Nation’s Success in Covering Children is in Peril

House Republicans recently released an outline of their plans to repeal and replace the Affordable Care Act and today an earlier version of the bill they were drafting was leaked.

While the leaked bill is likely an old draft, both of these documents confirm what I have suspected was coming — while repealing and replacing the ACA, Congress intends to radically restructure the Medicaid program, which has served children and families, individuals with disabilities, seniors in long term care for over 50 years while they are in the neighborhood and end the current guarantee of comprehensive, affordable coverage.

The Medicaid program currently serves 74 million people — approximately one in five Americans. The largest group of beneficiaries is children who constitute half of Medicaid enrollees – more than one in three kids in America is covered by Medicaid. Medicaid also covers half of all births in the median state, is the largest payer for long term care, provides coverage to people with disabilities including those with mental health and substance abuse disorders, and constitutes 56% of all federal funding that states receive. As a result, the importance of the Medicaid program as a central pillar of our nation’s health care system – especially for the most vulnerable among us — is hard to overstate.

Most of the public discussion and media coverage of  “Obamacare” repeal has focused on the marketplace. To the extent that Medicaid has been discussed at all, the fate of the law’s expansion (made optional by the Supreme Court’s landmark ACA decision) to parents and childless adults has been the issue. That is because Medicaid’s coverage for children and its many other roles long predate the ACA – in the case of children’s coverage. As readers of SayAhhh! well know, the success in connecting a record number of America’s children with coverage is the result of many decades of work through Medicaid and CHIP.  Indeed, outline released by the House of Representatives last week doesn’t even mention Medicaid in its section of “Key Facts” which forms the basis of the case for repeal.

The fate of the expansion itself alone is of course already hugely consequential and I’ll talk about that in a moment. But it is clear from both documents that Medicaid’s current financing structure for everyone – not just expansion enrollees — will be eliminated if House leaders have their way. While it is not yet clear if the House will pursue a “block grant” approach or a “per capita cap” (as was included in the leaked bill), or let states choose between the two, what is clear in my mind is that either approach would likely end the guarantee to comprehensive and affordable coverage that 37 million children (among others )currently have. We just released an issue brief on the risk either approach poses for children (as my colleague Elisabeth Burak  blogged about).

The intent of this mission is clear – to cut the federal budget. The vehicle we all know for this legislative undertaking will be a budget reconciliation bill because it only needs 50 votes in the Senate. Using reconciliation as the vehicle underscores that this is a budget-driven exercise – not a serious venture into Medicaid reform. Of course we don’t yet know how much the Republicans intend to cut, but we do now know that Medicaid is on the chopping block for sure.

The fate of the expansion has been a hot topic within the Republican party for some time – at the state level as well. The leaked bill makes clear the House leadership’s intend to repeal the expansion by eliminating the current enhanced matching funds. The proposal would pull down the match rate to the current match rate creating a cost-shift to states of $32 billion in 2019 according to estimates by the Center on Budget and Policy Priorities. The leaked bill proposes that this happen in 2020 (conveniently timed right after the election) so this number will have to be tweaked but gives a good sense of the huge cost-shift to expansion states that would likely prove insurmountable in a climate where state budgets are already struggling.

Moreover, seven states have “trigger” provisions in their Medicaid expansion programs which, in the absence of action by state legislators, would mean coverage for their expansion populations would end as a result of a reduction in the federal matching rate. And as I blogged about before, Arizona children are especially at risk if Congress does not fully fund the Children’s Health Insurance Program since their recently reopened CHIP program has a trigger provision as well.

In a poll released today by the Kaiser Family Foundation only 12% of those surveyed wanted Medicaid to be cut. Even 69% of Republicans want funding for the Medicaid expansion to continue. Moreover, about two-thirds of those interviewed also wanted to keep Medicaid’s current financing structure. This poll was taken even before much discussion of the House’s proposal had been debated  publicly – which will pair Medicaid cuts to the most vulnerable in part to fund the elimination of taxes, which mostly benefit the wealthy.

Virtually no public discussion of the impact of these changes on children has occurred. Rumor has it that the House wants to go forward with a markup the week of March 6th. I find it a shocking dereliction of duty by the House to move forward on these monumental Medicaid changes with no bill yet, no hearings, no estimates of the budget impact, or most importantly, with no examination of the impact these changes would have on children and their families, pregnant women, people with disabilities, and seniors in nursing homes.