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What the Future of Medicaid Could Look Like Under Clinton and Trump Presidencies

Todd Wiseman for the Texas Tribune
Presidential candidates Hillary Clinton and Donald Trump both have different takes on Medicaid-related issues, but what would those proposals look like in Texas?

Whoever wins this presidential election will have a lot of big decisions to make within their first year in office. One of those decisions is what to do about states, like Texas, that haven’t expanded Medicaid to more low income people under the Affordable Care Act.

According to the websites for the campaigns of Democratic Presidential Candidate Hillary Clinton and Republican Candidate Donald Trump, both have widely different plans.

Medicaid under Trump

Trump wants to repeal the health care reform law and turn Medicaid into a block grant system.

The first part would be deeply complicated, but this block grant program is something conservatives have wanted for a long time.

Dr. Deane Waldman, a doctor turned health care policy director for the right-leaning Texas Public Policy Foundation, says, in theory, block grants are beneficial because they allow the federal government to hand states a pile of money and the state can prioritize how that pot of money is spent. But, he says, it doesn’t always work that way.

“Washington will say, 'Yeah, we will give you money, but there are strings attached to it.'" he said. "And, they are pretty adamant about those strings and the strings are the control levers."

Historically, a true block grant system has never been implemented in Medicaid, Waldman says. That’s why he thinks it’s highly unlikely it will happen in a Trump presidency.

“[A]s long as they control where that money goes, and how it gets apportioned, then the reality is that we haven’t gotten as a state, Texas, has not gotten the freedom that you think a block grant has given."

And Anne Dunkelberg with the left-leaning Center for Public Policy Priorities says the idea of a block grant system is just too vague. She says the state will have to answer some basic questions before we even know what that will look like.

“What is it that you want to change about Texas Medicaid? Who do you what to get off the program, who’s covered now? What are the fewer benefits you want to provide?,” she explained. “So it’s a political talking point that does not get into serious policy.”

Medicaid under Clinton

Dunkelberg says a Medicaid expansion in Texas won’t change that much under a Clinton presidency.

If the state doesn’t expand Medicaid, it’ll still be getting fewer dollars in the future to repay hospitals for care they provide to people without insurance. And, she says, Clinton plans to sweeten the pot by having the federal government pay the entire cost of expansion for states that expand Medicaid late in the game.

However, it’s unclear whether that will be sweet enough for Texas.

“You know it may be a necessary but, not sufficient condition, for Texas moving forward,” she said.

Under a Clinton presidency, Dunkelberg says Texas could also consider an Indiana-like program, in which the state expands Medicaid in its own way. But, of course, that would be dependent on state lawmakers when they gavel in for the next session in 2017.

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