Republicans want to block-grant Medicaid but can’t agree on how

Most Republican lawmakers and President Donald Trump support a plan to turn Medicaid into a block-grant program, which would limit spending and give each state a set amount of money each year to care for its poor and disabled citizens largely in the way it sees fit, but they remain divided on just how to do it, Burgess Everett, Rachael Bade and Rachana Pradhan report for Politico.

One of the Republicans’ challenges is that Trump has said he wants to keep covered the roughly 11 million people who gained coverage under the Patient Protection and Affordable Care Act’s Medicaid expansion program, including 440,000 in Kentucky, while also supporting block grants.

These two ideas are “fundamentally at odds with each other because block grants are widely viewed as likely to result in sweeping cuts in government-subsidized health insurance for the poor,” which is making it hard for lawmakers to “coalesce around a plan,” Politico reports. In total, Medicaid covers roughly 70 million Americans.

Sen. Steve Daines, R-Mont., whose state expanded Medicaid under Obamacare, told Politico that he wants to make sure his constituents keep their coverage: “I’m not seeing any proposal or discussion around a replacement that doesn’t address the fact that we’ve got to take care of these folks that have expanded Medicaid.”

But House Budget Vice Chairman Todd Rokita, R-Ind., a strong advocate of block grants, said: “Medicaid is among the top three drivers of our debt. It’s unfair for the citizens of tomorrow to bear the burden through our debt load for the health care of today’s poor, and it’s especially not fair for them to pay for [able-bodied adults] who otherwise should be making their own way.”

But Republicans remain divided on whether to support fixed-rate block grants, which would cause “steep cuts to the program” or one that provides funding based on the number of people who qualify for it, rather than a fixed cap, often called “per beneficiary” or “per capita” payments, Politico reports.

Sen. Bill Cassidy, R-La., who supports the per-beneficiary plan, told Politico that straight block grants don’t account for demographic or population changes or variances in health-care costs from state to state.

Rodika, a strong conservative, supports the fixed grants because “limiting a resource, like block grants do, always increases innovation and efficiency,” adding that the per-beneficiary approach would be expensive and keep the federal government too involved the program.

House Speaker Paul Ryan’s “Better Way” agenda last year proposed that states be allowed to choose which option they prefer.

Critics, especially Democrats, say block grants would put coverage for millions of low-income people at risk. “They’re unlikely to support either plan,” Politico writes.

“I can’t conceive of any way in which a block grant would not put vulnerable people at risk,” Sen. Ron Wyden, D-Ore., told Politico. Republicans want, he said, “an ideological trophy — the repeal of [Obamacare] — and then maybe down the road we’ll talk about poor people.”

Despite their differences in opinion, Republicans are working to find a way to include Medicaid reforms into the fast-track Obamacare repeal bill, which is expected to pass both chambers in March or April. If they can figure this out, they won’t need Democratic help, but if they can’t, they will need at least eight Democrats to get the 60 needed votes in the Senate, which is “likely to prove impossible,” Politico reports.

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