An uncertain future: What could happen to Medicaid expansion?

Some Republicans want to convert Medicaid to a block grant model

This story has been updated

Republican plans to repeal the Affordable Care Act (ACA) raise questions about the future of state Medicaid expansions under the law.

Thirty-one states and Washington, D.C., have opted to expand Medicaid under the ACA. More than 12 million U.S. residents have gained Medicaid coverage in states that have expanded the program under the ACA.


President-elect Donald Trump has vowed to "immediately" repeal and replace the ACA once he takes office. Trump has since signaled support for some ACA provisions, but has not commented specifically on the law's Medicaid expansions.

Meanwhile, Senate Majority Leader Mitch McConnell (R-Ky.) has said repealing the ACA will be a "pretty high" priority now that a Republican has been elected president.

According to Vox, there are conflicting reports on whether Republicans also would seek to repeal the ACA's Medicaid expansions or whether they would try to keep the expansion in place.

The future of Medicaid expansions

Experts and lobbyists say legislation that Congress passed earlier this year to repeal and replace the ACA is the clearest outline for Republicans' future efforts to repeal and replace the law. The bill, which President Obama vetoed, would have eliminated funding for Medicaid expansions under the ACA.

However, eliminating Medicaid expansions could be politically difficult, Modern Healthcare reports. For example, governors in states that have expanded Medicaid likely would oppose a measure that would strip federal funding for the expansions.

As a result, lawmakers might propose legislation that allows states to modify their Medicaid expansions, according to Modern Healthcare.

Trump says he's open to just 'amending' the ACA

Yevgeniy Feyman, a Republican analyst and senior research assistant at Harvard's T.H. Chan School of Public Health, said, "Given that a few red states have expanded Medicaid," allowing states to modify their programs "might be a more realistic option" than completely repealing Medicaid expansion.

Alternative Medicaid expansions

According to Modern Healthcare, Trump's administration would be more likely than the Obama administration to approve conservative Medicaid expansion proposals. Trump's administration could use waivers and other methods to advance conservative ideas for expansion, such as implementing work requirements, which the Obama administration has opposed.

Further, Cindy Mann, a former deputy administrator at CMS and former director of CMS' Center for Medicaid and CHIP Services under the Obama administration, said, "It's possible that [Vice President-elect Mike Pence] would be interested in spreading" Indiana's alternative Medicaid expansion, which the state adopted while Pence served as its governor.

Allowing for more conservative Medicaid expansions could prompt more states to expand their programs under the next administration. Medicaid Health Plans of America spokesperson Joe Reblando said, "States that have expanded will leave it in place. And given the Republican tenet of giving states more control, states that haven't expanded yet may find increased flexibility on how to do so."

However, health care providers and patient advocates could oppose conservative Medicaid expansion proposals.

For example, Laura Gronowski—chief of staff at the Center for Health Affairs, an advocacy group for northeast Ohio hospitals—said the group "really opposed provisions in" Ohio's proposed alternative Medicaid expansion "as they didn't promote continuity in health care coverage and they would [have been] administratively burdensome." Nonetheless, Gronowski added, "If having that waiver were the only way to continue expansion, we would be open to having that conversation."

Federal funding limits

Republicans also have voiced support for converting Medicaid into a block grant program, which would limit federal funding for state Medicaid programs, according to CQ HealthBeat.

Joan Alker, executive director of Georgetown University's Center for Children and Families, said, "That would be an extraordinarily radical change, not only for new expansion enrollees but also for 37 million children who get coverage through Medicaid."

According to Ed Haislmaier, a health policy expert at the Heritage Foundation, another option would be for policymakers to allow states that expanded Medicaid to keep their current eligibility criteria in place but reduce federal funding for the expansions to about 50 percent, which is the standard level at which the federal government funds states' non-expanded Medicaid programs.

Under the ACA, the federal government will cover 100 percent of expansion costs through the end of this year then will gradually reduce its contribution to 90 percent by 2020.

However, reducing federal funding amounts could make it difficult for states to maintain the programs and make expansion less attractive for states that have not yet done so, Modern Healthcare reports (Mershon, CQ News, 11/14 [subscription required]; Dickson, Modern Healthcare, 11/12; Kliff, Vox, 11/14).

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