Experts weigh in how to cover the big changes GOP plans for Medicaid

As the country faces the possibility of massive Medicaid cuts, a panel of experts offered tips on how to navigate the fast-developing story in a Center for Health Journalism webinar this week.

Edwin Park, the vice president for health policy at the Center on Budget and Policy Priorities; Kathleen Nolan, a managing principal at Health Management Associates; and Lauren Sausser, a health care editor and reporter at The Post and Courier in Charleston, South Carolina, offered ideas and expertise on a story that could affect communities across the nation.

Park focused on Republican efforts to create a “per capita cap” on federal Medicaid dollars as well as plans to reduce the federal government’s share of funding for the Affordable Care Act’s Medicaid expansion – both of which would shift more responsibly to states.

For states that expanded Medicaid under the Affordable Care Act, the federal government fully funded those expenses for three years, then phasing down the contribution until it reaches 90 percent in 2020 and beyond. If the federal government’s contribution is further reduced, states that expanded Medicaid will have to shoulder more of the costs. So-called “trigger states” have a provision that would end the expansion if the federal contribution drops, Park said.

The other major proposed change is a “per capita cap,” which would affect all states. Under current law, the federal government pays a percentage of a state’s Medicaid costs, which averages about 57 percent though it varies by state. Per capita caps would allow the federal government to set a fixed amount for each beneficiary, “with that fixed amount set a level below what would be provided under the current financing system,” Park said. Those figures would likely be adjusted annually at a rate that doesn’t keep up with soaring health care costs, he added.

As states face massive cuts, they would have three choices, he said: Raise taxes; cut other parts of their budget such as education; or cut Medicaid, leaving more and more people uninsured or underinsured.

“Those cuts are only going to get more and more severe over the long run, particularly as the population continues to age,” Park said.

Potentially huge shock to health systems

Kathleen Nolan, formerly the director of state policy and programs for the National Association of Medicaid Directors, discussed the importance of viewing potential cuts amid the context of the broader health system, which has undergone major changes since the ACA’s passage. Reverting to the health system we had before Obamacare would be painful, she said.

For example, as the opioid crisis has worsened in recent years, states that expanded Medicaid have helped provide treatment for those beneficiaries battling addiction. And, as insured populations grew through Medicaid expansion, other funding streams that once helped with uninsured care are no longer in place.

“If you suddenly have an increase in uninsured, those health system and hospitals are not yet prepared to deal with that shift back,” Nolan said.

To deal with the loss of insurance for so many, some states might do something innovative, such as offer state-only insurance products. Other may create new programs to address specific health needs.

In every state — regardless of whether they expanded Medicaid under the ACA — Medicaid populations will face cuts under per capita caps.

Nolan said the people most impacted will be those who use the most services, such as the frail elderly in nursing homes and people with disabilities. She emphasized, though, that Medicaid beneficiaries should not be lumped together. The impact of changes will be different depending upon the population affected — distinct groups may be pitted against each other in a fight for diminishing dollars.

Even if the GOP’s efforts to “repeal and replace” collapse, changes are likely still in store for Medicaid through state-specific waivers under existing law, she said. For example, some states might look into work requirements, drug testing, or cost sharing for Medicaid beneficiaries, she said.  

“A lot of conversations around these kind of waivers are happening more in expansion states, particularly conservative expansion states,” Nolan said, adding that some conversations might extend into other Medicaid populations.

Explaining the impact to audiences

Those Medicaid conversations can be complex for the average newspaper reader, said the Courier and Post’s Sausser.  And it might not be something they think they care about.

That’s why she makes sure to include several key facts in articles involving Medicaid. Along with costs, she mentions how many people are enrolled in her home state and how many of them are children and disabled.

“There are a lot of negative stereotypes in South Carolina — and I imagine in other states, too — about who qualifies for Medicaid,” she said.

In covering Medicaid, Sausser suggested that reporters find a policy mentor who can help with complicated health policy questions. And, she recommended getting to know not only the state’s current Medicaid director, but also previous directors who might speak more candidly now that they’re no longer in office.

To cut through the policy jargon, Sausser shared how she uses personal stories to demonstrate Medicaid’s impact. She recently wrote about an 11-year-old girl with sickle cell disease, who  “has received 45 blood transfusions and has been hospitalized 49 times.”

“If you can put a face and a story with policy, I think that’s a winning combination,” she said. 

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Listen to the full webinar presentation here: