­ObamaCare fix hinges on Medicaid clash in Senate

­ObamaCare fix hinges on Medicaid clash in Senate
© Keren Carrion

The most divisive issue for Senate Republicans when it comes to repealing and replacing ­ObamaCare is what to do with Medicaid.

The Affordable Care Act gave states the option of accepting federal funds to expand Medicaid, the healthcare program for the poor and disabled. Millions of people gained health insurance after 31 states — including many with Republican governors — decided to accept the deal.

Repealing ­­ObamaCare would end the Medicaid expansion, cutting federal funds to all of those states.

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Some Republicans want to save the expansion at least through a transition period during which states would continue to get additional federal funds.

Others, including lawmakers from states that didn’t take the expansion, say all of ­ObamaCare has to go, with no long, costly transition period for Medicaid.

The fact that some states took the expansion and others didn’t provides a dividing line that will pit Republicans against one another.

Sen. John ThuneJohn Randolph ThuneRove warns Senate GOP: Don't put only focus on base Leaders nix recess with no shutdown deal in sight Senate advances measure bucking Trump on Russia sanctions MORE (R-S.D.) calls it the single thorniest issue of the entire debate.

“You don’t want to punish or penalize states that didn’t expand [Medicaid], but the states that did expand are going to say, ‘We don’t want to get punished for expanding, either.’ To me, that’s probably the thorniest and most difficult issue to resolve,” said Thune, the chairman of the Senate Republican Conference.

Twenty Republican senators represent states that expanded Medicaid under ­ObamaCare, which the federal government subsidized entirely for the first three years of the expansion. Many want to keep the federal subsidies providing for the expansion.

Thirty-two Senate Republicans represent states that opted out of the Medicaid expansion. Many of them don’t think it’s fair for states that opted in to keep getting federal help.

It’s a bigger fight in the Senate than in the House, where the GOP last week unveiled a proposal to roll back federal subsidies for Medicaid. The House plan does not specify when this would happen.

If states want to keep the Medicaid expansion, House policymakers say they will have to find the money themselves. If they cut back, they say, low-income individuals and families would be eligible for a new, yet-to-be-specified refundable tax credit to buy private insurance.

Ohio Gov. John Kasich, a Republican, said the House proposal “means phasing out coverage.”

“That is a very, very bad idea, because we cannot turn our back on the most vulnerable,” he told CNN’s “State of the Union.”

Nearly 620,000 people in Ohio were made eligible for Medicaid under ­ObamaCare.

Sen. Rob PortmanRobert (Rob) Jones PortmanSenators look for possible way to end shutdown GOP reasserts NATO support after report on Trump’s wavering Leaders nix recess with no shutdown deal in sight MORE (R-Ohio) says he wants to make sure that constituents who received new health coverage through Medicaid don’t lose it.

He and Sen. Shelley Moore CapitoShelley Wellons Moore CapitoOvernight Energy: Wheeler weathers climate criticism at confirmation hearing | Dems want Interior to stop drilling work during shutdown | 2018 was hottest year for oceans Dems blast EPA nominee at confirmation hearing Republican senators skeptical of using national emergency for wall funding MORE (R-W.Va.) have met with Republicans from other states that agreed to the Medicaid expansion.

Medicaid and the Children’s Health Insurance Program, which covers low-income minors, cover 29 percent of West Virginians. That’s the highest percentage of any state, according to the Kaiser Family Foundation.

“Sen. Capito is committed to ensuring that there is a stable transition when ­ObamaCare is repealed to avoid any gaps in coverage and ensure those currently covered by the Medicaid expansion are protected and retain access to healthcare,” said Amy Graham, a spokeswoman for Capito.

Sen. Chuck GrassleyCharles (Chuck) Ernest GrassleyDem calls for Cohen to testify before Senate panel over explosive report Senate Republicans eye rules change to speed Trump nominees IRS shutdown plan fails to quell worries MORE (R-Iowa) took fire from constituents angry about possible cuts to ­ObamaCare during a town hall meeting in Iowa Falls on Tuesday.

Grassley insisted that the 11 million new people who signed up for Medicaid under the 2010 law will still “be able to get the subsidy,” according to video of the meeting provided by American Bridge, a pro-Democrat advocacy group.

He said either states would subsidize the expanded enrollment or “there will be a refundable tax credit for low-income people.”

But just how the refundable tax credit would work has yet to be fully understood by many GOP lawmakers, and it’s unclear whether it would be enough to buy insurance covering the same services as Medicaid.

Controversy over repealing the Medicaid expansion erupted among Senate Republicans two years ago when they passed legislation under special budgetary rules at the end of 2015.

Senate Majority Leader Mitch McConnellAddison (Mitch) Mitchell McConnellDACA recipient claims Trump is holding ‘immigrant youth hostage’ amid quest for wall Former House Republican: Trump will lose the presidency if he backs away from border security Pence quotes MLK in pitch for Trump's immigration proposal MORE (R-Ky.) brokered a deal at the time to ease the concerns of colleagues such as Portman and Capito by proposing a two-year transition period to end the Medicaid expansion.

The stakes were lower then, because everyone knew President Obama would veto the bill.

President Trump is expected to sign the ­ObamaCare repeal measure into law, meaning whatever the Republican Congress does now is likely to become reality.

Sen. Steve Daines (R), whose home state of Montana also agreed to the Medicaid expansion, is floating a four-year transition period to a new safety net for low-income families.

“As [Vice President] Mike PenceMichael (Mike) Richard PenceLady Gaga blasts Pence as ‘worst representation of what it means to be Christian’ CNN's Tapper denies media 'hysteria' over BuzzFeed report Trump defends immigration proposal against 'amnesty' criticism from conservatives MORE said, we need to have a soft landing and not too long a runway. I’m actually tossing out a four-year kind of transition right now, but to really give the states the power there of how they want to spend money,” Daines told The Hill.

That kind of talk rankles conservatives such as Kentucky Sen. Rand PaulRandal (Rand) Howard PaulPressure mounts for Trump to reconsider Syria withdrawal House Republicans call for moving State of the Union to Senate chamber GOP rep: 'Rand Paul is giving the president bad advice' on Afghanistan and Syria MORE (R). Though his state adopted the Medicaid expansion, he’s adamantly opposed to “partial” repeal plans.

“One thing we were unified on about a year ago when we voted was complete repeal,” he said. “That’s all some of us are going to vote for.

“There’s still division. There are some people who want to keep part of ­ObamaCare,” he said. 

Peter Sullivan contributed.