How to best deliver health care services in the country has been an ongoing policy conversation for decades. In 2017, the Obama administration transitioned leadership to the Trump administration. President Trump, along with Congressional leadership, have made repealing and replacing the Affordable Care Act one of their top priorities. Since March, Congress has attempted to pass health care reform legislation through the budget reconciliation process. In July, those efforts stalled when the Senate was unable to pass the most recent version of legislation. For more information, background, and current developments, visit our Save Our Services page.
The Patient Protection and Affordable Care Act (ACA) was enacted in 2010 with the intent to provide health care coverage to all Americans by 2014. At the time of its passage, the ACA was the most significant federal legislation affecting people with disabilities since the passage of the ADA in 1992. The ACA eliminated insurance barriers for pre-existing conditions; removed yearly or lifetime coverage caps; provided for full coverage of certain preventive care; provided significant financial incentives to states to shift their state plan and optional services away from institutional and congregate care to more integrated community support settings; provided numerous opportunities and incentives for states to pilot demonstrations and innovations to achieve better health outcomes, greater access to care and supports, and cost efficiencies; and created a new authority for HCBS, the Community First Choice Option (Sec. 1915(k)), providing an enhanced federal match. Despite multiple legal challenges, the Supreme Court has consistently upheld the core provisions of the ACA, however, it left to the discretion of the states whether or not to expand Medicaid to cover individuals whose income is 138% of the Federal Poverty Level (FPL).
Under the new administration, health care reform efforts have included proposals to block grant or impose per capita caps on the Medicaid program, which would result in significant cuts to the program overall, and a shifting of costs to states.
Kaiser Foundation Medicaid Page: This dedicated page contains multiple informative analyses of the Medicaid expansion and repeal/replace proposals, including: 5 Key Questions: Medicaid Block Grants and Per Capita Caps and an informative video.
Avalere Report: This report explains how capped funding in Medicaid could significantly reduce federal spending.
State by State Medicaid 2017 Per Capita Expenses Chart: This chart shows state by state 2017 federal Mediciaid expenses, at the aggregate level and then by group. The chart is from pages 6-7 of this Urban Institute report.
National Governors Association Presentation: Here is a presentation by Avalere on the ACA expansion, commissioned by the National Governors Association. Slide 24 in particular compares recent Medicaid growth with what it would be under per capita caps.
National Health Law Program Fact Sheet: This fact sheet explains differences between per-capita caps and block grants.
GAO Discussion Paper: This paper lays out key considerations for designing a per-capita cap on federal funding.