Trump's Health Plan Does To Medicaid What Obama's Waivers Already Do

Republican presidential candidate Donald Trump, who issued a few more details to his healthcare reform plan, would give states “block grants” to manage health insurance for poor Americans because “state governments know their people best,” his proposal updated this week says.

But giving states flexibility to administer Medicaid isn’t a new idea because administrations from Obama through both Bushes to Reagan have granted waivers of all kinds. And an unprecedented number of states are also handing off administration of benefits to private health insurers like Aetna , Centene , Anthem , Molina and UnitedHealth Group as a way to save money or bring private technology and claims administration to a government program. Decisions to involve commercial insurers in Medicaid are also state decisions.

Some states require Medicaid enrollees to pay deductibles and co-payments or make coverage contingent on the recipient paying part of the premium. And the expansion of Medicaid under the Affordable Care Act has granted states unprecedented freedom, some would argue, on how to administer and provide health benefits.

Increasingly, states that have opted to expand Medicaid under the health law have asked for, and been given, waivers to administer the benefits how they want.

“While the waivers are each unique, they include some common provisions,” the Henry J. Kaiser Family Foundation says in its update on the ACA and Medicaid expansion waivers. “Common provisions...include implementing the Medicaid expansion through a premium assistance model; charging premiums; eliminating non-emergency medical transportation, an otherwise required benefit; and using healthy behavior incentives to reduce premiums and/or co-payments.”

There are 31 states plus the District of Columbia that have expanded Medicaid under the health law. At least a half dozen of the most recent state expansion have come via waivers.

Trump’s plan doesn’t say whether he would keep intact federal dollars allocated under the ACA to expand Medicaid or disclose how much his plan will save or cost.

The Affordable Care Act expands Medicaid in states that opt to do so using federal dollars that don’t require states to kick in through the end of this year. The ACA’s generous funding is different than Medicaid funding before the health law that generally split financing coverage for poor Americans between the state and federal government.

It would seem Trump might eliminate the waiver idea altogether, which would require an act of Congress. But Trump doesn’t provide specifics or mention waivers in his proposal.

“The state governments know their people best and can manage the administration of Medicaid far better without federal overhead,” Trump’s healthcare reform proposal issued earlier this week says. “States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources.”