The just-released Trump fiscal-2018 budget proposal is devastating news for 77 million poor and lower-income Americans. As the third largest domestic program in federal spending (behind Social Security and Medicare), it has been on the chopping block of the Republican agenda for some time. Enacted in 1965, this joint federal-state program has been a crucial part of a safety net for health care over its 52-year history for eligible  children and adults, the blind and disabled, seniors, and about 16 million adults who have gained eligibility since 2010 through Medicaid expansion under the Affordable Care Act (ACA).

The Trump budget would cut Medicaid spending by $834 billion and cover 14 million fewer people by 2026, while giving the wealthiest Americans a $600 billion tax cut, according to the Congressional Budget Office (CBO). Federal spending on Medicaid would be phased out through block grants to states, with the expectation that states pick up the slack for their vulnerable populations. The current federal-state share of Medicaid funding varies considerably by state—from 74 percent federal in Mississippi to 50 percent in California and New York. (1)

The recently passed House bill, the American Health Care Act (AHCA), would implement per-capita caps on federal spending on Medicaid in 2020. As an alternative to caps, states could opt to accept block grants any time after 2019, which would give states more flexibility on who would be covered, what services would be provided, and how providers would be compensated. Four Republican governors—from Arkansas, Michigan, Nevada and Ohio—immediately wrote to House and Senate leaders that “the House bill provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states.” (2)

The AHCA has moved on to the Senate, where many call it dead on arrival. A 13-man working group—no women, despite the AHCA’s one-year cut in funding for Planned Parenthood—has been tasked with crafting the Senate’s own bill. Major controversies will surround such issues as reversal of the ACA’s Medicaid expansion (supported by many Republican governors), possible higher premiums for older Americans, waivers that allow states to deny coverage based on pre-existing conditions or for such essential benefits as hospital care, contraceptive services and maternity care, work requirements for eligibility, and time limits on coverage.

Despite President Trump’s continued pressure for Congress to pass a bill that repeals and replaces the ACA quickly, many senators are calling for a slow approach, perhaps taking all this year, while they grapple with the growing opposition of those who will be impacted adversely by the House bill. High on that list are how the CBO will score the number of newly uninsured under a possible combined Senate-House bill, and the negative impacts on hospitals who would see drops in their numbers of paying patients and deficits challenging their survival, especially in rural areas.

Meanwhile, as Congress deliberates what to do about Medicaid, other parts of the Trump administration are proceeding to dismantle Medicaid in other ways. When Vice President Pence was governor of Indiana, he insisted on including monthly payments as a condition for expanding Medicaid, based on the belief that they promote personal responsibility when enrollees have more “skin in the game,” a time-worn GOP concept that just sets up financial barriers to care for lower-income people. The Healthy Indiana Plan was designed and implemented by consultant Seema Verma, who is now the new administrator for the Centers for Medicare and Medicaid Services (CMS) in the Trump administration. As a result, more than one-half of Medicaid recipients in Indiana at some point were unable to keep up with their monthly payments for top-tier care, and ended up with either intermittent coverage, lower-tier coverage (such as no dental and vision benefits and limited drug coverage), or no coverage at all. Now, Verma is working with Dr. Tom Price, head of the Department of Health and Human Services (HHS) to expand the “skin in the game” requirement to other states. (3)

It remains to be seen what Congress will do with this grenade on its desks. Public reaction will intensely oppose the breakup of Medicaid, long a key element of what safety net we have. Many patients will forgo necessary care, have worse outcomes, including increasing numbers of preventable deaths. A recent article by Mark Dudzic, a lifelong union activist now serving as national coordinator of the Labor Campaign for Single-Payer Healthcare, hits the nail on the head in these words:

Congress needs to be held accountable for conspiring behind closed doors to deprive millions of Americans of access to healthcare and undermining decent working class health plans while providing massive tax cuts to the rich. (4)

John Geyman, M.D. is the author of  Crisis in U.S. Health Care: Corporate Power vs. the Common Good and the recently released pamphlet Common Sense about Health Care Reform in America

visit: http://www.johngeymanmd.org

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(1) (McGinty, JC. Calculating the costs of curbing Medicaid. U. S. News: A2, June 3-4, 2017).

(2) (Rovner, J. Repeal and Replace Watch. A squeaker in the House becomes headache for the Senate: 5 things to watch. Kaiser Health News, May 4, 2017.)

(3) (Groppe, M. More than half of Indiana’s alternative Medicaid recipients didn’t make payment required for top-tier service. IndyStar, May 8, 2017.)

(4) (Dudzic, M. Six ways Trumpcare makes healthcare worse (and one way to make it better). Common Dreams, March 14, 2017.)