Senate Republicans are attempting to soften the impact of the Medicaid cuts in their nascent Obamacare-repeal bill, both by changing the details of the measure approved by the House and by employing gentler language to describe them.
Republicans say they are eyeing a multiyear “glide path” that would phase out Medicaid expansion more gradually. But, coupled with proposed caps on the program’s spending, some experts do not expect the outcomes to be any less draconian than under the House proposal.
The GOP has been plagued with criticism since the Congressional Budget Office determined that 14 million fewer people would be enrolled in Medicaid under the House bill. Additionally, CBO said spending would be reduced by $834 billion.
From the start, some Senate Republicans were uneasy with the House plan for Medicaid. Sen. Rob Portman of Ohio, whose state expanded, is pushing for a seven-year phase-out proposal for states, and several other lawmakers seemed open to having a slower phase-out.
Sen. David Perdue, however, is wary of a seven-year time frame. “I don’t support a seven-year glide path. That’s not a glide path; that’s permanency,” he said.
And some experts attest that a glide path would still produce similar outcomes to the House plan.
“You’re ending up with the same exact result. You’re adding tens of millions to the uninsured,” said Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities. Park also noted that some Medicaid-expansion states have triggers in their laws in which the expansion automatically ends if the matching rate falls.
Promoting a longer phase-out of the program’s expansion could be more about messaging to constituents than it is about results, said Molly Reynolds, a fellow in governance studies at the Brookings Institution.
However, Matt Salo, executive director of the National Association of Medicaid Directors, does not expect the CBO numbers around Medicaid would look the same in a Senate bill, particularly because moderates would likely not tolerate the $834 billion expected to be cut from the program under the House bill.
Salo said Republicans will have to put more money into Medicaid if they stretch the phase-out of the expansion, and would likely have to put more money towards states that didn’t expand. But in that case, the money wouldn’t necessarily have to go toward Medicaid, he suggested, but rather toward other programs such as reinsurance or high-risk pools.
Reducing cuts to the program would likely touch upon another key issue—Obamacare’s taxes. “If they choose to reduce the size of the Medicaid cut, they have to find a way to pay for it in the bill,” said Reynolds. “How committed are they to repealing all taxes? How flexible are they on the tax side of the bill?”
The growth rate for per-capita caps, a key feature of the Republican plan for the program, has also driven a wedge between different factions of the party. The American Health Care Act proposes to have the caps rise at a slower rate for Medicaid populations than is currently projected for per-beneficiary spending, according to the CBPP. But Sen. Pat Toomey would like spending for the program to be even lower.
Sen. Dean Heller, who is facing a challenging reelection next year, did not want to see spending go below that of the House bill.
“Well, I just don’t want to do worse than what the House did, and there’s a push to bring it below the House,” the Nevada Republican said. Heller added that he wanted to make sure his state’s governor could accept some of the changes that would be included in the legislation.
“That’s one thing for me to sit back here and legislate; it’s another thing for the governor to have to run the program,” he said.
A Medicaid expert, who requested anonymity because his organization has not taken an official stance on the Republicans’ plans, said states are justifiably concerned that the discussions on Capitol Hill about reforming the program aren’t as sophisticated as they need to be. He said that under a per-capita cap, states would have to evaluate all populations to see if they can afford to keep them covered.
The expert noted that, for the expansion population, there are “two bites at the apple”: the federal match rate going down and then the calculation of the cap baseline and growth rates. CBPP’s Park said the per-capita caps would incentivize states to freeze enrollments rather quickly.