Health policies and programs in the states face an uncertain future with the election of Donald J. Trump. During his campaign he vowed to repeal the Affordable Care Act.

Currently 73 million Americans are enrolled in the Medicaid program, a federal-state partnership program for which the federal government pays 62 percent of total expenditures. A Medicaid block grant, one proposal under discussion, might provide the states more flexibility but also might transfer more financial responsibility, especially in the long term, to the states. 

An article in today's Kaiser Health News suggests that a President Trump could dismantle much of the Affordable Care Act without Congressional action. For instance, just a stroke of his presidential pen could eliminate subsidies to persons between 100 and 250 percent of the poverty level. On the other hand, Clinton's proposals to support and build on the ACA would seem to require Congressional action. 

More than 20 legislators from 16 states--many of them in key leadership positions on health or budget committees that deal with Medicaid in their home states--attended a CSG policy academy in Washington D.C. on September 21-23, 2016, to learn how states are making reforms in their Medicaid program that pursue the health "triple aim": improving the quality of care for individuals, improving the health of populations, and reducing per capita costs of health care.

A comparison of U.S. Census data for 2013 and 2014, released in early 2016, shows that a greater portion of Americans in each state had health insurance in the more recent year. Nearly 8.5 million individuals gained health insurance coverage between 2013 and 2014. In 2014, all the provisions of the Affordable Care Act designed to increase access to affordable insurance were in place for states. Some states, however, decided not to expand income eligibility for Medicaid to 138 percent of the federal poverty level as the Supreme Court ruled in 2012 was the prerogative of the states, not Congress. The states that showed the greatest increase in coverage between 2013 and 2014 were states that expanded Medicaid income eligibility.

Gov. Matt Bevin, elected in November 2015 and who had pledged during his campaign to eliminate Medicaid expansion which brought health coverage to 400,000 previously uninsured individuals, announced yesterday his plan to transform Kentucky’s Medicaid system through an 1115 waiver. The new waiver will cover almost all the Medicaid enrollees eligible under the pre-expansion rules as well as all the newly eligible under the expansion rules.

Bevin said his plan is an opportunity “to come up with what is going to be truly a transformative and sustainable and fantastic program,” according The Courier-Journal coverage of the press conference. He pledged to both save money—$2.2 billion in combined state and federal funding over the next five years—and reduce the number of Medicaid enrollees—86,000 people by 2021 by moving them to private insurance.  

Despite pushing the federal government to provide 100 percent of the cost for health care for American Indians, what South Dakota Gov. Daugaard has characterized as a longstanding treaty obligation, on Feb. 29 Daugaard ruled out Medicaid expansion during this legislative session.

Last week, two states rejected Medicaid expansion, another is continuing negotiations with Washington and one is studying whether and how to continue expansion already in place and reduce the numbers of people eligible. Currently 31 states and the District of Columbia have expanded income eligibility for Medicaid as provided for by the Affordable Care Act. Sixteen states remain firmly in the non-expansion column.

On Tuesday, Jan. 12, John Bel Edwards signed his first executive order as Louisiana’s new governor to expand Medicaid eligibility to an estimated 300,000 individuals. The expansion is to be effective no later than July 1, 2016 according to the order.

Louisiana becomes the 31st state (plus DC) to expand Medicaid income eligibility as permitted by the Affordable Care Act.

South Dakota Gov. Dennis Daugaard may find that the third time is the charm as he negotiates with the federal government to live up to its treaty obligations to provide health services to the state’s Native Americans. Twice before in recent state history, governors have tried and failed to solve the longstanding problem, which results in a massive cost shift to state revenues to pay for health care for many Native Americans. In his Dec. 8, 2015, budget address in Pierre, S.D., Daugaard proposed that should the federal government fulfill its obligation to provide health services to Native Americans, the state would use the projected $67 million annual savings to the state to finance the cost of Medicaid expansion.

No state can ignore the challenge of controlling the cost of health care, estimated to reach one-fifth of GDP by 2020. Medicaid budget growth continues to strain states’ abilities to grow program priorities in other arenas. The uncertainty of federal commitment to current Medicaid matching formulas is exacerbated by the 2016 election. Promising state strategies to control costs of health care generally and Medicaid specifically were explored.  

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