More than 12 million Americans have gained coverage in states that expanded Medicaid eligibility under the Affordable Care Act. Those states may end up keeping that coverage, at least in some form, if the Trump administration and Republicans eliminate the law.
The ACA allowed states to expand eligibility to individuals with incomes up to 138% of the federal poverty level and committed the federal government to picking up 100% of the cost for new beneficiaries through Jan. 1, 2017, phasing down to 90% in 2020 and subsequent years. It was a deal many states were eager to take advantage of and even several Republican-led states couldn't resist.
“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 governor, 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.
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.
Simply eliminating the coverage carries significant political risks. 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. Arkansas Gov. Asa Hutchinson said last week that he will seek permission from the Trump administration to impose a work or work-search requirement, which the Obama administration denied.
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 providers and patient advocates in some states. The CMS recently denied Ohio's request to transition to a more conservative Medicaid expansion model 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.”
But even if states are allowed to maintain the eligibility level, Congress may reduce 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. That would make it difficult for states to maintain the programs and much less attractive for additional states to expand coverage.
Trump and congressional Republicans, meanwhile, 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 of the 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.”