Universal HealthcareBy NextBestFit
Solution path · States lose control and budgets shift between levels of government

Maintenance-of-effort payments from states

States pay the national program what they spent on Medicaid, indexed.

Draft decision:ChosenPhase 1: Enactment & buildConfidence: medium · not yet reviewed

States pay in what they spent on Medicaid.

To review: Locks in historical differences between states.

Review ledger

How this path connects

Addresses
States lose control and budgets shift between levels of government
This path
Maintenance-of-effort payments from states
Creates or worsens
Racial, income, and geographic disparities
Leaves funding vulnerable or inflexible

    Concrete changes if chosen

    What would actually have to change in law, agencies, payment rules, or systems.

    1. Require state maintenance-of-effort payments

    Effects

    Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.

    The question it answers
    States lose control and budgets shift between levels of government

    Requiring indexed state payments based on former Medicaid spending lowers federal costs through a simple contribution rule.

    What it fixes

    None identified.

    What it creates or worsens

    Who's affected

    Who gains
    Who loses

    Where it has been tried

    • Medicare Part D clawback: States pay Medicare for dual-eligible drug costs.
    • United States: Under the Medicare Part D phased-down state contribution (clawback) requirement for dual-eligible drug costs, state payments to the Medicare Part D trust fund totaled $15.8 billion in calendar year 2023 (2024).
      Sources: Centers for Medicare & Medicaid Services (2024)

    Other paths for “States lose control and budgets shift between levels of government”

    States administer under national rulesStates lose control and budgets shift between levels of governmentChosen