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Questions to Ask About the House Republican Health Reform Proposal

In this column for The Wall Street Journal’s Think Tank, Drew Altman discusses the critical issues to look for and questions to ask about the U.S. House task force health reform outline due out this week.

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The Fundamentally Different Goals of the Affordable Care Act and Republican Replacement Plans

Drew Altman discusses Republican and Democratic health reform objectives, and why GOP proposals and the Affordable Care Act are better understood as policies with very different goals, trade-offs and consequences.

Column/Op-Ed Read Post

Why Today’s Poll Numbers on Health Proposals Are Bound to Change

Drew Altman discusses how public opinion can change as health proposals move from the idea stage to real legislative debates in this Wall Street Journal Think Tank column.

Column/Op-Ed Read Post

Two Studies Draw Different Conclusions on State of Black America

In this column for The Wall Street Journal’s Think Tank, Drew Altman discusses how studies with conflicting views of progress and problems for African Americans can both be true, and why African Americans may feel the problems more than the progress.

Column/Op-Ed Read Post

Partisanship’s Grip On The Affordable Care Act

In this Wall Street Journal’s Think Tank column Drew Altman analyzes data from an upcoming Kaiser poll and discusses how partisanship is the dominant factor shaping views of the Affordable Care Act for Republicans and Democrats enrolled in marketplace plans.

Column/Op-Ed Read Post

Clinton-Sanders Contest Fuels Democratic Support for Expanding Obamacare

In this column for The Wall Street Journal’s Think Tank, Drew Altman discusses how the debate between Hillary Clinton and Bernie Sanders about how to get to universal coverage has generated more support among Democrats for expanding the Affordable Care Act (and less support for the law as is).

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This was published as a Wall Street Journal Think Tank column on June 20, 2016.
House Speaker Paul Ryan’s health-care task force is expected to outline its alternative to Obamacare this week. The outline reportedly will not include the level of detail that would allow much external analysis of its impact by health-care experts and the media, though Democrats are likely to attack its concepts, most of which will be familiar proposals that Republicans favor and that Democrats have opposed in the past. The outline is part of Mr. Ryan’s effort to add Republican policy ideas to the election debate, in particular to the presidential campaign, and seems aimed at helping down-ticket Republicans as a part of an agenda that can appeal to their base. Details will be needed to understand whether the plan is more progressive or regressive and how many uninsured people would be covered. Another big question is how Donald Trump will respond. One expected feature is a tax credit to help people pay for insurance. It matters whether this is a flat credit, which would be more regressive, or a progressive credit that would provide more help for lower-income people (like the Affordable Care Act does). The impact of tax credits can be complex and whether it varies by age and geography, as well as income, is important. A flat credit of around $2,000, for example, will be better on average for people earning more than about 200% of the poverty level (about $24,000 for a single person) and worse for people earning less than that; it may induce more people to buy high-deductible plans with somewhat lower premiums.
Previous Republican proposals called for converting Medicaid into a traditional block grant to the states. Giving each state a fixed allotment of federal dollars through a block grant can provide an incentive for states to limit enrollment or cut eligibility when the economy slows down and enrollment rises. When governors saw how many more uninsured people might be in their states under the traditional block-grant approach, many soured on the idea. Another approach that is reportedly part of the forthcoming GOP outline, called a per capita cap, allows federal payments to states to rise and fall with enrollment. But a primary Republican goal is to limit future federal Medicaid spending. And as growth in federal Medicaid spending tightens in the future and health costs rise, states may face an incentive to limit the benefits they provide for low-income residents. If the cap on federal spending hits far enough down the road, more governors may be persuaded to support the idea in return for the flexibility they would get; if the cap hits sooner, fewer may support it.
Democrats are sure to oppose any Medicaid cap as a cut in program funding and as a fundamental change to the federal-state Medicaid bargain in which the federal government matches state efforts based on a formula reflecting state needs. Without the prospect of millions losing coverage, a per capita cap is a tougher target for Democrats than the traditional block grant was. For states, the Medicaid wars with the federal government have historically been framed as a fight about flexibility and control when they have always been at least as much, if not more, about money and the consequences of federal funding reductions. I learned this firsthand while overseeing a Medicaid program for a Republican governor in New Jersey in the late 1980s. Overall, the ACA has increased the number of people with health coverage by about 20 million. Without specific details of the GOP proposal, it will be difficult to assess how much that would change if all the elements expected to be part of the Republican outline were implemented.
Donald Trump’s reaction is even harder to predict than its impact. He could choose not to comment or to endorse some elements but not others. His campaign website says that any health reform effort “must begin with Congress.” Mr. Trump has said that he opposes any cuts to Medicare and Medicaid but has also endorsed a Medicaid block grant. He has endorsed high-deductible health insurance plans with savings accounts and allowing the purchase of insurance across state lines, both of which are expected to be elements of the Republican outline. Health policy has not been a focus for Mr. Trump so far, though it may come into play in the general election in back-and-forth over Obamacare or when Hillary Clinton challenges Mr. Trump’s health-care ideas and command of detail about the issues.
Debate over the forthcoming GOP outline will reflect both partisan politics in an election year and strongly held differences in policy goals between Republicans and Democrats. For those of us in the business of independent analysis, the expected lack of detail will make informing the discussion more challenging.
[post_title] => Questions to Ask About the House Republican Health Reform Proposal [post_excerpt] => In this column for The Wall Street Journal's Think Tank, Drew Altman discusses the critical issues to look for and questions to ask about the U.S. House task force health reform outline due out this week. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => questions-to-ask-about-the-house-republican-health-reform-proposal [to_ping] => [pinged] => [post_modified] => 2017-02-06 14:50:51 [post_modified_gmt] => 2017-02-06 19:50:51 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=191378 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [1] => WP_Post Object ( [ID] => 189914 [post_author] => 71503784 [post_date] => 2016-06-07 07:04:09 [post_date_gmt] => 2016-06-07 11:04:09 [post_content] => This was published as a Wall Street Journal’s Think Tank column on June 7, 2016. Rep. Pete Sessions and Sen. Bill Cassidy introduced legislation last month calling for replacing elements of the Affordable Care Act. A House task force established by Speaker Paul Ryan is expected to follow with more health-care proposals. These Republican health plans are generally referred to as “replacements” for the ACA–in the spirit of “repeal and replace”–as though they would accomplish the same objectives in ways that conservatives prefer. But the proposals are better understood as alternatives with very different goals, trade-offs, and consequences. Whether they are “better” or “worse” depends on your perspective. To boil down to the most basic differences: The central focus of the Affordable Care Act is expanding coverage and strengthening consumer protections in the health insurance marketplace through government regulation. By contrast, the primary objective of Republican plans is to try to reduce health-care spending by giving people incentives to purchase less costly insurance with more “skin in the game,” with the expectation that they will become more prudent consumers of health services. They also aim to reduce federal spending on Medicare and Medicaid and the federal government’s role in both programs. Elements of the ACA were designed to reduce costs, such as the law’s Medicare payment reforms, and elements of Republican plans such as tax credits aim to expand access to insurance, but the primary aims of the ACA and the Republican plans differ.
 In public discussion the architects of these Republican plans often gloss over their differences from the ACA. But it is not as if they can somehow achieve the same things the ACA achieves, just in a way that involves less spending and regulation. Sen. Orrin Hatch acknowledged the fundamental difference in goals during the 2012 election: “Conservatives cannot allow themselves to be browbeaten for failing to provide the same coverage numbers as Obamacare. To be clear, it is a disgrace that so many American families go without health insurance coverage. But we cannot succumb to the pressure to argue on the left’s terms.”
The differences between Republican and Democratic objectives make it tricky to fairly evaluate the GOP proposals. With the ACA now the status quo, should Republican plans be evaluated against whether they maintain or don’t maintain ACA coverage gains and insurance protections? Should they be evaluated on how well they achieve their own objectives–promoting consumer choice and lower-cost insurance plans, reducing marketplace regulation, and reducing federal spending and the federal role in health care? Should GOP proposals and the ACA both be assessed against general criteria pretty much everyone in health care uses, such as how well they improve access and quality, and control costs? All of these metrics can be used, but conservatives and liberals are likely to weigh them differently. There are many ideas that conservatives have favored embodied in the ACA, just as there are ideas in Republican plans that will be palatable to Democrats. But fundamentally, Democrats could not cover almost everyone, while ensuring that they get comprehensive benefits and that sick people were protected in a market that had excluded them and at the same time achieve Republican goals. In the same way, Republicans cannot deregulate, reduce spending and the federal role, give consumers more skin in the game and all the while achieve Democratic goals. There is an inherent tension between the objectives each side wants in health reform.
Karl Rove recently wrote in The Wall Street Journal that “Republicans must campaign on credible, substantive alternatives to ObamaCare.” That seems fair enough. But health-care experts, the media, and architects of health-care proposals can do more to make it clear that the ACA and Republican plans are not different means to the same ends but means to different ends–each legitimate depending on one’s political and policy priorities, and each with their own trade-offs and consequences for the public.
[post_title] => The Fundamentally Different Goals of the Affordable Care Act and Republican Replacement Plans [post_excerpt] => Drew Altman discusses Republican and Democratic health reform objectives, and why GOP proposals and the Affordable Care Act are better understood as policies with very different goals, trade-offs and consequences. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-fundamentally-different-goals-of-the-affordable-care-act-and-republican-replacement-plans [to_ping] => [pinged] => [post_modified] => 2017-02-06 14:54:07 [post_modified_gmt] => 2017-02-06 19:54:07 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=189914 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 188919 [post_author] => 36621681 [post_date] => 2016-05-24 07:22:20 [post_date_gmt] => 2016-05-24 11:22:20 [post_content] =>
This was publishes as a Wall Street Journal Think Tank column on May 24, 2016.
Kaiser Family Foundation polling from February on how public opinion of single-payer health care is swayed by the framing of arguments for and against the proposal.
Gallup polling released last week showed majority support–58%–for replacing the Affordable Care Act with a federally funded health system. The same poll found 51% support for repealing the ACA. There is a basic point that often gets lost in reaction to poll findings like these: They measure the public’s initial response to ideas and words, and proposals such as single payer or ACA repeal that people associate with candidates–but they don’t tell us much about the likely level of support for a policy if there is a real debate about legislation before Congress, with winners and losers laid bare. It’s always a fair bet that support would decline for big changes that come with big trade-offs–whether it is single-payer health care or ACA repeal or something else–but there is no way to know those levels in advance, and support could rise or fall depending on how a legislative debate plays out. Consider single-payer health care as an example. In February, the Kaiser Family Foundation monthly tracking poll simulated some of the arguments the public might hear in a debate about single payer. As the chart shows, public sentiment about a single-payer plan moves in both directions depending on the arguments heard. For instance, 50% of the public supports the idea of a single government health plan, but that share fell by 14 points if people heard that such a plan would “require Americans to pay more in taxes” and diminished by 20 points if they heard it would  “give the government too much control over health care” or “eliminate the health care law.” Those arguments would be made in a substantive debate about single-payer legislation. Similarly, support grew by 11 points if people heard that legislation would “ensure that health care was a basic right” or that it would “reduce health insurance administrative costs.” Support rose by 13 points if they heard it would “eliminate private insurance premiums, copays and deductibles paid by employers and individuals.”
 The same could be true in a debate about legislation to repeal the ACA. Opinion about the health-care law has been stubbornly partisan and resistant to change. But the prospect of the 20 million people who have gained coverage becoming uninsured again if the ACA is repealed could shift some ACA critics who support repeal into the other camp. Or, if there are Republican alternatives to the ACA that people find plausible and attractive, some ACA supporters could move in the other direction.
How opinion changes in a legislative debate depends on not only the arguments or the facts but also on who is making the point, how influential and credible those sources are, and the potency of their messages. Put another way: Polling questions asked now about ideas such as replacing the ACA with a federally funded health-care system don’t tell us much about which way public opinion would break in a real national debate about single-payer health care, repealing the ACA, or any other major health legislation where partisans and interest groups can be expected to take to the airwaves and there will be winners and losers.
[post_title] => Why Today's Poll Numbers on Health Proposals Are Bound to Change [post_excerpt] => Drew Altman discusses how public opinion can change as health proposals move from the idea stage to real legislative debates in this Wall Street Journal Think Tank column. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => why-todays-poll-numbers-on-health-proposals-are-bound-to-change [to_ping] => [pinged] => [post_modified] => 2017-02-06 16:26:12 [post_modified_gmt] => 2017-02-06 21:26:12 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=188919 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 188333 [post_author] => 36621681 [post_date] => 2016-05-13 13:25:47 [post_date_gmt] => 2016-05-13 17:25:47 [post_content] =>
This was published as a Wall Street Journal's Think Tank column on May 13, 2016.
In the past few weeks, one report painted a picture of real progress in the African American community with gains on many critical measures, while another – a survey my organization conducted with the New York Times – painted an alarming portrait of life for African Americans in Chicago and the prospects for African American youth there. Both the more positive and negative portrayals are accurate, but it’s very clear why statistical progress is hard for African American residents in cities like Chicago or Baltimore or Ferguson to appreciate. The more positive picture came in a New York Times story about federal data showing significant gains for black Americans in infant mortality, suicide rates, teen births, and even deaths from homicide which fell significantly, all driving gains in life expectancy for African Americans. In the story, Harvard sociologist Robert J. Sampson is quoted as saying: “ The decline in violence is a major social fact that is really reshaping society and the lived experience of kids growing up-particularly blacks.” That may seem jarring after Ferguson and Baltimore and the regular reports of violence in Chicago, to name just a few urban areas plagued by crime and tensions between the community and police.
SOURCE: Kaiser Family Foundation/New York Times Survey of Chicago Residents (conducted April 21- May 3, 2016)
SOURCE: Kaiser Family Foundation/New York Times Survey of Chicago Residents (conducted April 21- May 3, 2016)
The Kaiser Family Foundation/New York Times survey of Chicago residents shows the other side of the coin. In that survey, as the chart shows, 54% of blacks in Chicago say it is very likely for a young person in their community to end up in jail, 49% to be a victim of a violent crime, and 47% to join a gang. By contrast 36% of blacks say a young person in their neighborhood is very likely to graduate from high school and 26% expect them to graduate from college. Almost half of black residents report knowing a victim of gun violence and 41% of black men said there was a time when they felt their life was in danger. Confidence in the police is so low that 54% of black residents say that if you call the police in a dangerous situation it either won’t make things better or will make them worse. One picture, the more positive one, is the bird’s eye view of gradual changes over time, and the other is the worm’s eye view of point in time reality today. We see this in other areas as well. The economy has been gradually improving, but people don’t experience it because, until recently, wage growth has been flat. Health spending has been growing at historically moderate rates, but people don’t feel it because what they pay out of pocket for health care is going up. Similarly, as shown by Sabrina Tavernise’s excellent reporting in the New York Times, there have been gains over time for black Americans on many measures, and gaps have closed between blacks and whites on measures such as homicide rates and life expectancy. Still, reality on the ground is a far different thing. There were fifty one homicides in Chicago in January and two hundred and forty two shootings. Chicago may be an especially troubled city but it is also emblematic of problems in other urban areas. It is more than understandable why African Americans in many urban communities would have a hard time taking the bird’s eye view of statistical progress when the reality they see every day is so different – and troubling –  and why their trust in local institutions and hope for a better future for young people is fraying.
[post_title] => Two Studies Draw Different Conclusions on State of Black America [post_excerpt] => In this column for The Wall Street Journal's Think Tank, Drew Altman discusses how studies with conflicting views of progress and problems for African Americans can both be true, and why African Americans may feel the problems more than the progress. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => two-studies-draw-different-conclusions-on-state-of-black-america [to_ping] => [pinged] => [post_modified] => 2017-02-06 16:37:36 [post_modified_gmt] => 2017-02-06 21:37:36 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=188333 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 187989 [post_author] => 36621681 [post_date] => 2016-05-10 08:07:32 [post_date_gmt] => 2016-05-10 12:07:32 [post_content] =>
This was published as a Wall Street Journal' Think Tank column on May 10, 2016.
Kaiser Family Foundation chart looking at the reaction of those enrolled in health-care plans through the Affordable Care Act marketplaces on whether they benefited from or were negatively affected by the 2010 law.
You might think that people enrolled in the Affordable Care Act’s marketplace plans would like their coverage more or less depending on whether they have a high or low deductible, or receive a subsidy to help them pay their premium. Those factors and other elements of their coverage matter, but by far the biggest difference between those in marketplace plans who say they have benefited from the ACA or been negatively affected by it is whether they are a Republican or a Democrat. That’s one finding from an analysis of a Kaiser Family Foundation survey of people covered in the non-group insurance market, which provides the clearest illustration I have seen yet of how partisanship colors people’s views of the ACA. In the Kaiser survey, which will be published next week, 29% of Republicans in marketplace plans (i.e., Obamacare) say they have benefited from the ACA compared with 75% of Democrats, a 46-point difference. There is no reason to believe that there are demographic differences between these Republican or Democratic marketplace enrollees that would explain this large of a difference in their responses. They are all purchasing coverage in the ACA marketplaces, and most members of each group are receiving premium subsidies under the law. Overall, substantially more marketplace-plan enrollees say that they benefited from the ACA (54%) than say they were negatively affected (35%).
Are Republicans more negative because they feel they were forced by the law to purchase marketplace coverage? Or perhaps because they associate it with President Barack Obama, whom they don’t like? Or because they have heard bad things about Obamacare on right-leaning talk radio or cable news? Do Democrats say they have benefited because they like the president and support the law and watch left-leaning cable news? There is no way to know for sure. What is clear, though, is that the sharpest difference between enrollees in similar ACA marketplace plans is their partisan perspective.
Many expected that as people gained direct experience with the ACA, those experiences would shape their views as the law evolved from a political symbol to a reality in their lives. Advocates of the ACA thought opinions toward the law would become more positive, and critics felt the opposite. Six years after the Affordable Care Act became law, partisan perspectives still seem to trump experience. It’s a reminder of the extent to which partisanship colors perceptions of policy and programs, including the ACA.
[post_title] => Partisanship's Grip On The Affordable Care Act [post_excerpt] => In this Wall Street Journal's Think Tank column Drew Altman analyzes data from an upcoming Kaiser poll and discusses how partisanship is the dominant factor shaping views of the Affordable Care Act for Republicans and Democrats enrolled in marketplace plans. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => partisanships-grip-on-the-affordable-care-act [to_ping] => [pinged] => [post_modified] => 2017-02-06 16:41:24 [post_modified_gmt] => 2017-02-06 21:41:24 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=187989 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 187346 [post_author] => 36621681 [post_date] => 2016-05-01 10:42:40 [post_date_gmt] => 2016-05-01 14:42:40 [post_content] =>
This was published as a Wall Street Journal's Think Tank column on May 1, 2016.
Kaiser Family Foundation polling data of Democratic support over the past year for expansion of the Affordable Care Act or implementation of the law as it stands.
Among the most hotly debated of the issues Hillary Clinton and Bernie Sanders have taken on in the Democratic primary contest is how best to get to universal health insurance coverage. The former secretary of state favors incremental steps, and the senator calls for a single-payer system. That debate, and their focus on universal coverage as their goal, appears to have had a modest and perhaps surprising effect on attitudes toward the Affordable Care Act. The health-care law is an issue about which public attitudes seldom shift, yet the share of Democrats who want to expand the Affordable Care Act rose over the past year. As the chart above shows, a year ago 38% of Democrats supported expanding the ACA rather than implementing the law as it is–which 35% supported–and 18% supported repealing or scaling back the law. Over the past year the percentage rose by 13 points: 51% of Democrats support ACA expansion as of April. The debate moved the bar, but this does not mean health care became a driving issue in the primaries, though it was always in the mix of key topics for Democratic voters. In the recent Democratic primary in Pennsylvania, for example, exit polls show that one in five Democratic voters picked health care as an issue important to their vote. That’s about half as many as the voters who cited the economy and jobs as key to their choice.
At the same time interest grew in expanding the ACA, the share of Democrats who have an unfavorable opinion of the law also rose. It climbed six percentage points, to 25%, in the Kaiser Family Foundation’s April health tracking poll, up from 19% in March. Republican opposition toward the law remained stable over the same period.
Presidential elections have had an impact on public support for the ACA in the past. The numbers fell when Republicans blasted the law during the primary campaign in 2012. Now we are seeing support for expansion tick up as Democratic candidates debate how best to reach universal coverage. The takeaway seems to be: What the candidates talk about can sway opinion on policy, even if it doesn’t always affect how people vote.
[post_title] => Clinton-Sanders Contest Fuels Democratic Support for Expanding Obamacare [post_excerpt] => In this column for The Wall Street Journal's Think Tank, Drew Altman discusses how the debate between Hillary Clinton and Bernie Sanders about how to get to universal coverage has generated more support among Democrats for expanding the Affordable Care Act (and less support for the law as is). [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => clinton-sanders-contest-fuels-democratic-support-for-expanding-obamacare [to_ping] => [pinged] => [post_modified] => 2017-02-06 16:44:01 [post_modified_gmt] => 2017-02-06 21:44:01 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=187346 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 191378 [post_author] => 36621681 [post_date] => 2016-06-20 14:13:45 [post_date_gmt] => 2016-06-20 18:13:45 [post_content] =>
This was published as a Wall Street Journal Think Tank column on June 20, 2016.
House Speaker Paul Ryan’s health-care task force is expected to outline its alternative to Obamacare this week. The outline reportedly will not include the level of detail that would allow much external analysis of its impact by health-care experts and the media, though Democrats are likely to attack its concepts, most of which will be familiar proposals that Republicans favor and that Democrats have opposed in the past. The outline is part of Mr. Ryan’s effort to add Republican policy ideas to the election debate, in particular to the presidential campaign, and seems aimed at helping down-ticket Republicans as a part of an agenda that can appeal to their base. Details will be needed to understand whether the plan is more progressive or regressive and how many uninsured people would be covered. Another big question is how Donald Trump will respond. One expected feature is a tax credit to help people pay for insurance. It matters whether this is a flat credit, which would be more regressive, or a progressive credit that would provide more help for lower-income people (like the Affordable Care Act does). The impact of tax credits can be complex and whether it varies by age and geography, as well as income, is important. A flat credit of around $2,000, for example, will be better on average for people earning more than about 200% of the poverty level (about $24,000 for a single person) and worse for people earning less than that; it may induce more people to buy high-deductible plans with somewhat lower premiums.
Previous Republican proposals called for converting Medicaid into a traditional block grant to the states. Giving each state a fixed allotment of federal dollars through a block grant can provide an incentive for states to limit enrollment or cut eligibility when the economy slows down and enrollment rises. When governors saw how many more uninsured people might be in their states under the traditional block-grant approach, many soured on the idea. Another approach that is reportedly part of the forthcoming GOP outline, called a per capita cap, allows federal payments to states to rise and fall with enrollment. But a primary Republican goal is to limit future federal Medicaid spending. And as growth in federal Medicaid spending tightens in the future and health costs rise, states may face an incentive to limit the benefits they provide for low-income residents. If the cap on federal spending hits far enough down the road, more governors may be persuaded to support the idea in return for the flexibility they would get; if the cap hits sooner, fewer may support it.
Democrats are sure to oppose any Medicaid cap as a cut in program funding and as a fundamental change to the federal-state Medicaid bargain in which the federal government matches state efforts based on a formula reflecting state needs. Without the prospect of millions losing coverage, a per capita cap is a tougher target for Democrats than the traditional block grant was. For states, the Medicaid wars with the federal government have historically been framed as a fight about flexibility and control when they have always been at least as much, if not more, about money and the consequences of federal funding reductions. I learned this firsthand while overseeing a Medicaid program for a Republican governor in New Jersey in the late 1980s. Overall, the ACA has increased the number of people with health coverage by about 20 million. Without specific details of the GOP proposal, it will be difficult to assess how much that would change if all the elements expected to be part of the Republican outline were implemented.
Donald Trump’s reaction is even harder to predict than its impact. He could choose not to comment or to endorse some elements but not others. His campaign website says that any health reform effort “must begin with Congress.” Mr. Trump has said that he opposes any cuts to Medicare and Medicaid but has also endorsed a Medicaid block grant. He has endorsed high-deductible health insurance plans with savings accounts and allowing the purchase of insurance across state lines, both of which are expected to be elements of the Republican outline. Health policy has not been a focus for Mr. Trump so far, though it may come into play in the general election in back-and-forth over Obamacare or when Hillary Clinton challenges Mr. Trump’s health-care ideas and command of detail about the issues.
Debate over the forthcoming GOP outline will reflect both partisan politics in an election year and strongly held differences in policy goals between Republicans and Democrats. For those of us in the business of independent analysis, the expected lack of detail will make informing the discussion more challenging.
[post_title] => Questions to Ask About the House Republican Health Reform Proposal [post_excerpt] => In this column for The Wall Street Journal's Think Tank, Drew Altman discusses the critical issues to look for and questions to ask about the U.S. House task force health reform outline due out this week. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => questions-to-ask-about-the-house-republican-health-reform-proposal [to_ping] => [pinged] => [post_modified] => 2017-02-06 14:50:51 [post_modified_gmt] => 2017-02-06 19:50:51 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=191378 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [comment_count] => 0 [current_comment] => -1 [found_posts] => 181 [max_num_pages] => 31 [max_num_comment_pages] => 0 [is_single] => [is_preview] => [is_page] => [is_archive] => [is_date] => [is_year] => [is_month] => [is_day] => [is_time] => [is_author] => [is_category] => [is_tag] => [is_tax] => [is_search] => [is_feed] => [is_comment_feed] => [is_trackback] => [is_home] => 1 [is_404] => [is_embed] => [is_paged] => 1 [is_admin] => [is_attachment] => [is_singular] => [is_robots] => [is_posts_page] => [is_post_type_archive] => [query_vars_hash:WP_Query:private] => 9915d3f4cd94929301c4a5eba4687d57 [query_vars_changed:WP_Query:private] => [thumbnails_cached] => [stopwords:WP_Query:private] => [compat_fields:WP_Query:private] => Array ( [0] => query_vars_hash [1] => query_vars_changed ) [compat_methods:WP_Query:private] => Array ( [0] => init_query_flags [1] => parse_tax_query ) )

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