By NextBestFitCover the territories in the national program on the same terms as the states
Residents of Puerto Rico and the other territories are enrolled in the national program like everyone else, with the same benefits, payment rules, and federal funding.
Universal means every U.S. citizen; the territories join with the last wave.
To review: Higher federal cost (GAO's Puerto Rico estimate implies about 1.6 to 3 times today's federal Medicaid spending there). Parity Medicaid is the smaller alternative.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Define program residency to include all five territories
- Remove the territories' Medicaid caps and fixed matching rates from federal law
- Make Medicare Part B enrollment automatic in Puerto Rico
- Set geographic payment adjustments for the territories
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
- U.S. territories get capped, lower federal health funding
National enrollment gives territory residents the same benefits, payment rules, and federal funding as other citizens, ending funding cliffs and coverage gaps with the mainland. Higher clinician payments may slow moves to the mainland.
- Raises spending or loosens control over it
Full national inclusion raises federal spending substantially relative to current federal Medicaid spending in Puerto Rico.
- Limits choice or applies one rule to every setting
National rates may not fit island cost structures without adjustments.
- States lose control and budgets shift between levels of government
National inclusion reduces territory control over program administration.
Who's affected
- Residents of U.S. territories
- U.S. territories get capped, lower federal health funding: Capped and temporary federal funding leaves their health coverage less secure.
- Hospitals, clinics, and care organizations
- U.S. territories get capped, lower federal health funding: Territory providers are paid less than mainland peers.
- Doctors, nurses, and other clinicians
- U.S. territories get capped, lower federal health funding: Territory providers are paid less than mainland peers.
- Territory governments
- U.S. territories get capped, lower federal health funding: Temporary funding laws create recurring funding cliffs.
- Taxpayers and public budgets
- U.S. territories get capped, lower federal health funding: Capped territorial funding limits federal spending in the short term.
- Raises spending or loosens control over it: Public budgets pay the added spending.
- State governments
- States lose control and budgets shift between levels of government: States that designed their own programs lose control, and budgets shift between levels of government.
- Set geographic payment adjustments for island costs
- Let territory governments administer enrollment under national rules, as states do
Where it has been tried
- Puerto Rico (GAO estimate): GAO estimated federal Medicaid spending in Puerto Rico would have been $1.1–2.1 billion as a state in 2011, versus $685 million actually spent.
- Hawaii and Alaska: Non-contiguous states receive open-ended federal Medicaid funding under the same formula as other states.