After weeks of false starts, House Republicans seem to have a plan, or at least the outline of a plan, to replace the Affordable Care Act.
The 17-page document, which was obtained this week by Paige Cunningham at the Washington Examiner, is a broad strokes policy outline about dismantling major provisions of the Obama administration's signature health care law. But the document also reads like a set of mechanical talking points–"Obamacare has failed," "the law is only getting worse," "repeal is relief"–that Republican lawmakers might need if and when they're confronted by constituents angry over the possibility of losing their health care.
There are still a lot of details left to be filled in as the House prepares to introduce formal legislation later this month, but the existing proposal is clearest on what it would eliminate or overhaul. Namely: Medicaid. And that may be the whole point.
"The proposal goes way, way, way, beyond the Affordable Care Act," Sara Rosenbaum, a professor of health law and policy at George Washington University, told me. "It's like [it's] a cover for dismantling the Medicaid program."
The proposal calls this "modernizing" Medicaid, but what the document outlines is rolling back the expansion enacted under the Obama administration, which extended health care to an estimated 12 million people in 32 states (including Washington, DC) and replacing its open-ended funding with block grants—a set amount of money that is handed to states and does not change if there is increased need—or a "budget" that similarly locks in funding levels.
“The Medicaid program, a critical lifeline for some of our most vulnerable patients, is three times the size as—and costs three times as much as—under President Clinton. This is not sustainable,” the document reads.
It also assures readers that the GOP doesn't intend to "pull the rug out" from anyone who currently receives Medicaid through the expansion, but its dramatic restructuring of the entitlement program will likely mean significant holes in state budgets. Even if they are phased in, the math is pretty simple: If you give states less money to cover medical costs, something has to give.
"Unless a state were to stop funding its roads, its schools, and big chunks of its other human services and activities," it will not be able to make up enough of the difference to fund Medicaid at its current levels, Rosenbaum said.
And that means people lose coverage. Poor people, sick people, middle-income people who may be supplementing coverage they receive through their employer with Medicaid. It's a lot of people.
According to the Center on Budget and Policy Priorities, in 2015, 97 million low-income people received their health benefits through Medicaid. What that looks like month to month is covering "33 million children, 27 million adults (mostly in low-income working families), 6 million seniors, and 10 million persons with disabilities."
It's also a program that works: studies have found, just as you'd expect, that extending health care to people opens up access to preventative care and keeps people healthier.
An upheaval of that system that does not grow Medicaid budgets as more people need care could be catastrophic.
"The damage is incalculable. It's a proposal that in my view reflects a total misunderstanding of Medicaid's role in the health care system," Rosenbaum said.