There's much in health care policy that divides Republicans. But there's one major idea that unites them: block grants for Medicaid.
It’s in the budget proposal that House Budget Chair Rep. Tom Price, Trump’s pick to run Health and Human Services, released this year. It was in Trump’s own health care platform during the campaign. And it is what Trump advisor Kellyanne Conway was talking about on television news shows this weekend as the administration’s preferred path forward.
In its simplest form, turning Medicaid into a "block grant" simply means handing control of the program — and the funding for it — over to the states. But in all these plans the details reveal something else, too: a massive cut to Medicaid spending that could throw tens of millions of people off the program. To understand how that works, you need to understand the unusual way that Medicaid works.
Right now, states split the cost of Medicaid with the federal government
Medicaid, the federal entitlement program that covers low-income Americans, is perennially the largest item in state budgets. Medicaid spending is shared between the federal government and states, with each paying a set percent of each beneficiary's costs. In return for the federal match, states must meet certain requirements for coverage set by the federal government.
The federal/state split varies from state to state, with the feds footing a higher percent of the bill in states where people earn less. That's why in Mississippi, for example, the federal government pays for 74 percent of each beneficiary’s costs, but only 50 percent in Massachusetts.
Medicaid pays this amount regardless of how many people are on the program. In that way, Medicaid is an open-ended funding commitment to cover a set percent of enrollees’ bills. When the need for Medicaid rises — like during a recession, or a particularly bad flu season — the federal government is committed to meeting it.
A block grant would limit the federal government's commitment
Instead of paying a set percentage of each enrollee's bill, they would pay a specific amount to each state. It would then be up to the states to figure out how to best spend those funds.
"It sets an agreement that this is the amount of money you're going to spend and there should be no surprises," says Tony Keck, who previously directed South Carolina’s Medicaid program, told me in a prior interview.
Some recent block grant proposals — including those from Louisiana Gov. Bobby Jindal and House Speaker Paul Ryan (R-WI), when he served as budget chair — would cap Medicaid spending, only allowing spending to grow due to inflation and population growth. That usually amounts to about 3 percent growth on average, the Bipartisan Policy Center notes. By contrast, Medicaid has typically grown at 7 percent annually.
Price has overseen the introduction of multiple House budgets. And they don’t get especially specific about what growth rate he would set for a block grant proposal, whether it should be indexed to inflation or some other metric.
The 2016 and 2017 budgets both include broader policy statements that say, “Instead of tying States’ hands with Federal requirements for Medicaid, the Government should return control over to the States.” But they don’t specify how, exactly, the block grant proposal would work.
Block grants don't have to cut Medicaid spending — but they usually do
It’s certainly possible to give state governments more flexibility to implement changes to Medicaid without also slashing federal spending on the program. If it wanted to, the federal government could double Medicaid funding and call it a block grant — but that's not what typical block grant proposals do.
The Center for Budget Policies and Priorities, using public data, estimates that the block grant in the House 2017 budget, which Rep. Price oversaw as Budget Chair, would cut Medicaid spending by $1 trillion over a decade. This works out to cutting the program’s budget by about 23 percent — but it’s important to know that the cuts get much bigger over time.
CBPP expects that the block grant proposal would lead to $7 billion in reduced spending in 2017 and a $169 billion reduction in 2026. This would be equivalent, in 2026, to cutting away one-third of the program’s budget.
In return for accepting less money, block-granted states would get additional flexibility to decide how, exactly, Medicaid dollars get spent.
"Everybody's proposal is slightly different, but at the end of the day, it's a fixed sum of money," says Deborah Bachrach, who previously ran New York's Medicaid program and is currently a partner at the law firm Manatt, Phelps and Phillips.
How could states handle those cuts?
That's the biggest question. The Kaiser Family Foundation assessed the block grant proposal in Ryan's 2012 budget and estimated that it would mean between 14 and 20 million fewer people receiving Medicaid by 2022. There's no similarly granular analysis of Price’s block grant proposal.
Block grant supporters argue that with the lower funding, alongside more flexibility, states could run more efficient Medicaid programs.
"I've got state plan amendments to make simple changes, in theory, that the federal government should want to happen," Keck said. "I want to bring dietitians into the program, but that's been held up for a year."
Keck said he would gladly accept quality metrics — a requirement to, for example, reduce infant mortality — as part of a block grant agreement. That would curtail states trying to hit the spending metric by simply not providing care.
Block grant opponents don't think the savings are possible without harming benefits, either by dropping people off the program or cutting into the benefits they receive. A block grant system would be very different from the current Medicaid program where all people in certain categories — low-income pregnant women, for example — are guaranteed access to the program. There are mandatory groups of people states have to cover.
"The administrative costs of Medicaid are the lowest of any insurer in the country," says Bachrach. "You can't do the cuts through administration. And if more primary care and community-based services could save 30 percent, we would have done that already."
The details of who states could and couldn't cut — and how much they could alter the benefit package — aren't spelled out in a lot of block grant proposals, which makes it difficult to predict how, exactly, states would react to the new funding system.
"If you're going to cut spending that much, you're going to need to give governors tools to do it," says Joan Alker, executive director at the Georgetown Center for Children and Families. "It might be waiting lists or enrollment caps. People can't have a guarantee of coverage unless there's an assurance of open-ended federal funding."
The nonpartisan Congressional Budget Office, for its part, is skeptical that states could increase efficiency enough to offset the spending cuts.
"If states were given additional flexibility … they might be able to improve the efficiency of those programs in delivering health care to low-income populations," the agency wrote in its 2012 analysis of the Ryan budget. "Nevertheless, even with significant efficiency gains, the magnitude of the reduction in spending relative to such spending in the other scenarios means that states would need to … make considerable cutbacks."
Medicaid is flexible in some ways — and inflexible in others
There are definitely things that states can't change about Medicaid: They can't cap enrollment for certain populations, like low-income children, women who are pregnant, or the blind and disabled who fall under certain earning thresholds.
At the same time, there does seem to be a lot of space for experimentation. Indiana, for example, runs a Medicaid program that requires enrollees to pay a monthly premium, like in private insurance. Oregon is using budget caps to try to drive down its health care spending. And in Arkansas, the state is using Medicaid dollars to buy beneficiaries private health insurance plans.
All of those types of changes, however, require a sign-off from the federal government — which Medicaid directors note can be a frustrating process that takes years.
"There were days I would have given anything for more flexibility and less regulatory oversight," says Bachrach. "But that's essentially the quid pro quo of matching dollars. It's a pain in the neck, but the dollars are worth it."
Keck was less sanguine about the hold-ups that federal approval can cause.
"They're holding us up, and it's difficult to get the approvals," he says. "The assumption about block grants is that states are just going to be bad to their citizens, and we can't trust them. But I think we could be delivering better services if we weren't stuck waiting."