如果共和党赢得削减资金的议案，数百万人可能面临失去医疗补助的危险

【中美创新时报2025 年 2 月 26 日编译讯】（记者温友平编译）众议院共和党人正在寻找支付特朗普总统减税措施的方法，他们呼吁削减联邦政府在医疗补助支出中的份额，其中包括一项将有效削弱《平价医疗法案》 2014 年扩大该计划的提案。《纽约时报》记者Noah Weiland 和 Sarah Kliff 对此作了下述报道。

削减医疗补助支出是众议院共和党周二通过的预算法案的核心，除非各州决定在医疗补助资金方面发挥更大作用，否则这可能导致全国数百万美国人失去医疗保险。

共和党正在考虑降低联邦政府必须向参加扩张计划的州支付的 90% 份额。这一变化可能在十年内产生 5600 亿美元的节省，共和党希望用这笔钱来延长特朗普 2017 年的减税政策，该政策将于 2025 年底到期。延长减税政策预计将花费 4.5 万亿美元，这意味着共和党必须从众多选择中寻找医疗补助以外的节省方式。

降低联邦对医疗补助扩张人口的支出可能会有效削弱该计划。大约 10 个已经扩大计划的州制定了所谓的触发法律，如果联邦政府减少对人口的资助，这些法律就会逆转医疗补助扩张。

这一变化可能会让参与奥巴马医改计划的 40 个州面临艰难的选择。它们可以承担额外的费用以保留数百万人的医疗补助，削减保险范围，或者寻求削减其他大型政府计划的资金以抵消联邦资金的减少。

医疗补助覆盖了 7000 多万人，是美国最大的医疗保险计划，也是各州最大的单一资金来源。去年，超过 2100 万根据扩张前的指导方针不符合医疗补助资格的成年人获得了保险。该计划此前主要限制孕妇、残疾人或老年人的加入。

在扩张计划下有资格享受医疗补助的人中，有 60 岁的 Jeannie Brown 是蒙大拿州贝尔格莱德公立学校系统的兼职公交车司机。从 2009 年开始，Brown 有五年多没有医疗保险，由于健康状况恶化和照顾残疾孙女而逃避医疗。

布朗的年薪约为 25,000 美元，她陷入了所谓的覆盖缺口，她的薪水太高，无法享受医疗补助，而她的薪水又太低，无法享受奥巴马医改的大量补贴。

2015 年，蒙大拿州立法者投票通过了《平价医疗法案》扩大医疗补助覆盖更多成年人的选项，布朗便报名参加了。她说，她开始看初级保健医生，医疗补助支付了手部手术、膝关节置换术、双乳切除术和吸入器的费用。

上周，她在科罗拉多州一家儿童医院表示：“做护理人员非常累，尤其是照顾那些有很多健康需求的人。”她的孙女曾被送往那里接受紧急护理。“如果我得不到我所需要的预防性护理，我的身体状况会更糟。我可能会残疾。”

保守派批评扩大医疗补助计划，认为这迫使联邦政府花费过多且不成比例的资金来为医疗补助计划原本不打算服务的人群提供医疗服务。

自由主义智库卡托研究所卫生政策研究主任迈克尔·坎农说：“联邦对体格健全的成年人的更高匹配会产生不良的激励，从而将资金从更脆弱的人群中转移出去。”

共和党人还指出，他们所说的医疗补助计划支出出乎意料地失控。近年来，一些州的医疗补助费用意外激增，部分原因是许多美国人在冠状病毒大流行期间推迟了医疗服务。宾夕法尼亚州民主党州长乔希·夏皮罗最近提议将州对该计划的支出增加 25 亿美元。

削减联邦政府对医疗补助计划的财政承诺的举措可能会深刻改变联邦政府与各州分担责任的方式，即为一些最贫困的美国人以及为他们提供医疗服务的提供者和养老院提供医疗服务。

曾在前总统乔·拜登手下负责医疗补助计划的丹尼尔·蔡 (Daniel Tsai) 表示，这一变化相当于“将财政责任从联邦政府大规模转移到各州”。

“各州将面临巨大的预算漏洞，不得不在如何做正确的事情来保障人们的医疗保障”和如何保留其他计划之间做出决定，”他说。“各州将陷入资金困境。”

特朗普总统似乎意识到削减该计划的政治风险，上周表示他不会动医疗补助计划。他后来批准了众议院议长迈克·约翰逊谈判的众议院预算，该预算要求削减 8800 亿美元由众议院能源和商业委员会监督的项目，例如医疗补助计划。

密苏里州共和党参议员乔什·霍利 (Josh Hawley) 上周告诉《赫芬顿邮报》，他已提交了参议院预算决议修正案，禁止削减医疗补助。2021 年，密苏里州扩大了医疗补助计划，超过 30 万低收入居民加入了这一行列。

俄亥俄州共和党众议员吉姆·乔丹 (Jim Jordan) 周日表示，立法者可能会专注于对医疗补助计划实施全国性工作要求，这是一项有争议的提议，仅相当于国会共和党人寻求的削减额的一小部分。俄亥俄州最近向特朗普政府请求允许试行这项政策。

蒙大拿州民主党前参议员乔恩·泰斯特 (Jon Tester) 表示，医疗补助计划削减对美国农村地区的影响可能比对城市地区的影响更大，因为该计划以极少的医疗服务提供者维持贫困地区。“这是一个有趣的难题，因为大多数美国农村地区的赤字比美国城市地区要深得多，”他说。

“如果你取消医疗保健，你就无法在那里生活，”泰斯特说。

共和党人还在考虑限制联邦政府在州医疗补助计划上的支出，这种做法被称为“整体拨款”或“人均上限”。这一策略可以在十年内节省多达 9000 亿美元。

根据 KFF 的数据，如果各州从联邦政府那里承担费用并保持其扩张人口不变，他们将在十年内花费超过 6000 亿美元，增幅近 20%。许多州在十年内将缺口超过 100 亿美元，而一些较大的州，如纽约州和加利福尼亚州，将面临超过 500 亿美元的缺口。

本文最初发表于《纽约时报》。

题图：北卡罗来纳州克莱德市的 Mary Beth Cochran 在周二与众议院民主党人一起在华盛顿举行的集会上发表讲话，反对共和党提出的预算法案。Chip Somodevilla/Getty

附原英文报道：

Millions may face loss of Medicaid if GOP wins cuts to funding

By Noah Weiland and Sarah Kliff New York Times,Updated February 25, 2025 

Mary Beth Cochran of Clyde, N.C., spoke at a rally with House Democrats to speak out against the proposed Republican budget bill Tuesday in Washington.Chip Somodevilla/Getty

WASHINGTON — House Republicans hunting for ways to pay for President Trump’s tax cuts have called for cutting the federal government’s share of Medicaid spending, including a proposal that would effectively gut the Affordable Care Act’s 2014 expansion of the program.

Cutting Medicaid spending, which is central to the budget bill that House Republicans passed on Tuesday, could result in millions of Americans across the country losing health coverage unless states decide to play a bigger role in its funding.

Republicans are considering lowering the 90 percent share that the federal government is required to pay to states that enroll participants in the expansion. The change could generate $560 billion in savings over a decade, money that Republicans want to use toward extending Trump’s 2017 tax cuts, which are set to expire at the end of 2025. Extending the tax cuts is expected to cost $4.5 trillion, meaning Republicans will have to find savings beyond Medicaid from a long menu of options.

A move to lower federal spending on the Medicaid expansion population could effectively gut the program. Around 10 states that have expanded their programs have so-called trigger laws that reverse the Medicaid expansion if the federal government decreases funding for the population.

The change could leave the 40 states that participate in the Obamacare program with a difficult set of choices. They could shoulder the extra costs to preserve Medicaid coverage for millions, make cuts to coverage, or look for cuts from other large government programs to offset the reduction in federal funds.

Medicaid, which covers more than 70 million people, is the largest health insurance program in the nation, and the largest single source of funding for states. More than 21 million adults who were not eligible for Medicaid under pre-expansion guidelines received coverage last year. The program had previously restricted enrollment primarily to those who were pregnant, disabled or elderly.

Among those who qualified for Medicaid under the expansion was Jeannie Brown, a 60-year-old part-time bus driver for the public school system in Belgrade, Mont. Brown went more than five years without health insurance beginning in 2009, avoiding medical care as her health deteriorated and she cared for her disabled granddaughter.

Brown, who makes around $25,000 a year, had been trapped in the so-called coverage gap, with a salary too high for Medicaid, and too low for a heavily subsidized Obamacare plan.

After Montana lawmakers voted in 2015 to take up the Affordable Care Act’s option to expand Medicaid to cover more adults, Brown enrolled. She began to see a primary care doctor, and Medicaid paid for hand surgeries, knee replacements, a double mastectomy, and her inhaler, she said.

“Being a caregiver is extremely exhausting, especially with someone who has a lot of health needs,” she said last week from a children’s hospital in Colorado, where her granddaughter had been flown for emergency care. “If I didn’t have the preventative care I needed, I’d be in a much worse place physically. I’d probably be disabled.”

Conservative critics of Medicaid expansion have argued that it forces the federal government to spend exorbitantly, and disproportionately, to cover health services for a population Medicaid was not intended to serve.

“The higher federal match for able-bodied adults creates perverse incentives to divert funds from more vulnerable populations,” said Michael Cannon, the director of health policy studies at the Cato Institute, a libertarian think tank.

Republicans have also pointed to what they say is unanticipated runaway Medicaid spending. Some states have seen unexpected surges in Medicaid costs in recent years, in part because many Americans delayed care during the coronavirus pandemic. Governor Josh Shapiro of Pennsylvania, a Democrat, recently proposed a $2.5 billion increase in state spending on the program.

The move to pare back the federal government’s financial commitments to Medicaid could profoundly reshape how it shares responsibility with states to offer health care to some of the poorest Americans, as well as the providers and nursing homes that care for them.

The change would amount to a “massive transfer of the financial responsibility from the federal government to states,” said Daniel Tsai, who oversaw Medicaid under former President Joe Biden.

“You’d have states having enormous budget holes making decisions between how to do the right thing to keep people covered” and how to preserve other programs, he said. “States are going to be cash strapped.”

President Trump appeared to sense the political risks in cutting the program, saying last week that he would not touch Medicaid. He later endorsed the House budget that Speaker Mike Johnson negotiated, which called for $880 billion in cuts to programs overseen by the House Energy and Commerce Committee, such as Medicaid.

Senator Josh Hawley, Republican of Missouri, told HuffPost last week that he had filed an amendment to a Senate budget resolution prohibiting cuts from Medicaid. After his state expanded the program in 2021, more than 300,000 low-income residents joined the rolls.

Representative Jim Jordan, Republican of Ohio, said on Sunday that lawmakers may focus on imposing a national work requirement on Medicaid, a controversial proposal that would amount to only a fraction of the cuts congressional Republicans are seeking. Ohio recently asked the Trump administration for permission to test out the policy.

Former senator Jon Tester, Democrat of Montana, said that Medicaid cuts could have a more sweeping effect on rural America than urban areas because of how the program sustains impoverished areas with few health providers. “And that’s an interesting conundrum because most of rural America is a much deeper red than urban America,” he said.

“If you take away health care, you can’t live there,” Tester said.

Republicans are also considering limiting how much the federal government spends on a state’s Medicaid program, a practice known as block granting or per capita caps. That strategy could save as much as $900 billion over a decade.

If states picked up the costs from the federal government and kept their expansion populations in place, they would spend more than $600 billion to do so over a decade, an increase of almost 20 percent, according to KFF. Many states would be short more than $10 billion over a decade, and some larger states, such as New York and California, would face a shortfall of more than $50 billion.

This article originally appeared in The New York Times.