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IT’S GOT ITS OWN SET OF RULES AND COSTS. IT VARIES BY STATE, AND PLANS CAN GO BY DIFFERENT NAMES, MEANING SOME PEOPLE MIGHT NOT EVEN KNOW THEY’RE ON MEDICAID. STILL, IT’S THE LARGEST SINGLE SOURCE OF HEALTH CARE, PROVIDING COVERAGE TO 1 IN 5 AMERICANS. THAT’S MORE THAN 71 MILLION PEOPLE. SO WHO ARE THOSE PEOPLE? AND WHAT’S CHANGING UNDER PRESIDENT TRUMP’S NEW SPENDING BILL? ROBIN RUDOWITZ IS THE VICE PRESIDENT OF KFF, ALSO DIRECTOR FOR ITS PROGRAM ON MEDICAID AND THE UNINSURED. ROBIN, THANK YOU FOR JOINING ME. APPRECIATE IT. THANK YOU FOR HAVING ME. TELL ME HOW WE GOT TO MEDICAID IN THE UNITED STATES. IT WAS CREATED IN 1965 AT THE SAME TIME AS THE MEDICARE PROGRAM, AND MEDICAID WAS DESIGNED TO PROVIDE HEALTH INSURANCE COVERAGE TO INDIVIDUALS WITH LOW INCOMES AND LIMITED RESOURCES. THERE’S THIS RELATIONSHIP BETWEEN THE STATES AND THE FEDS WHEN IT COMES TO HOW MEDICAID IS ACTUALLY FUNDED AND IMPLEMENTED. THE FINANCING IS SHARED, STATES DESIGN THEIR PROGRAMS WITHIN THESE BROAD FEDERAL RULES. SO MAKE DECISIONS ABOUT, YOU KNOW, WHAT LEVEL OF COVERAGE AND HOW TO PAY PROVIDERS. AND THEN THEY DRAW DOWN WHAT’S CALLED A MATCH FROM THE FEDERAL GOVERNMENT. SO THAT MATCH RANGES ACROSS STATES BASED ON THE STATES INCOME LEVELS. SO STATES THAT HAVE LOWER PER CAPITA INCOME, LIKE MISSISSIPPI, HAS A HIGHER FEDERAL SHARE THAT THE FEDERAL GOVERNMENT REIMBURSES THE STATE FOR. WHAT WERE SOME OF THE BIGGEST CHANGES THAT WERE MADE UNDER THIS NEW BILL THAT WAS BROUGHT FORTH BY BOTH PRESIDENT TRUMP AND REPUBLICANS OVER THE NEXT TEN YEARS? THE PROVISIONS IN THE BILL WOULD REDUCE FEDERAL MEDICAID SPENDING JUST OVER $1 TRILLION. SO THAT IS A LARGE AMOUNT OF REDUCTION IN FEDERAL DOLLARS IN THE OVERALL HEALTH CARE SYSTEM. AND WHAT IS GOING TO STATES. BUT THE BIGGEST CHANGES ARE RELATED TO REQUIRING STATES TO IMPOSE WORK REQUIREMENTS ON THEIR AFFORDABLE CARE ACT EXPANSION POPULATION. SO THEN WHAT DOES THAT MEAN FOR PEOPLE WHO ARE, FOR THE MOMENT, UNABLE TO WORK? WHEN YOU LOOK AT THOSE WHO ARE NOT WORKING, MOST SAY THEY’RE NOT WORKING BECAUSE THEY HAVE SOME BARRIER TO WORK. EITHER THEY HAVE AN ILLNESS OR DISABILITY, THEY HAVE CARETAKING RESPONSIBILITIES. SO THESE NEW REQUIREMENTS REQUIRE INDIVIDUALS TO BE WORKING 80 HOURS PER MONTH OR HAVE ANOTHER QUALIFYING ACTIVITY. BUT THESE ARE REALLY ALSO REPORTING REQUIREMENTS BECAUSE OFTEN THE STATE MIGHT NOT KNOW THAT AN INDIVIDUAL IS WORKING. AND WE KNOW FROM OTHER EXPERIENCE, IT’S OFTEN DIFFICULT FOR INDIVIDUALS TO PROVIDE THAT THAT DOCUMENTATION OR THAT REPORTING. WHAT’S THE IMPACT POSSIBLY ON STATE GOVERNMENTS? STATES ARE LIKELY TO RESPOND TO THE CHANGES AT THE FEDERAL LEVEL IN DIFFERENT WAYS. STATES OFTEN NEED TO BALANCE THEIR BUDGETS ON AN ANNUAL BASIS. SO STATES MIGHT NEED TO MAKE SOME HARD DECISIONS ABOUT WHO THEY COVER, AND ALSO LOOK AT WHAT KINDS OF COVERAGE IN TERMS OF BENEFITS AND SERVICES ARE COVERED. SO THEY COULD EITHER MAKE CHANGES TO THE MEDICAID PROGRAM OR MAKE CHANGES TO OTHER PIECES OF THEIR BUDGET. OF COURSE, THE LARGEST PIECE OF STATE BUDGETS IS USUALLY ELEMENTARY AND SECONDARY EDUCATION, SO THAT IS DIFFICULT TO MAKE CHANGES TO. AND THE OTHER OPTION, OF COURSE, IS TO RAISE REVENUES AT THE STATE LEVEL. BUT THAT IS ALSO QUITE UNPOPULAR TO RAISE TAXES AT THE STATE LEVEL. ROBIN RUDOWITZ, VIC