The Senate Puts Medicaid on the Chopping Block

A draft version of the AHCA released Thursday shows even deeper cuts to the program than the House version.

Chip Somodevilla / Getty / Katie Martin /The Atlantic

The new AHCA is a lot like the old AHCA.

After weeks of secret gestation in back rooms, the Senate released a discussion draft of the chamber’s version of the American Health Care Act. Like the version passed through the House to cheers in May, it is likely to make health care less affordable for low-income, sick, and near-elderly people; it makes Obamacare tax credits for exchange coverage less generous; it restricts and slashes Medicaid funding deeply over the next decade; and it attempts to smooth euphemistically-named “market disruptions” from all those reforms by injecting billions into state funds and reinsurance.

There are some substantial changes in the specifics, though. For starters, the Senate bill would tweak the House bill’s tax subsidy for private insurance purchased on the exchanges. The final version of the House bill provided a tax credit to people making up to 400 percent of the federal poverty line that would be less generous than the existing ACA credits. It would also reduce the amount of expenses covered as recipients get older and have more expenses.

The Senate’s version would cut the eligibility for premium tax credits to those earning up to 350 percent of the poverty line. It would be slightly more generous for poor and near-poor people, although credit percentages would taper off more sharply as recipients grow older, and they would be severely restricted for people as their income approaches that 350 percent threshold. Unlike the House plan, however, the Senate plan would fund Obamacare exchange cost-sharing subsidies through 2019, which would soften some of the immediate impacts of a less generous tax credit.

The House’s bill would allow private insurers to charge people more as they grow older, and permit plans in certain states to cover fewer services. It also would have made exchange coverage more expensive and less comprehensive on average for low-income, sick, and older people. It would likely reduce coverage for pregnant women and people with mental-health issues as well. The last Congressional Budget Office score found that many of the 23 million fewer people who would be covered were drawn from those groups, as well as many of those who would keep coverage but suffer dramatic increases in premiums.

The Senate bill would alleviate some of these issues with slightly more generous credits for the poor, but would keep those central disruptions intact, and would leave more middle-class people without affordable coverage. It also allows even less generous plans to stand as benchmarks for exchange and employer coverage, which could likewise contribute to disruptions and deductible increases.

In recognition of the disruptions to the state-level exchanges through which individuals purchase coverage, the House bill set up a “Patient and State Stability Fund,” which would inject over $100 billion into state high-risk pools and reinsurance funds. The Senate largely replicates this approach with slightly less funding, although it does add an additional $2 billion fund for fighting the opioid crisis in 2018.

The much more drastic changes in the Senate bill as compared to the House bill come in the realm of Medicaid. The House bill immediately ended enhanced funding for the Medicaid expansion to able-bodied low-income adults under the ACA, while the Senate bill would slowly phase that funding out. This, in theory, would put millions fewer people immediately in the ranks of the uninsured and increase government spending over the House plan. But seven states (Arkansas, Illinois, Indiana, Michigan, New Hampshire, New Mexico, and Washington) have “trigger laws” that would immediately void their Medicaid expansions with any change in federal support, and it’s likely more states would choose to shutter their expansions well before the end of the enhanced funding window in the face of rising costs.

The House’s plan also restructured the open-ended funding of Medicaid to a per-capita cap scheme, where states receive a capped amount of funding each year per enrollee, and could choose to receive the funding up front in block grants. That Medicaid restructuring increased yearly funding by the medical Consumer Price Index plus 1 percent, a measure designed to keep per-capita caps roughly in line with inflation in the industry, but one that would also underfund Medicaid over time, leading to a growing gap between the number of patients who would be eligible under current guidelines, and the funds available to pay for their care.

Several independent analyses have concluded that this funding structure would lead to large-scale shortfalls in every state, which would need to be closed by reducing enrollment or benefits, and cutting capacity to respond to disasters and public-health crises. Those affected most would be poor children, people with mental-health issues, and disabled people.

After President Trump reportedly called the House draft “mean” earlier this month, many observers expected the Senate to produce a more moderate plan. Instead, the Senate plan actually deepens long-term Medicaid cuts. The bill keeps the same basic inflationary index of the House bill until 2025. But after that, instead of using the more generous medical inflationary index (since costs in the health-care sector increase faster than broader measures of inflation), the Senate plan uses the general Consumer Price Index for all urban consumers (CPI-U), which will dramatically slow the rate at which funding for the program increases.

A recent report from the Urban Institute shows some of the long-term effects of this switch in inflationary indexes. While it assumes an existing Medicaid expansion and compares an immediate difference in indexing, instead of the 2025 phase-in, the paper illustrates how Medicaid funding will be flattened in the future under the CPI-U. States will have to plan for much less generous Medicaid funding down the road, and most signs point to even more cuts in benefits and eligibility for some of the most vulnerable populations than under the House plan.

That restriction on Medicaid might seem like bad politics, and it remains to be seen if moderate Republicans will warm to the bill, or if public pressure will change some minds. But among the Republican base especially, Medicaid remains deeply unpopular, and is frequently maligned. Even as strengthening the private-insurance subsidies became a key issue for Senate Republicans, Medicaid remained a target, and reducing its generosity has long been a rather uncontroversial piece of the party’s goals.

The full impact of all these changes in the Senate draft won’t be known until it receives a score from the CBO. But what appears clear is that along with broad cuts in Obamacare taxes that mostly benefit middle-class and upper-income people, the Senate plan—perhaps even more so than the House plan—is a massive constriction of the safety net. It will have a substantial impact on both wealth and health, shifting the benefits of public policy away from the poor and the sick, and toward the healthy and the affluent. For Republicans who have long despised the redistributive effects of Medicaid, that is precisely the point.