This Brookings opinion piece says whether or not the Supreme Court strikes a blow at the ACA's state exchange subsidies in June, it is essential for Congress to remake Medicaid and CHIP, into a more rational and efficient structure. According to Brookings, such a redesign requires three steps:
- Encourage states unwilling to expand traditional Medicaid under the ACA to adopt a well-designed private option;
- Split Medicaid into three separate programs, tailored to three different populations: Blend Medicaid for able-bodied households, together with CHIP, into the tax credit and subsidy program created under the ACA for private plans obtained through the exchanges or through the place of work; Put the disabled and other high-cost individuals with multiple needs in a revamped Medicaid program which would provide much greater flexibility for states to combine health, housing and other funds and to experiment with better ways to serve that population; Stop trying to serve the long-term care supports and services of America's elderly within Medicaid, they should become part of a revamped strategy for addressing the overall supports and service needs of the elderly;
- Section 1332 of the health reform law allows states to apply for sweeping waivers from many of the mandates and other provisions of the ACA and to coordinate those waivers with the other waivers available under CHIP and even Medicare. States can begin using such waivers in 2017, and could combine ACA waivers with the Section 1115 waivers available under Medicaid. With these waivers available to them, states can explore sweeping changes in their Medicaid programs and can design those changes in tandem with a radically different version of the ACA within the state after 2017.