Alex Ruoff

Altering the House’s Obamacare repeal bill to aid Medicaid expansion states may be
impossible under Senate rules, lawmakers said May 9.

The Senate’s version of the American Health Care Act
(H.R. 1628) must cut the federal deficit to the same extent as the House bill in order to qualify
for the budget reconciliation process that allows bills to pass with a simple majority,
senators told reporters. This means new money for states that expanded their Medicaid
programs under the Affordable Care Act would have to be paid for by new revenue or
cuts elsewhere, Sen. Ron Johnson (R-Wis.) told reporters.

Several Republicans senators mentioned a “softer landing” for ending Medicaid expansion
funding compared with the House bill, either extending how long the federal government
supports expansion states or adding funds for high-risk pools or higher tax credits
to support people who lose Medicaid coverage. Either way, the Senate bill must achieve
the same savings as the House bill, which looks to cut $880 billion in future Medicaid

“I think we’d like to take the Medicaid provisions and engineer a softer landing that
still eventually gets to the same place,” Sen. Roger Wicker (R-Miss.) told reporters.

Sen. Rob Portman (R-Ohio) told reporters he wants to increase tax credits for some
of the poorest Americans, to offer additional support for people who might lose Medicaid
coverage if the ACA is repealed.

The House bill, passed May 4, would freeze federal Medicaid expansion funds starting
in 2020. The legislation would also convert the public health insurance program into
a per-capita cap system, which would give states a flat amount per year instead of
the current system of matching state spending at a given rate.

Senators May 9 discussed converting Medicaid to a block grant system or capping federal
funding based on the number of Medicaid beneficiaries in the states to find additional
savings, lawmakers told reporters.

Complicating this issue is the fact that senators don’t know exactly how much deficit
reduction would be achieved under the House repeal bill. The version of the AHCA first
considered by the House in March was projected to reduce federal deficits by $337
billion over 10 years, according to a Congressional Budget Office

Questions About Changes

Republican senators are debating how to support the 11 million adults who gained coverage
under Medicaid thanks to the ACA. Many are supportive of the House bill’s move to
create high-risk insurance pools, which subsidize the cost of insurance for people
with expensive medical conditions.

Sen. Susan Collins (R-Maine) gave a presentation to fellow Republican senators on
the high-risk pool her state once used, which assigned high-cost beneficiaries on
individual plans to a reinsurance pool, funded by a fee on insurers in the state.
Plans were reimbursed by the state nearly all the cost of covering people in these
pools, offsetting the risk of insuring them and forestalling a need to raise premiums.

Collins said the House bill grossly underfunds these high-risk pools. Such programs
would cost about $15 billion per year, she said.

“We would need a great deal more funding for this to work,” Collins said.

The House bill included $23 billion specifically for these kinds of programs and an
additional $115 billion in state grants, all spread out over 10 years.

Sen. Cory Gardner (R-Colo.), however, said lawmakers think high-risk pools could
help Medicaid expansion states like his.

There has been discussion among senators about changing Medicaid disproportionate
share hospital (DSH) allotments, additional money given to hospitals that serve a
large Medicaid and uninsured population. The ACA reduced federal support for DSH allotments.

Some lawmakers want to increase DSH allotments to make up for Medicaid cuts, Sen.
David Perdue (R-Ga.) said.

To contact the reporter on this story: Alex Ruoff in Washington at

To contact the editor responsible for this story: Brian Broderick at

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Senators Unsure if They Can Save Medicaid Expansion – Bloomberg BNA