Medicaid Changes under the BCRA and Possible State Responses
Our analysis examines the changes in the BCRA that would phase out the enhanced matching rate for the ACA Medicaid expansion and limit federal Medicaid spending to a capped amount per enrollee for five eligibility groups (expansion adults, other adults, children, the elderly and people with disabilities). First, under the BCRA, for states that adopted the expansion as of March 1, 2017, the enhanced federal match would phase out from 90% in 2020 to 85% in 2021, 80% in 2022, 75% in 2023 and then to the regular state match rate in 2024 and beyond. This phase out lowers federal Medicaid spending relative to current law, under which federal financing for the expansion population would remain at 90% in 2020 and in subsequent years.
Second, under the BCRA, federal Medicaid spending for most enrollees would be limited to a set amount per enrollee. To establish these limits, states would use data from FY 2014-2016 to develop base year per enrollee spending that would be inflated to 2019 based on the medical component of the consumer price index (CPI-M). Beginning in 2020, federal spending would be limited to the federal share of spending based on per enrollee amounts calculated by inflating the base year spending by CPI-M for children and adults and CPI-M plus one percentage point for the elderly and disabled. Beginning in 2025, all per enrollee limits would be increased by general inflation (CPI-U). Certain spending and populations would be excluded from the per enrollee caps, including enrollees who do not receive the full scope of Medicaid benefits.
States could respond to these changes in federal policy in several ways. We examine changes in federal Medicaid spending under two possible scenarios of state responses: (1) All states, both expansion states and non-expansion states, fill gaps in the loss of federal funding and maintain coverage, including the ACA Medicaid expansion coverage, and (2) states that expanded Medicaid under the ACA fully drop their expansions but maintain spending and coverage for other groups, resulting in declines in both federal and state spending. In the second scenario, we model the loss of federal dollars that the state would have received had it fully maintained its expansion.