From the earliest days of Obamacare, a great many Democrats and others on the left have wanted a “public option.” At least one plan offered in the Obamacare exchanges should be a government plan, they proclaimed. The state of Nevada may make that wish a reality, if the governor signs a bill just passed by the legislature – allowing everyone who resides there to buy into the state’s Medicaid program.
Why does the left like this idea? Because they are ideologically committed to the propositions that when it comes to health care (1) non-profit is always better than for-profit and (2) public is always better than private.
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We can estimate the impact of the AHCA per-capita cap on the pre-Obamacare Medicaid population by using data from CMS, which expects that the federal government will spend approximately $6.7 trillion on the legacy Medicaid program from 2017 to 2026. If we apply CBO’s estimate of future medical inflation to the AHCA, we get to a spending reduction of $107 billion from 2017 to 2026. $107 billion represents 13% of the CBO’s estimate of the AHCA’s Medicaid spending cuts. More importantly, it represents a paltry 1.6% of total federal spending on the legacy Medicaid program over that time frame.
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Most people agree that Medicaid should help the poor, particularly those whose poverty is related to their age and disability. However, the Affordable Care Act requires the federal government to pay a much greater share of the medical bills for nondisabled, nonpregnant adults than it does for elderly individuals, people with disabilities, children, and pregnant women.
The share of state Medicaid spending paid for by the federal government—known as the Federal Medical Assistance Percentage, or FMAP—had remained relatively unchanged throughout the program’s history until Congress and the executive branch changed that share, providing a strong incentive for states to expand Medicaid coverage to this new population of nondisabled, nonpregnant adults.
The new FMAP formula and expansions created two significant problems:
- The federal government rewards states much more generously for providing services to individuals who fit the new criteria than to individuals who arguably are more in need of assistance
- The Medicaid expansion overlooks differences among states in their capacity to fund services for this new population, benefiting states with high per capita income at the expense of low-income states.
As it considers repeal and replace legislation, Congress should reexamine this arrangement. Congress should seek to devise a Medicaid financing structure that treats eligible populations equitably and recognizes the differences in fiscal capacity among states.
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Senate Republicans are struggling to agree on health reform, and the biggest divide concerns Medicaid. The problem is that too many seem to accept the liberal line that reform inevitably means kicking Americans off government coverage.
This narrative serves the liberal goal of scaring the public to preserve ObamaCare, but center-right and even liberal states have spent more than a decade improving a program originally meant for poor women and children and the disabled. Even as ObamaCare changed Medicaid and exploded enrollment, these reforms are working, and the House bill is designed to encourage other states to follow.
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President Trump’s recent 2018 budget proposal, which includes roughly $800 billion in cuts to Medicaid over the next decade, has led to howls of outrage from Democrats.
Medicaid’s defenders claim that it’s a bargain for patients and taxpayers alike. As Sen. Schumer put it, “Medicaid has always benefitted the poor. That’s a good thing.” A recent issue brief from the Kaiser Family Foundation, meanwhile, concludes, “Medicaid is cost-effective.”
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President Trump has proposed a budget that increases government spending from $4 trillion today to $5.5 trillion in 2027. Only in the alternative reality of Washington can this be described as “budget cuts.” Looking at individual programs, it is a gross mischaracterization to state that spending on Medicaid programs will be cut. The new budget proposes to increase federal Medicaid spending from $378 billion a year today to $524 billion a year in 2027. It shows how far removed Washington is from everyday Americans for this increase of $146 billion to be called a cut. The fundamental problem is that special interests are addicted to the rising path of spending. Altering this path by increasing spending at a slower rate opens change-makers to extraordinary attacks.
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In the United States, the difference between being in poverty and out of poverty is a job. The nation’s public assistance programs successfully alleviate suffering among low-income households, but they fail to raise self-sufficiency because they do not connect able-bodied people to work. Going forward, policymakers must incorporate work requirements throughout the safety net, which are proven to enhance programs like TANF and the EITC. Medicaid is an ideal candidate for work requirements, as it would encourage over 1 million people to find work without greatly disrupting the program itself.
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The Trump administration appears to have scrapped one of the key tools the Obama administration used to encourage states to expand Medicaid under the Affordable Care Act.
The shift involves funding that the federal government provides to help hospitals defray the cost of caring for low-income people who are uninsured. Under a deal with Florida, the federal government has tentatively agreed to provide additional money for the state’s “low-income pool,” in a reversal of the previous administration’s policy.
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Congressional Republicans have called for restructuring Medicaid, reviving a debate that has largely remained dormant for two decades. During the mid-1990s, Congress and President Clinton advanced competing Medicaid reform proposals. Republicans urged that the federal government issue Medicaid block grants to states. The White House and congressional Democrats proposed instead to place per capita limits on federal Medicaid payments to states. The most salient difference between these approaches is that per capita allotments retain the individual entitlement to Medicaid while block grants generally do not. Today, Republicans who once resisted Medicaid per capita allotments support them, and Democrats who backed such allotments oppose them. Given this legislative history, policymakers seeking common ground might look to Medicaid per capita allotments as a point of departure.
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In what will be a busy week in Washington, the Republican House hopes to take another whack at ObamaCare reform, a large chunk of which is Medicaid. As if this were not enough to handle, Donald Trump promises a “big announcement” Wednesday about his tax plan, which will likely include cuts in the corporate tax rate.
Let us stipulate that Medicaid reform and corporate tax cuts are both excellent initiatives. Done properly, each would offer Americans, including those at the lower end of the income scale, a better deal than they have now. Unfortunately, pitching health-care reform as the way to help “pay for” corporate tax cuts undermines the best arguments for both.
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