State Flexibility for Medicaid: How Much? | Geriatrics | JAMA Forum Archive | JAMA Network
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State Flexibility for Medicaid: How Much?

President Trump’s budget proposal and the recent House health legislation included substantial reductions in Medicaid. Understandably, those cuts have focused attention on the potential effect on coverage for lower-income individuals. But there’s another important and related conversation that needs attention: how much flexibility should states have in redesigning the federal-state Medicaid program?

State flexibility has long been integral to Medicaid. After Medicaid was decoupled from the welfare system in the 1996 welfare reforms, states could explore using the program to cover working households. And for more than 20 years, Medicaid’s 1115 waivers have been a tool to permit a variety of state-designed modifications of Medicaid, allowing a federal administration to permit (within statutory limits) a variety of state-proposed changes. Recent examples include expanding eligibility and adding new features such as health savings accounts (HSAs) (eg, in Indiana), and using Medicaid funds to enroll beneficiaries in private coverage (eg, in Arkansas).

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