Despite President-elect Donald Trump's campaign promises to repeal and replace the Affordable Care Act, Medicaid expansion might survive, at least in some form.
More than 12 million people gained coverage in expansion states according to a report HHS released this year. The Affordable Care Act allowed states to expand eligibility to individuals with incomes up to 138% of the federal poverty level with the government picking up 100% of the cost for new beneficiaries through Jan. 1, 2017.
“While the teardown of the ACA has iconic value, the path forward for the new administration will not be simple,” said Katherine Hempstead, a senior program officer at the Robert Wood Johnson Foundation.
Officials in some states that expanded eligibility under the law say they will work to preserve coverage levels. Louisiana's Democratic Gov. John Bel Edwards “will work closely with the president-elect, his advisers and our congressional delegation to preserve the gains we have made in coverage,” said Robert Johannessen, a spokesman for the Louisiana Department of Health.
Medicaid officials in other states said it's simply too early to speculate what action they'll take since the ACA remains the law of the land. Also, it's possible that whatever legislation comes next will allow states to modify, not end, the programs.
“Given that a few red states have expanded Medicaid, this might be a more realistic option,” said Yevgeniy Feyman, a Republican analyst and senior research assistant at Harvard T.H. Chan School of Public Health.
A key example of what may happen is how things have played out in Kentucky. Republican Gov. Matt Bevin campaigned on an anti-Obamacare platform but ultimately chose to maintain Medicaid expansion in his state and seek a waiver to incorporate more conservative principles in the program. More than 400,000 people had gained coverage under the expansion before he took office.
“The lesson is that there could be a real political backlash when you try to take away something that's so valuable, so critical,” said Ron Pollack, executive director of Families USA, an advocacy organization.
With the Bevin scenario in mind, experts say there could be a greater push to go away from a traditional Medicaid expansion to one that includes more conservative provisions such as a work requirement, or the ability to lockout people below the poverty level that don't pay premiums.
There is already evidence of this, with Arkansas' Gov. Asa Hutchinson saying Wednesday morning that he will approach the Trump administration to impose a work or work search requirement to be eligible for Medicaid. HHS under the Obama administration had denied the request.
HHS under a Trump administration is more likely to embrace conservative expansion waivers, such as the one adopted in Indiana under governor and now Vice President-elect Mike Pence.
“States that have expanded will leave it in place,” said Joe Reblando spokesman for Medicaid Health Plans of America. “And given the Republican tenet of giving states more control, states that haven't expanded yet may find increased flexibility on how to do so.”
But that notion gives pause to patient and provider advocates in some states. The CMS recently denied a waiver from the its Republican Gov. John Kasich to transition into a more conservative Medicaid expansion that would drop adult beneficiaries who don't pay into a health savings account, regardless of their income.
“We really opposed provisions in the Healthy Ohio waiver as they didn't promote continuity in healthcare coverage and they would be administratively burdensome,” said Laura Gronowski, chief of staff for the Center for Health Affairs, an advocacy group for Northeast Ohio hospitals. But, she added, “If having that waiver were the only way to continue expansion, we would be open to having that conversation.”
Another scenario could be that states are allowed to continue to maintain the 138% FPL eligibility level but Congress reduces the federal match to standard levels, which are around 50%, according to Ed Haislmaier, a health policy expert at the Heritage Foundation, a conservative think tank.
But Trump and congressional Republicans have also signaled a desire to turn Medicaid into a block-grant program.
In that case, “the real question will be whether they maintain adequate protections for enrollees—at a basic level, the individual federal entitlement, adequate benefit packages for enrollees, and growth rates sufficient to support actuarially sound rates for health plans,” Meg Murray, CEO, Association for Community Affiliated Plans, said in a statement. “Poorly implemented block grants will threaten the social safety net—and our fellow Americans who depend on it.”
