AAC F A M I L Y & F R I E N D S
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www.naco.org
About NACo – The Voice of America’s Counties National Association of Counties (NACo) is the only national organization that represents county governments in the U.S. NACo provides essential services to the nation’s 3,068 coun- ties. NACo advances issues with a unified voice before the federal government, improves the public’s understanding of county government, assists counties in finding and sharing inno- vative solutions through education and research and provides value-added services to save counties and taxpayers money.
Counties’ role in health care likely to be impacted by Trump Administration
Paul Ryan’s health care restructuring proposal would mean per capita cap or block grant for Medicaid
By Brian Bowden One of the promises President-elect Trump made to his
supporters was to repeal and replace the Affordable Care Act (ACA), or Obamacare. Congressional Republicans have also made Obamacare a target for repeal and have proposed sig- nificant changes to other federal health care programs. What might this mean for county governments, which play
a pivotal role in caring for America’s low-income residents, especially serving as the safety net for those who are unable to afford medical care? Historically, most states have required counties to provide
health care for low-income, uninsured or underinsured resi- dents — care that is often not reimbursed. An Urban Insti- tute study estimated that states and localities spent $20 bil- lion on uncompensated care in 2013. Meanwhile, counties invest $83 billion annually in com- munity health systems and support 976 hospitals, 714 long- term care facilities, 750 behavioral health authorities and more than 1,900 local public health departments. Te federal entitlement program known as Medicaid is the
largest source of health coverage in the country, covering ap- proximately 75 million individuals. Established in 1965, Medicaid is federal-state-local part- nership that provides health insurance coverage to low-in- come children and their families, seniors and people with disabilities. Unlike Medicare, which is financed and admin- istered by the federal government, Medicaid is jointly fi- nanced by the federal government and the states, with local governments’ support in many states. Counties contribute to the program in 26 states, and in the latest year in which data is available, local governments contributed approxi- mately $28 billion to the program. Te ACA expanded Medicaid. States were offered the op- tion to expand the population served by the Medicaid pro- gram to include low-income adults without children. Tirty-two states and the District of Columbia exercised that option to expand coverage beyond families, children, pregnant women, the elderly and the disabled. Medicaid reduces the amount of uncompensated care that must be provided by county health systems, easing the strain on
COUNTY LINES, FALL 2016
county budgets. Yet the Medicaid expansion is likely the most vulnerable
provision of the ACA under a Trump Administration and a Republican Congress. In June, House Speaker Paul Ryan and the House Repub-
lican Task Force on Health Care Reform unveiled a white paper describing a vision to restructure America’s health care system as a part of Ryan’s A Better Way Campaign. If enacted, the proposal would withdraw the states’ option to expand the Medicaid program and would require them to accept either a new Medicaid per-capita cap allotment or a block grant. Under this plan, beginning in 2019, each state would
receive a fixed limit of federal funding for four categories of beneficiaries – the aged, disabled, adults, and children — amounts based on 2016 averages. Funding would be adjusted for inflation, which typically rises slower than health care costs. States opting out of a per capita cap could receive a block grant, which would have a similar effect. As health care costs inevitably exceed the amount allotted by the federal govern- ment, states and counties would be left the bear the burden. “Counties are very concerned about the risks of changing
the structure of Medicaid from an open-ended, federal-state- local partnership to a new cap or block grant model,” said Fulton County, Ga., Commissioner Joan Garner, chair of NACo’s health policy steering committee. “When health care costs rise or if there is another eco- nomic downturn, states and — more likely, counties — will be on the hook to cover the gap between the federal allot- ment and the local need.” In the upcoming weeks, President-elect Trump and the in- coming Administration and Congress will need to determine just how they will change the health care system to follow through on their promises to undo the ACA. In that process, counties must ensure that the federal-state-
local partnership is respected and financial burdens are not simply shifted to counties. As the public’s attention will be placed on Washington and states, counties must work with their members of Congress to remind them that all health is local. Impending changes in the nation’s complex health care system must take into account the role of counties.
Brian Bowden serves as NACo’s Associate Legislative Director
for Health and staffs NACo’s Health Steering Committee, lobby- ing Congress and the Administration on all health issues impacting counties including Medicaid, behavioral health, public health, jail health and long-term care.
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