Democratic state legislators have embarked on long shot bids to preserve Medicaid expansion as threats of massive federal cuts hang over the program for low-income people.
Forty states and the District of Columbia broadened Medicaid eligibility for adults without disabilities through the Affordable Care Act of 2010. Nine expansion states have "trigger laws" in place that would end the expansions if Washington tightens the purse strings, as the congressional GOP is gearing up to do. Three more states have laws requiring reviews that could lead to terminations under those circumstances.
Related: Congress passes budget, teeing up huge Medicaid cuts
The Democratic legislators behind the push to repeal or soften the trigger laws know Republican governors and leaders of GOP-led state legislatures — and fiscally conservative Democrats — are unlikely to go along. They also recognize that provisions to protect state budgets from shifts in federal policy were critical to winning bipartisan support to expand Medicaid in the first place.
Yet Democrats in the Illinois, North Carolina and Virginia legislatures are trying anyway, if only to highlight the consequences of President Donald Trump and congressional Republicans' plan to slash Medicaid funding by up to $880 billion over 10 years. Illinois has a Democratic governor and the party controls both chambers of the General Assembly, while North Carolina and Virginia have divided governments.
North Carolina state Rep. Julia Greenfield (D) co-sponsored a bill to lower the threshold at which the state’s Medicaid trigger law goes into effect to 65%, rather than 90%. Greenfield, a nurse by training serving her first term in the legislature, acknowledged the bill is unlikely to become law.
“I don’t think it’ll see the light of day,” Greenfield said. “But Democratic messaging has not been great, and that is one of the things that I am focused on as a new legislator. It’s very important for people to understand what we are trying to do but we can’t do because we don’t have the power to push bills through.”
In North Carolina, implementing a Medicaid trigger law was part of the delicate political compromise to expand Medicaid, said North Carolina Healthcare Association President and CEO Josh Dobson. Reconvening the General Assembly to amend the trigger law would be a “heavy lift,” he said.
“There’s no question it would affect hospitals if Medicaid expansion goes away because currently these individuals have health insurance. The fear is that if they lose that health insurance, they would end up back in the emergency room, which is not good for anyone,” Dobson said.
Illinois state Rep. La Shawn Ford (D) said he voted for the Medicaid trigger law in 2013 to secure the coverage expansion and protect it from future cuts at the state level. But Ford sponsored legislation to scrap it and instead wants to get to work finding state funding to replace lost federal dollars.
“It takes forensics to figure out what areas we could cut the waste and be more efficient to be able to fill that 90% void,” Ford said. “But I do believe that it's going to be important that we find efficiencies in our budget to try to make sure that we protect the Affordable Care Act.”
Illinois would face a $7.4 billion shortfall if Congress cuts Medicaid funding and would be unable to close the gap, said a spokesperson for the state Department of Healthcare and Family Services. “The responsibility for these consequences would lie directly with the Republicans who have chosen to push the cuts forward,” the spokesperson said.
The Affordable Care Act of 2010 authorized a Medicaid expansion to anyone earning up to 133% of the federal poverty level, which is $15,650 for an individual. The federal government pays states 90% of the costs for covering this population and states are responsible for the remaining expense.
That enhanced federal support for Medicaid expansion is in Congress's crosshairs, along with other major changes to Medicaid including work requirements, funding caps and limitations on provider taxes that help finance the program. Medicaid expansion covers 21&nbsb;million people, according to government data compiled by the health policy research institution KFF.
Reducing the federal match rate for Medicaid expansion would save $561 billion over 10 years, according to a document the House Budget Committee distributed to lawmakers in January. Implementing a per-capita cap would diminish federal funds by $900 billion, the committee estimates.
Congress is getting close to deciding how much it will take out of Medicaid, despite Trump's promise to veto Medicaid cuts and a split within the GOP about how far to go.
The Medicaid expansion funding appears particularly vulnerable. Its legacy as part of the ACA is one reason why, said Larry Levitt, executive vice president of policy at KFF. “Many Republicans view the Medicaid expansion as more 'Obamacare' than Medicaid, which makes it a political target,” he said.
As soon as next week, the House Energy and Commerce Committee, which has jurisdiction over Medicaid, will begin marking up its part of a sweeping tax-and-spending cuts package. Under the fiscal 2025 budget resolution Congress approved last month, the panel is charged with finding $880 billion in spending reductions, the lion's share of which would have to come from Medicaid because Trump declared Medicare untouchable.
Capitol Hill Democrats are in the minority, giving them potentially even less influence over what happens next than their counterparts in state legislatures. But drawing attention to the consequences of Medicaid cuts could still offer political benefits, Levitt said.
“There's an element of political messaging, of wanting to express support for Medicaid expansion and taking an opportunity to spotlight what Republicans are trying to do,” Levitt said. “Trying to weaken the trigger laws now [is], in a sense, setting up the big debates that would occur if expansion is truly rolled back nationally.”
Unlike the federal government, states are required to balance their budgets. States facing a potential recession sparked by Trump's tariffs would struggle to bridge federal Medicaid cuts, said Joan Alker, executive director of the Georgetown University Center for Children and Families. “They're not going to have good choices,” she said.
The shortfall would trickle down to providers. Medicaid comprises 19% of hospital revenue nationwide, KFF reported in February.
“No matter how those effects translate, there will be massive cuts to hospitals. They're going to lose more money than any other industry, except for maybe nursing homes,” said Darbin Wofford, deputy director of healthcare at Third Way, a centrist think tank.
