Com­mit­tee Re­pub­lic­ans re­ques­ted ideas from Re­pub­lic­an gov­ernors about how to provide more flex­ib­il­ity over their states’ Medi­caid pro­grams.

Archam­bault said that con­ver­sa­tion will likely re­main broad, while spe­cif­ic waiver re­quests would yield more de­tailed pro­pos­als.

What We're Following See More »
Ex-CIA Officer Arrested for Assisting China
1 hours ago

"A former C.I.A. officer suspected of helping China identify the agency’s informants in that country has been arrested, the Justice Department said on Tuesday. Many of the informants were killed in a systematic dismantling of the C.I.A.’s spy network in China starting in 2010 that was one of the American government’s worst intelligence failures in recent years, several former intelligence officials have said. The arrest of the former agent, Jerry Chun Shing Lee, 53, capped an intense F.B.I. investigation that began around 2012 after the C.I.A. began losing its informants in China."

Park Service Panel Resigns En Masse
1 hours ago

"Three-quarters of the members of a federally chartered board advising the National Park Service abruptly quit Monday night out of frustration that Interior Secretary Ryan Zinke had refused to meet with them or convene a single meeting last year. The resignation of nine out of 12 National Park System Advisory Board members leaves the federal government without a functioning body to designate national historic or natural landmarks. It also underscores the extent to which federal advisory bodies have become marginalized under the Trump administration."

GOP Leaders Dangle CHIP Fix to Avert Shutdown
10 hours ago

"House GOP leaders on Tuesday night pitched a new strategy to avert a looming government shutdown that includes children's health funding and the delay of ObamaCare taxes. Lawmakers need to pass a short-term stopgap bill by midnight Friday, when money for the federal government runs out. The latest GOP plan would keep the government’s lights on through Feb. 16, and be coupled with a six-year extension of funding for the popular Children's Health Insurance Program (CHIP). The continuing resolution or CR would also delay ObamaCare's medical device and Cadillac taxes for two years, and the health insurance tax for one year starting in 2019."

With Deadline Approaching, Lawmakers Sounding Notes of Pessimism
14 hours ago

"A key Senate negotiator and White House official on Tuesday expressed little hope for an immigration deal this week but nonetheless predicted that Congress can avoid a government shutdown." Marc Short, the White House Capitol Hill liaison, said he's optimistic about a deal on DACA overall, but not this week. Senate Majority Whip John Cornyn also said he doubts an agreement can be made before week's end.

Nielsen Defends Trump Before Senate Judiciary
20 hours ago

"Homeland Security Kristjen Nielsen confirmed that President Trump used 'tough language' in an Oval Office meeting last week over immigration policy, but she said she did not hear him describe some African countries and Haiti as 'shithole countries,' as has been reported." When pressed she, also said she "didn't know" whether Norway was a predominately white country.


Welcome to National Journal!

You are currently accessing National Journal from IP access. Please login to access this feature. If you have any questions, please contact your Dedicated Advisor.