Although potential changes to the individual insurance market drew most of the fire during debate in the House over the American Health Care Act, Medicaid has moved to the spotlight in the Senate. Providers and some parents of medically fragile children warn there could be dire consequences if Medicaid funding is constrained, but they seem to lack the political capital to get GOP lawmakers to reverse course.
Advocates are saying this could be because Medicaid is largely misunderstood, and people aren't fully aware of the reasons why and when someone ends up qualifying for the government insurance, which covers 70 million Americans.
The director of the organization that represents Medicaid directors said many people equate the program with welfare. That view, he said, pushes people past the issue of government spending.
"It's more of a tribal question of the deserving poor and the undeserving poor," said Matt Salo, executive director of the National Association of Medicaid Directors. He said that some voters feel "a benefit that I get is something that I deserve, or earned, or is good, but a benefit my neighbor gets is a handout. I think we need to challenge that."
Salo was one of three lobbyists assembled in Washington, D.C., by public relations firm FleishmanHillard to talk about healthcare in the Trump era Wednesday.
Most people don't know that seniors have to pay out of pocket for nursing home or assisted-living stays that last more than a month, and that once they run out of money, it's Medicaid that pays the bills, he said. They wrongly believe Medicare pays for long-term care.
Branding is another factor. The fact that some states have renamed Medicaid—such as BadgerCare in Wisconsin or SoonerCare in Oklahoma—means even Medicaid recipients may not know they're enrolled in the program.
Medicaid also helps millions of seniors pay their Medicare Part B premiums for outpatient services and part of their prescription drug benefit.
"I can't tell you how many people turn 65 and are shocked they have to pay something," said Allyson Schwartz, a former Democratic congresswoman from Pennsylvania and current CEO of the Better Medicare Alliance, a Medicare Advantage advocacy group, adding that many seniors end up asking, "Isn't it free?"
Salo pointed to elements of the Medicaid waivers that may be submitted from states such as Maine as proof that some politicians are associating Medicaid with welfare dependency. Five states would like to tie Medicaid coverage to work requirements, drug testing, a lifetime limit or some combination of those.
He said that 60% of Medicaid spending is on the elderly and disabled, with a huge amount of that paying for round-the-clock care for people who are unable to take care of themselves. The waiver ideas reveal there's a disconnect between the professed goal of making Medicaid more financially sustainable for the government and "the reality of where our cost drivers are," he said.
Jim Gerlach, CEO of the Business-Industry PAC, is a former Republican congressman from Pennsylvania. He endorsed the idea that Medicaid needs fundamental reforms because deficit spending cannot be tackled without touching Medicaid, Medicare or Social Security. He noted that two-thirds of federal spending is for those three programs and interest on the national debt.
They need fundamental reforms "so these programs can be sustaining 10, 20 years down the road," he said.
However, Gerlach said it's "a huge if" that the Senate can pass a bill this summer.
Salo said the amount of federal funding that would go away in the House bill—between the end of an enhanced match for the expansion population and a per capita cap—most likely cannot be made up by state revenue.
Even if states are given the authority to restrict Medicaid drug formularies, change how they pay federally qualified healthcare clinics, and are allowed to split the cost of mental health hospitalizations with the federal government, he said that's not enough to cover the cost-shift. "Will there be some number of states that can hang on? Sure. But that's not going to last long."