The Crusader Newspaper Group

Expect Medicaid to change, but not shrivel, under Donald Trump

By Robert Pear,

The expansion of Medicaid, a central pillar of the Affordable Care Act, faces immense uncertainty next year, with President-elect Donald J. Trump and top Republicans in Congress embracing proposals that could leave millions of poorer Americans without health insurance and jeopardize a major element of President Obama’s legacy.

But influential figures in surprising quarters of the new administration might balk at a broad rollback of Medicaid’s reach, favoring new conditions for access to the government insurance program for the poor but not wholesale cutbacks.

Mike Pence, the vice president-elect, is proud of the Medicaid expansion he engineered as governor of Indiana, one of 31 states that expanded eligibility under the Affordable Care Act. The Indiana program has conservative features that emphasize “personal responsibility” and require Medicaid beneficiaries to make monthly contributions to savings accounts earmarked for health care.

Another Trump adviser, Gov. Chris Christie of New Jersey, hails the expansion of Medicaid in his state, saying more than half a million people are receiving “more and better health care.” The federal government pays the full cost for newly eligible beneficiaries from 2014 through 2016 and at least 90 percent of the costs in later years under the health law.

It is hard to overstate the importance of Medicaid, which insures 77 million people, pays for more than half of all births in some states, covers about two-thirds of nursing home residents and provides treatment for many people addicted to opioids. Spending on Medicaid, by the federal government and states combined, exceeds $500 billion a year.

Of the 20 million people who have gained coverage under the Affordable Care Act, officials estimate, 12 million are insured by Medicaid — with few of the problems that have plagued the new insurance exchanges, or marketplaces.

But change is coming. In his campaign manifesto, Mr. Trump said Congress must repeal the Affordable Care Act and give each state a lump sum of federal money — a block grant — for Medicaid. Congress passed legislation in January to repeal the health law and roll back its Medicaid expansion. Mr. Obama vetoed the measure, but Speaker Paul D. Ryan of Wisconsin has vowed to put similar legislation on a Republican president’s desk.

Without even waiting for legislation, the Trump administration is almost certain to give states more leeway to run their Medicaid programs as they wish, federal and state officials say.

A number of states have already proposed co-payments and work requirements for people on Medicaid. In an effort to protect beneficiaries, the Obama administration has limited the use of co-payments and has not allowed work requirements. But state officials say that such changes are likely to be allowed in some form in a Trump administration.

Cindy Gillespie, the director of the Arkansas Department of Human Services, said that with the election of Mr. Trump, she saw “a real chance for states to take back a bit of control over Medicaid and other safety net programs.”

Darin Gordon, who stepped down in June after 10 years as the director of Tennessee’s Medicaid program, predicted that “there will be greater receptivity in the new administration to state proposals that were shut down by the Obama administration.”

Cindy Mann, the top federal Medicaid official from 2009 to January 2015, said it was entirely possible that a Trump administration would “make different judgments” about Medicaid waivers, the vehicle for a wide range of state innovations and experiments. The federal government has broad discretion to approve state demonstration projects if the secretary of health and human services finds they are “likely to assist in promoting the objectives” of the Medicaid program.

On Nov. 1, the Obama administration rejected a waiver request from New Hampshire, which wanted to impose a work requirement and more stringent standards for Medicaid beneficiaries to show they were United States citizens and residents of the state. The requirements “could undermine access, efficiency and quality of care,” the administration said.


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