By Erin Mershon, CQ Roll Call
November 17, 2016 -- Most Republicans are eager to move forward with their long-promised repeal of President Barack Obama's signature health care overhaul, now that they will control Congress and the White House in 2017. But for more than a quarter of GOP lawmakers, repeal could eliminate significant federal funding their states are counting on to support the expansion of the Medicaid program.
There are 20 Republicans in the Senate and 120 more in the House who represent the 32 states, including the District of Columbia, that chose to expand their Medicaid programs under the 2010 health law. Some 15.7 million Americans gained Medicaid or Children's Health Insurance Program coverage since enrollments under the law began in October 2013. In just the first year, expansion states benefited from about $47.2 billion in federal funding, according to the latest data.
That reality complicates repeal deliberations. Republican senators from expansion states danced around the issue in interviews this week, emphasizing more than some of their more conservative colleagues that discussions are preliminary and that any plan to repeal coverage should include a transition period to make sure those with benefits now don't lose them. None of the Republican senators representing those states committed to supporting a repeal of the expansion, but at the same time, none promised to preserve it without changes.
"That to me is critical, that we don't all of a sudden leave people out in the cold, that we work toward a transition and we create a better program that works for everybody and gives better health care options for those people on Medicaid," said Sen. Shelley Moore Capito of West Virginia, a state that expanded in May 2013 to cover almost 100,000 more people.
"We've got to make sure we're looking at what the impacts are in terms of repeal," said Sen. Dan Sullivan, R-Alaska. In that state, Gov. Bill Walker, an independent, broadened eligibility in 2015. "For citizens who have followed the law, abided by the law, we certainly want to minimize any negative impacts."
The reconciliation bill (HR 3762) that Obama vetoed earlier this year included a transition period of almost two years.
"When you go back and look at what we did last year, there was a transition period," emphasized Sen. Rob Portman, R-Ohio. "The idea was to leave time for Congress to come up with an alternative, not to pull the rug out from under people."
Republican leaders haven't yet said whether they plan to repeal the part of the 2010 health law that expanded Medicaid. When Republicans moved earlier this year to repeal the health law through the budget process known as reconciliation, the House initially didn't repeal expansion, but the Senate version did and the House agreed. The vetoed legislation is eyed as an early draft for next year's efforts.
Asked this week about whether a repeal bill would include Medicaid expansion, leaders of several congressional committees with jurisdiction over health care said it was too early to say.
"To be determined," said House Ways and Means Chairman Kevin Brady, R-Texas.
"That's going to be up to the leadership," said Senate Finance Chairman Orrin G. Hatch, R-Utah.
Republicans in both chambers also emphasized that they plan to include Medicaid changes in their promised effort to replace the health law. Republican replacement plans, including an oft-cited proposal from House Speaker Paul D. Ryan, R-Wis., have focused on restructuring the program into so-called block grants or per capita caps, which would reduce federal funding growth for the program.
None of those proposals spelled out details, including whether the funding would be based on the number of people in an expanded Medicaid program or a pre-expansion one.
Shift to the States
Sen. John Barrasso, R-Wyo., who helms the Senate Republican Policy Committee, acknowledged the complicated politics surrounding a repeal of Medicaid expansion—but speculated that the changes could be popular with state officials who might otherwise worry about losing their funding.
"You want to give states more authority. Indiana, with Gov. Mike Pence who's coming in as vice president, expanded Medicaid. He got waivers to do it, and he could have even done a better job with more authority," he said. "What we're trying to do is get the decisions out of Washington and back to the states."
Sen. Cory Gardner, R-Colo., whose state expanded Medicaid in 2013, said overhauling the program is key to ensuring its sustainability.
"Those people who think we can just keep this as it is in Medicaid still haven't answered the question of how it's sustainable long term, how they're going to pay for it long term without breaking this country," he said. "There is a tremendous amount of federal money in the Medicaid program and that's what people haven't explained to millions of people around the nation, is how is that sustainable going forward?"
Rep. Andy Harris, R-Md., a member of the conservative House Freedom Caucus, voiced similar thoughts.
"My philosophy is the states should be helping a whole lot more," he said. "You want expansion, then let's increase the [state matching percentage] on the expansion, then states can choose if they want expansion, that's fine. But the federal government is out of money."
Sen. Lisa Murkowski, R-Alaska, said in an interview that she and others in her state are worried about the costs the state will face, now that it has expanded. Though the 2010 health law initially funded 100 percent of the cost of expansion, next year it will pay just 95 percent of the costs. In 2020 and beyond, the federal government will fund 90 percent of the costs under current law.
"We're just in the first year of expansion and it's actually quite a tough situation for our state, as we realize that the cost for expansion is beyond what they had anticipated," she said. "The legislature's coming in in January, and it's my understanding that this is one of the things that's on deck for them, in terms of how we can deal with expanded Medicaid costs."
Asked about repealing expansion, she added, "I'm not weighing in right now either way."
