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Another Argument for ACA Repeal Bites the Dust

While the Senate bill to repeal the Affordable Care Act (ACA) appears dead for now, efforts to undo the ACA’s Medicaid expansion — which has enabled 11 million low-income people to get health coverage — will likely continue. So let’s put to rest the thoroughly debunked claim that the Medicaid expansion has enlarged state waiting lists for home- and community-based services (HCBS), which give people needing long-term health care services an alternative to nursing homes.

The claim — which Vice President Mike Pence leveled at the National Governors Association meeting last weekend — is false, as we’ve explained. It’s just a smoke screen for the Trump Administration and those Republican lawmakers who want to end the Medicaid expansion as part of an ACA repeal.

Vice President Pence said that in Ohio, an expansion state, nearly 60,000 people were stuck on HCBS waiting lists because “Obamacare has put far too many able-bodied adults on the Medicaid rolls.” Ohio Governor John Kasich’s spokesperson quickly refuted this claim, which state officials had previously refuted. Months ago, an analyst from the Foundation for Government Accountability, which has repeatedly blamed the Medicaid expansion for state HCBS waiting lists, admitted at a congressional hearing that “there is no correlation” between state decisions to expand Medicaid and HCBS waiting lists.

States have had waiting lists for HCBS since their inception in 1981. State data show no connection between waiting lists and state decisions on expansion. Nine of the 11 states without HCBS waiting lists are expansion states, and the two states with the biggest waiting lists — Texas and Florida — are non-expansion states. (Texas’ waiting list of over 204,000 people in 2015 represents almost one-third of the nation’s total.) Moreover, most expansion states’ waiting lists either didn’t change or shrank between 2014, when expansion took effect, and 2015. Waiting lists in most non-expansion states grew.

Ironically, if not egregiously, the Vice President leveled his claim to push for a bill that would not only end the Medicaid expansion but also make HCBS especially vulnerable to deep cuts. The Senate bill would have cut Medicaid by $772 billion in the first decade and roughly $2.6 trillion — or more than a third — over the second decade. Like the House-passed ACA repeal bill, it would have put a fixed cap on per-beneficiary federal Medicaid funding, cutting funding to the states by growing amounts over time. So, while the Senate bill is off the table, threats to the Medicaid expansion certainly are not.

States have waiting lists because they already limit the number of HCBS beneficiaries due to funding constraints. The program is a likely target for cuts under the current ACA repeal bills because they’re largely an optional Medicaid benefit that states can cut when facing shortfalls (unlike nursing home care, which state Medicaid programs must cover) and because states spend more on HCBS than any other optional benefit.

Simply stated, the threat to HCBS isn’t the Medicaid expansion or the ACA; it’s the efforts to repeal the ACA or change Medicaid’s financing in ways that would sharply reduce federal funding — efforts that could resurface in the future.