President's Budget Proposal
On May 23, the president submitted his FY 2018 budget proposal to Congress. As of this writing (Trump to Pitch Deep Cuts to Anti-Poverty Programs, Medicaid (Bloomberg Politics, 5/22/17); Trump to Propose Big Cuts to Safety Net in New Budget, Slashing Medicaid and Opening Door to Other Limits (Washington Post, 5/21/17) .), the budget has not been official released, but the media have reported on its expected contents, based in part on a leaked document. According to reports, the president proposes to severely cut safety-net programs such as welfare (Temporary Assistance to Needy Families), food stamps (Supplemental Nutrition Assistance Program), the Earned Income Tax Credit (for working families with children), and possibly SSDI (Social Security Disability Insurance) and SSI (Supplemental Security Income). In addition, the budget reportedly proposes the same Medicaid restructuring and cuts (per capita caps and block grants) that are included in the House-passed health care bill, and would further cut federal spending for the program. See
According to a leaked explanation of the proposed budget for the Department of Health and Human Services, the administration proposes increases in funding for the Title V Maternal and Child Health Block Grant, and the Maternal, Infant, and Early Childhood Home Visiting program, among other programs. It also proposes continuation of CHIP funding for another two years (through 2019), but proposes to end, after FY 2017, the current extra federal match (23 percentage-point "bump") and the maintenance-of-effort (MOE) provision, which requires states to maintain their Medicaid and CHIP eligibility policies for children. (The Medicaid and CHIP Payment and Access Commission and the children's health community recommend a five-year extension of the program with continuation of the 23 percentage-point "bump" and the MOE provision.) At the same time, the president proposes to "zero out" the line items for Autism and Other Developmental Disabilities, Universal Newborn Hearing Screening, and Emergency Medical Services for Children, among other programs.
It is important to remember that the president's budget is only a proposal; Congress will make final spending decisions (although the president ultimately must agree with them in order to sign the appropriations bills into law). See Just the Facts...The Congressional Budget Process and How the President's Budget Fits In (Brooke Lehmann, Capitolworks, 5/22/17).
Health Care Legislation
As reported in the May 10 Update, the House approved the American Health Care Act (AHCA, H.R. 1628) on May 4 with only Republican votes. In addition to replacing significant parts of the Affordable Care Act (ACA), that bill would fundamentally restructure and cut the Medicaid program. (See the May 10 Update and the list of articles and resources below.)
Since passage of the bill by the House, people have talked about the bill being "in" the Senate. For practical purposes it is, but the public learned last week that the bill had not actually been formally transmitted across the Capitol. This is because the House is awaiting a "score" from the Congressional Budget Office (CBO) verifying that the bill meets standards that will allow it to be taken up under the "reconciliation" process in the Senate. The CBO estimate is expected to be released on Wednesday, May 24.
Under reconciliation rules, a bill can pass the Senate with only 51 votes, rather than the 60 usually needed to advance Senate legislation. To enjoy that privilege, the bill must reduce federal spending by an amount specified in the budget resolution, and those savings must come from programs within the jurisdiction of specified committees. In this case, there must be savings of $2 billion over ten years equally divided between programs within the jurisdiction of the Senate Finance Committee and the Senate Committee on Health, Education, Labor and Pensions (HELP). The Finance Committee has jurisdiction over Medicaid and taxes. The HELP Committee has jurisdiction over insurance regulations, which generally do not have significant impact on federal spending.
If the CBO score shows that the bill will not qualify for reconciliation status in the Senate, then the House may have to amend the bill and vote on it again. See House May Need to Vote Again on GOP Obamacare Repeal Bill (Bloomberg Politics, 5/18/17). Legislation needs 216 votes to pass the House. The AHCA passed the House by a vote of 217-213. Given the negative feedback that many House Members subsequently received from constituents, it might not be easy to get the 216 votes needed to pass the bill again.
As noted, it will take 51 votes to pass the (amended) bill in the Senate. Since there are only 52 Republican Senators, and the bill is not expected to get any Democratic support, the Republicans can afford to lose no more than two votes. (In his role as President of the Senate, Vice-President Pence would break a 50-50 tie.) It will be challenging to develop a bill that can satisfy the most conservative Senators and the more moderate Republicans, particularly those representing states that have taken up the ACA's Medicaid expansion to cover low-income childless adults. See The Senate's Super-Wonky, Super-Important Medicaid Debate (Vox, 5/16/17).
While many Senators are concerned about the AHCA's gradual elimination of the ACA's Medicaid expansion to low-income childless adults (as well as some of the bill's non-Medicaid provisions), few Senators have expressed concern about the Medicaid caps in the House bill, despite their significant impact. Accordingly, Medicaid advocates are working to educate Senators and their staffs about the AHCA's Medicaid caps - about how they would affect states and Medicaid beneficiaries, and about the fact that, unlike the Medicaid expansion, the restructuring and cutting of the basic Medicaid program are not related to the ACA.
It has been reported that there are bipartisan conversations going on behind the scenes in the Senate. A recent article in Politico describes "backchannel" communications among Senators who would like to see a bipartisan bill emerge from the Senate, either on principle or because they think a Republican-only bill is not feasible.
For more information about the AHCA and its impact, see -
Summaries of AHCA:
Analyses of AHCA Impact:
Restructuring Medicaid in the American Health Care Act: Five Key Considerations (Kaiser Family Foundation, 5/15/17)
Can States Survive The Per Capita Medicaid Caps In The AHCA? (Health Affairs Blog, 5/17/17)
What the American Health Care Act Means for States (National Academy for State Health Policy (5/9/17) :
Obamacare Replacement Threatens Kids' Health Coverage (USA Today, 5/13/17)
Gaps in Coverage among People with Pre-Existing Conditions (Kaiser Family Foundation, 5/17/17)
Impact of per capita caps on home and community-based services (Center on Budget and Policy Priorities, 5/18/17) (includes state-specific information on the number of people receiving Medicaid home and community-based care)
For more summaries and analyses of the AHCA and related materials, see the May 10 Washington Update.