Trojan Reform: What the American Health Care Act did While No One was Looking

After weeks of much speculation, conjecture, controversy, and sensationalism, the U.S. House of Representatives passed the American Health Care Act (AHCA) by a narrow vote of 217-213. While this was Congress' second attempt at passing this particular bill, dismantling the Affordable Care Act has been a GOP promise since its inception. To date, many bills have been offered to repeal the ACA, but it took a change in Administration before any of these efforts were taken seriously.

The AHCA fulfills the GOP’s promise to repeal a health care bill that they have always found fundamentally flawed. And, while the Senate must of course still have their turn at “repeal and replace” and the two chambers which have little in common, must agree on a finalized bill the AHCA, as written, does repeal much of the core components of the ACA. But that’s just the beginning of what the AHCA did. In the shadows of the political theater that consumed much of the public’s attention, the GOP did something else they have been promising to do for years. They enacted entitlement reform.

How could this have happened? What entitlement program did they reform? The easiest question to answer first is the latter. The House Bill narrowly, but demonstrably dismantles the shared federal and state entitlement program known as Medicaid. Not by repealing ACA-related Medicaid expansion. Nope. Expansion is an addition to the Medicaid program that came about through the ACA. The Medicaid program, separate and apart from the Expansion provision in the ACA, has existed for decades and has served our nation’s most vulnerable populations. Expansion provisions in the ACA allowed states to grow their Medicaid programs if they chose. That single provision was in fact repealed by the AHCA. However, the AHCA went on to dismantle the Medicaid program in its entirety. Impossible? Unfortunately, no.

By cleverly leading those of us who are not health insurance experts to believe that the Medicaid expansion and the Medicaid entitlement program were one in the same, the House was able to eviscerate this entitlement program as it has stood for decades. Some might wonder how the Expansion provision could be repealed without a restructuring of the core program. Simple. The House could have repealed just the Expansion. They could have forced states to roll back enrollment over the course of a couple of years and re-establish the original baseline population that Medicaid had always covered. Instead, they restructured the entire program capping the amount of money that states will receive to administer this program. Such a change can have no other outcome other than to reduce the number of beneficiaries Medicaid covers, the types of services that are allowable and the reimbursement rates that providers receive. Is the Medicaid program perfect? Of course not. But has it served a vital role in maintaining our nations' public health and well-being? Yes.

So, as we turn our attention to the Senate, please keep a couple of things in mind regarding Medicaid. While it is indeed an income-based entitlement program, Medicaid is also a health insurance program that protects several other vulnerable populations. For example, children who have suffered abuse and neglect and have been removed from their homes are covered by Medicaid and therefore have access to the health and mental health services that they need to heal. Medicaid also offers coverage to children with special health care needs to help them meet their complex needs while helping their families avoid financial ruin. And finally, it’s not widely known that children who receive Special Education services in our public schools do so thanks to Medicaid. Unless the Senate takes steps to significantly change the Medicaid portion of the AHCA, this program will no longer be an entitlement serving these populations.

Picture your daughter or son playing goalie on their youth soccer team. How many times in just one game does the cleat of an opponent come close to kicking her head? How many times has your son “had his bell rung” playing Pop Warner football? Could such a collision cause a traumatic brain injury? Absolutely. Would your child need Medicaid to help deliver the services that such a chronic and significant injury would require? Perhaps. Would your child receive such coverage and your family receive the needed financial support? Not under the AHCA.

Let’s keep our eye on the ball this time as the Senate works to define their health care bill. If in fact “repeal and replace” is the intended goal of this legislative process, then let’s keep it to that. And this time let’s be ready for the semantics that makes the difference between true repeal and Trojan repeal.

Brooke Lehmann MSW, JD is a Partner at Capitolworks, LLC and a Lecturer at the Batten School for Leadership and Public Policy at the University of Virginia.