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.

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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.

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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.
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  • 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.
  • No majority support for any single approach to reform
  • 44% want to keep ACA but make significant changes
  • Slight majority of Americans (53%) approve of the ACA

“The Senate Republican health care bill, the Better Care Reconciliation Act of 2017, is on thin ice, with about ten Republican Senators expressing reservations about the bill. Can Mitch McConnell get 50 senators to yes? What are the implications for the future of health care in America if he can—or can’t?

To help answer these questions, we’re fortunate to be joined by Grace-Marie Turner, the most influential health care scholar in the conservative movement.”

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Sioux Falls Specialty Hospital in South Dakota is regularly full. Its doctors and nurses often have to work longer hours or perform elective surgeries such as hip or knee replacements on weekends.

“In many cases, patients have to wait forever,” said Dr. R. Blake Curd, an orthopedic surgeon and the hospital’s CEO. “We don’t have the physical capacity to take care of them.”

He would like to expand the hospital by adding beds or rooms, but he isn’t allowed to do so because of the Affordable Care Act, or Obamacare. The law largely bans the expansion of hospitals such as Curd’s, which are partly owned by doctors. New physician-owned hospitals also cannot be set up unless they forego government reimbursement from Medicare or Medicaid.

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A new government report explains why Republicans, after nine years of opposing Obamacare, are having such a hard time repealing it.

The answer: It’s pretty much about the money. It’s not about providing Medicaid coverage to low-income adults.  Some moderate Republicans who profess concern for the needy are actually trying to shift more of the cost of providing them Medicaid coverage from their states to the federal government.  They’re holding out for more federal cash for their states. And they just might get it – from Senate Democrats.

Obamacare made an offer to states that agreed to extend Medicaid eligibility to childless, nondisabled, low-income adults: The federal government would pay 100 percent of the medical bills for this new category of “expansion adults.” That percentage would slowly decline, but never fall below 90 percent. The District of Columbia and 31 states jumped at the offer.

The federal government pays a much lower federal matching percentage for every other category of recipients, including children, blind and disabled adults, pregnant women, and the frail elderly. That matching rate varies from 50 percent in states with relatively high per capita incomes (California, for example) to nearly 75 percent in the poorest state (Mississippi).

The Senate bill to “repeal and replace” Obamacare would leave the Medicaid expansion in place, but would ultimately eliminate the higher federal reimbursement for their care.  The federal government would bear the same share of medical assistance for nondisabled, childless adults as it does for pregnant women and people with disabilities.  It slowly phases out the current Medicaid reimbursement policy that discriminates on the basis of age, gender, pregnancy, and disability.

Some Senate Republicans are clinging to this inequitable arrangement that provides a sweet deal for their states.

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Republican senators Ted Cruz and Mike Lee are pushing for an amendment to the Senate GOP’s Better Care Reconciliation Act (BCRA) that would substantially alter the current landscape of health-insurance regulation. They believe their amendment, which aims to give insurers much more freedom to offer any kind of product they want to customers, would go a long way toward restoring a free market to health care, and would result in lower premiums for millions of consumers.

The strong commitment of these senators to this particular amendment, and the insistence on its inclusion in the Senate bill by conservative groups, reveals a broad misunderstanding among conservatives of what is wrong with health care in the United States, and what is needed to build a market-driven system.

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The biggest problem with Obamacare is that it expanded health coverage through Medicaid, a program with notoriously poor access to doctors, because Medicaid pays doctors far less than private insurance. The Senate Republican health care bill aims to change that, by giving states the ability to offer an innovative new model to their poorest residents: direct primary care.

The fact that people enrolled in Medicaid have poor access to physicians is well-documented in the literature (see here and here and here). To take one example, kids with acute asthma attacks on Medicaid only had a 45 percent chance of securing a doctor’s appointment, compared to 100 percent of those with private insurance.

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