As Republicans enter the second month of total control of the federal government, there is little evidence they are any closer to fulfilling their campaign promise of repealing the Affordable Care Act.

One of the many stumbling blocks to “repeal and replace” has been the Medicaid expansion which accounts for roughly half of the more than 20 million people who gained coverage through the ACA.

Many Republicans in Congress come from states that embraced the expansion, which is almost entirely federally funded and extends coverage to those with incomes up to 133 percent of the federal poverty level.

Some of them naturally want to preserve the program that many of their constituents enjoy. But their goal comes into conflict with other Republicans, including conservative hardliners who are against the program in principle, as well as those from states that did not choose to expand and don’t want to see other states continue to receive more federal assistance.

In an attempt at compromise between the two camps, a GOP lawmaker has proposed a solution that will keep the expansion in place in states that have already pursued it and offer additional federal funds to states that rejected it.

The extra money for the non-expansion states would come through the Disproportionate Share Hospital program, which is set up to assist states to offset what hospitals spend treating the uninsured.

However, the proposal, which has been put forth by Rep. Brett Guthrie, R-Ky., would also freeze the expansion of Medicaid, meaning that those who would be eligible under current rules may not be eligible in the future.

For years, leading Republicans have called for turning Medicaid into a block grant program, under which states would be allocated a certain amount of money and be given discretion over who that money should provide coverage for. That idea has been embraced by President Trump and has been championed by Secretary of Health Tom Price.

Guthrie has also floated a variation of the block grant idea called “per-capita caps,” under which states would get a set amount of money per enrollee, as opposed to state block grants, which do not take into account the number of enrollees, but rather the overall state population.

Democrats are bound to oppose all of the GOP proposals, arguing they will lead to reduced benefits for those in great need.

Instant Insights /

Republicans consider partially preserving Medicaid expansion

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