President Donald Trump said during his presidential bid that he would not cut Medicaid, Medicare or Social Security, the massive entitlement programs that account for nearly half of federal spending.

But as Republicans in Congress and the White House seek to undo the Affordable Care Act, they’re going beyond the 2010 health care law to also dramatically change how Medicaid is funded.

Both the president’s new budget blueprint and the House GOP’s Obamacare replacement would cut hundreds of billions of dollars in funding for that joint state-federal program, which serves low-income children and their caretakers, pregnant women, disabled individuals and the elderly.

U.S. Sen. Pat Toomey of Pennsylvania, who is part of the Senate GOP working group drafting a health care bill and leading the effort on Medicaid changes, argues that Medicaid is growing at an unsustainable pace and they want to limit future spending. But doing so would leave states scrambling to replace those federal dollars as costs rise, say health policy experts and Democratic Pennsylvania Gov. Tom Wolf.

Right now, those states share in any unexpected cost spikes, but they would bear more of the burden under a capped system, Rudowitz said.

In Pennsylvania, Medicaid costs typically have grown at a faster rate than the medical CPI, said Sarah Galbally, Wolf’s secretary of policy and planning.

“We’ve have done a lot over the last couple of years to control our Medicaid growth and keep it as low as possible, but Pennsylvania has an aging population and that’s an expensive population to provide health care to,” Galbally said.

Wolf and Toomey spoke on the phone recently about the health care negotiations, and the governor told the senator that any changes that shift costs to the state budget would likely result in a loss of care for those on Medicaid.

Galbally said state officials don’t expect they could fill the full gap. It’s not yet clear whether the state would seek to change who is eligible, cut back benefits, or both.

Asked recently about the smaller payment that Pennsylvania could expect, Toomey described the program’s current growth as “unsustainable.” As for the payments covering Medicaid’s expansion, he said states will need to make a decision.

“To suggest that the federal government is being unreasonable when we’re offering to pay more than half of the cost of an expansion that we didn’t support in the first place, I’m sorry, I just disagree,” Toomey told reporters.

The next glimpse at what states may need to prepare for could be coming soon. The Senate aims to have a partial draft of its health care bill by the time congressional lawmakers return from recess on June 5, though significant divisions remain among Senate Republicans.

Toomey and Portman, those working most closely on Medicaid, have different views on that portion. Portman has pushed for more gradually undoing the Medicaid expansion. Toomey has said he’s “open” to discussion on that, but wants to ensure that a transition does occur.

Twitter @LauraOlson


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Federal Medicaid decisions will roll down to states