Conservatives put a target on Medicaid spending

• But the safety-net health program now costs more than $800 billion annually, with the federal government footing about 70% of the bill.

State of play: Former President Trump's presidential policy platform is conspicuously silent on Medicaid while he's pledged not to touch Medicare or Social Security.

• Still, conservative groups from the Republican Study Committee to the Paragon Health Institute to the Heritage Foundation want to turn Medicaid into block grants, impose work requirements or reduce the federal share of program costs for states where coverage has been extended.
• The conservatives' beef: The ACA opened up eligibility for able-bodied, working-age adults and offered states extra money to do so, driving up program costs that are swelling federal deficits.
• A playbook from Paragon, co-written by former Trump administration economic adviser Brian Blase, would phase out the 90% federal share of Medicaid costs for the expansion population, giving states the same federal funding for all Medicaid enrollees.
• Under the plan, only households below the federal poverty level could still qualify for Medicaid, while those above the poverty level would instead be eligible for tax credits to buy coverage on Affordable Care Act exchanges.

The changes would save the federal government between about $252 billion and $530 billion over eight years, depending on how states respond. But states' costs would increase by at least $110 billion over that time — likely forcing some to pare benefits or enrollment.

• The Paragon blueprint is a contrast to Heritage's Project 2025, which would cap the federal Medicaid funding available to states. However, Paragon's document says the think tank will release future briefs examining options to set fixed federal Medicaid rates.

The latest: The Trump campaign remains mum on its plans. As president, Trump backed an ACA repeal bill that called for $880 billion in cuts to Medicaid.

• Campaign spokesperson Karoline Leavitt told Axios that Trump wants to "end the financial drain on our health care system and ensure that our country can continue to care for American citizens who rely on Medicaid, Medicare and Social Security."

Reality check: Overhauling Medicaid isn't necessarily a political slam-dunk for Republicans, said Chris Jennings, a Democratic consultant.

• Republican candidates not explicitly raising Medicaid cuts "suggests that they're already beginning to get concerned that it may not be easy," he said.

• Nearly 9 in 10 Medicaid enrollees said in a recent KFF poll that the program should stay largely the same as it is today. More than 70% of adults overall agreed, including more than half of Republicans surveyed.
• North Carolina's adoption of a Medicaid expansion plan last year brought the number of states with expanded programs to 40, making a major overhaul more complicated.

The other side: Medicaid changes floated by conservative think tanks "would have a dramatic effect on beneficiaries' access to health coverage and to needed health care services," Edwin Park, a research professor at Georgetown University's Center for Children and Families, told Axios.

• Park called the notion that Paragon's proposal would protect vulnerable Medicaid beneficiaries "preposterous." States that keep Medicaid expansion under the plan would have to cut other parts of the program or other state spending such as education, according to a blog post he co-wrote.
• Expanding Medicaid to able-bodied adults earning up to 138% of the poverty level improved access to health care, and has been linked to better health outcomes and better health care system finances.

Meanwhile, Democrats used last week's 59th anniversary of the program to showcase Medicaid as a campaign talking point.

• "This November, Medicaid is on the ballot. … That's why we must elect Democrats up and down the ballot and protect Medicare and Medicaid from Republican extremism," Democratic National Committee chair Jaime Harrison said in a statement last week.