Senate Republicans, scrambling to win support for their health-care bill, pushed a measure Thursday that they said could ease the impact of the bill’s Medicaid cuts on low-income people.

Advocating for the new direction is a little-known health official who is now at the center of the health-care fight: Seema Verma, head of the Centers for Medicare and Medicaid Services, which oversees the two federal medical programs.

. . .

Despite the surge in enrollment and spending—or perhaps because of it—Medi-Cal, California’s Medicaid program, has failed to fulfill its stated goal of improving health-care access for the indigent and disabled. A recent report from the Santa Clara County Civil Grand Jury highlighted the conundrum many of the state’s Medicaid enrollees face: “You’ve Got Medi-Cal, but Can You Get Medical Care?” By extending Medi-Cal to younger, healthier people—many of whom could be better served by the kind of bare-bones private insurance that ObamaCare outlawed—California has made it harder for those who most need low-cost care to get it.

. . .

Medicaid has become one of the most hotly debated issues in health reform. Almost all agree that reform is badly needed. In Congress, it has become a numbers game about millions of people and billions of dollars. One side decries the poor health outcomes that will derive from people losing coverage; the other argues that Medicaid desperately needs reform, not only to serve today’s recipients but also to effect solvency for future generations. Many are being told that empowering the federal government further is the way forward; conversely states, both red and blue, feel they can better serve their citizens if they were given more flexibility in managing Medicaid. How Medicaid is reformed is critical to the future of health care reform because it will form the template for the design of Medicare and private insurance going forward.

. . .

Rolling back ObamaCare’s Medicaid expansion has become the focal point of the health-care debate, and rightly so. Without fundamental change, Medicaid—expanded or not—will push state budgets to the brink even as it fails to help the most financially vulnerable Americans.

Consider Oklahoma, our home state. Despite intense lobbying by hospital corporations, the state Legislature stood strong and refused the Medicaid expansion. But the Medicaid rolls increased anyway, and at a dramatic cost to priorities like education, public safety and transportation.

. . .

The Medicaid status quo is not effectively serving the health care needs of the disabled, elderly, children, and pregnant women in poverty. Policymakers should ignore hyperbolic political rhetoric claiming that conscientious reforms to secure and improve the safety net for Medicaid’s core populations and to provide better options for coverage and care to others will result in a situation in which “thousands will die.” Obamacare expanded the poorly performing Medicaid and claimed success for doing so. These new recipients can fare better under a new system that broadens their access to quality care. A Medicaid premium support program can accomplish that worthy end.
. . .

We are 2 former Administrators of the Medicare and Medicaid programs, under Presidents Barack Obama and George H. W. Bush. Although we represent different political parties, we take pride in the accomplishments of these 2 programs, which collectively help millions of US residents get the health care they need.

Medicaid has become a major focus in the debate over repealing the Affordable Care Act (ACA), because the proposed replacement bills go beyond the ACA into the underlying Medicaid program that was originally passed by Congress in 1965. As we have overseen the Medicaid program at various stages, we are familiar with its successes, its areas for improvement, its effect on state budgets, and its importance to millions of ordinary people who count on the program and will need it in the future.

. . .

In the 1990s, there was plenty of teeth-gnashing by welfare reform opponents over changing the funding structure for cash assistance, implementing work requirements, and creating time limits – rhetoric that sounds eerily similar to much of the health reform coverage today.

Mostly absent from the welfare discussion was the role that earned income tax credits (EITC) would play in reform. Similarly, in the current health care debates over Medicaid changes there is a lack of any reference to proposed tax credits.

. . .

The Senate Republicans’ Better Care Reconciliation Act of 2017 (BCRA) would partially repeal and replace Obamacare and make major changes in the Medicaid program. The bill would secure a significant federal entitlement reform by addressing a central health policy issue: the structure, function, and financing of the Medicaid program. It would achieve three major policy goals: reform the entitlement, redirect Medicaid funding to the poorest and most vulnerable members of society, and provide greater authority and flexibility to state officials to manage their own Medicaid programs.
 . . .
  • 56% say Medicaid should target set spending to the disabled, elderly, children, and pregnant women in poverty based on their specific needs.
  • 62% say it is a bad thing that Medicaid expansion spends money on childless adults, rather than the most vulnerable populations the program was designed to serve.
  • 57% say it is a bad thing that Obamacare gave states higher reimbursements for adding able-bodied adults to Medicaid than for serving the elderly and disabled.

The last man to pull out of the Republican race against Donald Trump was John Kasich, the Ohio governor, a long-shot contender for the presidential nomination whose chances had long since faded. But he has returned to the role of thorn in Mr Trump’s side as Republicans in Washington struggle to reform Obamacare, leading a group of governors trashing their own party’s plan.

The intra-party revolt is rooted in Republican proposals to gut Medicaid, a programme for the poor that provides insurance to 69m Americans. Republicans have long seen it as an emblem of mismanaged welfare programmes that distend government and discourage people from working. But Mr Kasich is showing change is afoot.

He was one of 16 governors from Republican-led states that took an option to expand Medicaid offered by Obamacare, adding 700,000 Ohioans to the programme, despite the broad distaste for Barack Obama’s reforms in his party. In recent weeks he has stressed its vital role in treating people ravaged by opioids and other drugs, which killedan average of 11 Ohioans each day last year, and those suffering from schizophrenia, bipolar disorder and other mental illnesses.

. . .