GOP proposals would dramatically change Medicaid

WASHINGTON — A contingent of House Republicans is trying to push the nation’s health insurance program for poor and vulnerable Americans deep into conservative territory, past a firewall the Obama administration maintained for eight years.

A partisan vote Thursday afternoon by the House Budget Committee would require able-bodied adults to hold a job to qualify for Medicaid.

That profound change long has been popular on the far right as a way to promote personal responsibility, but opposed by Democrats who fear it would deny health care to many people who need it the most.

Compelling people to work, which would align Medicaid with a similar requirement in the nation’s main welfare program, was one of a trio of moves that committee Republicans recommended as they approved legislation they hope will begin to dismantle the Affordable Care Act, popularly known as Obamacare.

Over protests from Democratic lawmakers, the panel also recommended that an expansion of Medicaid under Obamacare be dismantled sooner than the GOP’s proposed American Health Care Act envisions. And committee members voted that states should be able to convert Medicaid from an entitlement program — covering anyone who is eligible — into a block grant, under which the federal government provides a state a fixed annual sum and frees it from federal rules.

Friday morning, President Donald Trump said he was “100 percent” behind the work requirement and block-grant option. The bill could go to the full House next week.

The three votes on Thursday did not formally alter the legislation, which House Speaker Paul D. Ryan, R-Wis., and his allies are trying to rush through the chamber amid a political obstacle course. The Budget Committee merely puts forward changes to be considered.

While the House Budget Committee is trying to nudge the program toward the right, moderate Republican governors and senators are fighting to ward off the loss of millions of dollars in federal aid to the 31 states, plus the District of Columbia, that expanded their Medicaid programs.

Iowa expanded the Medicaid program and added insurance for hundreds. The state is in its first year of turning management of the program over to private insurers.

GOP governors from Arkansas, Michigan, Nevada and Ohio sent their own health-reform proposal Thursday to Ryan and Senate Majority Leader Mitch McConnell, R-Ky. The four had been working behind the scenes on an alternative.

The current 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,” they wrote. As part of their proposal, the governors urged Congress to preserve the increased level of federal payments that Obamacare provides for adults in the expansion group — and, if necessary for fiscal reasons, cut back eligibility limits rather than cutting the higher reimbursements.

A legacy of Lyndon Johnson’s War on Poverty in the 1960s, Medicaid has been a shared responsibility of the federal government and states. The current tug of war is likely to shift that balance and affect how generous the program is.

The current legislation allows the expansion states like Iowa to keep enrolling people until the end of 2019, and the government would continue paying for nearly all their costs. After that, the government would not provide the higher funding level for anyone new on the Medicaid rolls, presumably prompting most states to retreat to their previous income thresholds.

The budget panel went further than the current bill, recommending that the extra funding end right away.

But the sharpest exchange this week has been over requiring able-bodied adults on Medicaid to hold or train for a job. Republicans suggested that such a requirement would save the government money and encourage those in the program to take greater responsibility.

Medicaid now covers some 68 million low-income Americans, including children, pregnant woman, people who are older or disabled and others who are poor. About 11 million of the beneficiaries are people with somewhat higher incomes who joined through the expansion.

A Kaiser analysis last month found that eight in 10 adult Medicaid recipients live in working families — and 59 percent who are not disabled have a job.

Most who do not work have major obstacles, such as an illness or disability or caregiving responsibility for a relative, and nearly one in five are in school.

During the Obama administration, at least a half-dozen states sought permission to include work or job-training requirements as part of their Medicaid programs.

In each case, the request was denied.