The big changes in the new Senate bill — including dropping a tax cut for the rich and rolling back insurance regulation — were meant to influence blocs of senators and to address policy concerns.
But there were also many more small changes, apparently calibrated to woo particular lawmakers. A detailed side-by-side comparison of the old and new bills reveals a handful of special provisions meant to favor particular states, some with new funding attached. Here’s our breakdown of what several of them do, and which state’s lawmakers they may please. One provision has already been titled the “Polar Payoff” — nickname ideas for the others are welcome.
HELPS Louisiana, Montana and Alaska
WHAT IT DOES The health law puts federal Medicaid payments on a diet, creating a set amount it will pay states for each Medicaid beneficiary, based on historical spending, and then letting that amount grow by a fixed amount each year.
Several senators have expressed concerns about the growth rate, which is expected to rise more slowly than medical spending for Medicaid patients. But the base amount each state gets will matter, too. This formula change will give states that expanded their Medicaid programs late more money for each person who is enrolled in the program. Senator Bill Cassidy from Louisiana may be the vote that leadership was trying to court with this change. He has been generally supportive of the health bill, but he has also expressed misgivings. As recently as Thursday, he was recommending that the Senate consider an alternative health reform plan.
HELPS Florida, probably.
WHAT IT DOES The Medicaid spending caps are devised to grow slowly over time, and some critics have worried that the restrictive formula will make it hard for states to respond to public health crises, like the widespread lead poisoning in Flint, Mich., or the Zika epidemic, which may become costly in Florida.
The bill sets aside $5 billion, outside the formula, which can be spent on declared public health emergencies between 2020 and 2024. In a tweet before the bill’s release, Senator Marco Rubio of Florida said that such a provision would be necessary for the bill to earn his support.
HELPS Alaska, Arizona, South Dakota, North Dakota, Montana, New Mexico and Oklahoma
WHAT IT DOES Instead of splitting the bill for health care provided to Native Americans under Medicaid, the bill would require the federal government to pay 100 percent of their medical bills. Those payments would not count toward the federal spending limits for the rest of Medicaid.
The change provides some budget cushion for any state with a large native population. Chris Jacobs at the Federalist reported that South Dakota Gov. Dennis Daugaard has been requesting this policy change for over a year.
But the state with the largest percentage of native residents is Alaska, and Lisa Murkowski, one of that state’s senators, is seen as a shaky vote on the bill.
WHAT IT DOES Alaska keeps coming up. This provision, previously reported by Bloomberg News, which called it the “polar payoff,” is the state’s most explicit goody. The bill establishes a large fund to help state insurance markets. And it sets aside 1 percent of that fund as extra money for states with health care costs that are 75 percent higher than the national average — something that is the case only in Alaska.
HELPS Florida and Texas, especially.
WHAT IT DOES The Medicaid program sets aside extra money for states to help safety-net hospitals cover the costs of uncompensated care. The payments are distributed according to a formula meant to account for how many poor and uninsured residents are likely to live in a given place. The Affordable Care Act cut those payments, on the theory that more Americans would have insurance coverage, and the Republican bill would restore those cuts and give extra funding to states that did not expand their Medicaid programs under Obamacare.
Revisions to the Senate bill would also tweak the formula used to calculate the payments. Florida and Texas would be big beneficiaries of the change, but 10 other states would also get increased funding, according to an analysis from the Medicaid and CHIP Payment and Access Commission.