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From NPR News, this is ALL THINGS CONSIDERED. I'm Audie Cornish.
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And Melissa Block. Medicaid is the nation's largest health insurance program. It serves nearly one in five Americans. As a result, it's putting increasing strain on the budgets of states who pay about 40 percent of its costs.
CORNISH: If the 2010 health law proceeds as planned, Medicaid could see as many as 11 million more people added to its roles over the next decade. That's a prospect that thrills some and terrifies others. As part of our series Solve This, NPR's Julie Rovner looks at the very different ways Democrats and Republicans would deal with the Medicaid program.
JULIE ROVNER, BYLINE: When you say the word Medicaid, most people think of moms and kids on welfare. And it's true, moms and kids who get welfare do also generally get Medicaid health coverage. In fact, says Harold Pollack of the University of Chicago, working-age adults and children make up about 75 percent of Medicaid's population. But they're responsible for only one-third of its costs.
HAROLD POLLACK: Two-thirds of the dollars that are spent on Medicaid are spent on elderly and disabled people, many of whom have multiple challenges and a good number of whom are either in nursing homes or are disabled people who also receive Medicare.
ROVNER: And while Medicaid is the health program for the poorest of the poor, it's also the program for the medically needy, people whose extreme health needs aren't met by their private insurance, people like Marty and Shannon Svikhart of Baltimore, Maryland and their three-year-old daughter, Simone.
MARTY SVIKHART: Where's your high fives?
ROVNER: Simone was born prematurely and, despite a huge smile and a headful of blonde hair, she still suffers from a long list of ailments, says mom Shannon.
SHANNON SVIKHART: Cystic fibrosis is her primary diagnosis, hydrocephalus, a brain bleed. Right now she also has high blood pressure. Eventually will have to have open heart surgery.
ROVNER: Shannon quit her job as a dietician to care for Simone fulltime. Husband Marty works for a company that makes decking equipment, and they have good health insurance but it's not enough. Because Simone still needs to be on a ventilator at night, she needs a night nurse, and Marty Svikhart's insurance will only pay for 90 days of coverage per year for that.
SVIKHART: If we had to pay out of pocket for home nursing, that would average about $140,000 out of pocket per year - financially unmanageable unless we hit the lottery or something.
ROVNER: Under a special program, Medicaid helps pay the family's night nursing costs. Shannon Svikhart says it's made a huge difference.
SVIKHART: That means that Marty and I can sleep. Marty travels, so if we didn't have that, he would have had to quit his job, probably work locally.
ROVNER: That's all well and good, say critics of Medicaid, to allow families like the Svikharts to stay safely middle class. The problem is it's simply too expensive.
GRACE MARIE TURNER: For many states, it's the biggest item in their budget. They're all struggling to figure out what to do.
ROVNER: Grace Marie Turner is a conservative health policy analyst and was a member of the Bush administration's Medicaid commission in 2005. Turner says one of the biggest problems is the amount of micromanaging of Medicaid that comes from Washington.
TURNER: So you wind up with all of this red tape and bureaucracy and it's costly. And in my opinion, we wind up with a program that provides the worst care to the most vulnerable people. We have got to solve this.
ROVNER: Mitt Romney says he would solve the problem basically by ending Medicaid's status as a shared federal-state program. He'd turn the money back to the states in the form of block grants and let them craft their own programs. But he'd also make his Medicaid plan a money-saver. Romney told "60 Minutes" last month he'd do that by allowing the amount of federal funds to grow more slowly than medical inflation.
MITT ROMNEY: That's a lower rate of growth than we've seen over the past several years, a lower rate of growth than has been forecast under federal management. And I believe on that basis you're going to see us save about a hundred billion dollars a year.
ROVNER: Conservatives insist states can run their programs more efficiently without cutting people or services. Liberals like Harold Pollack are far more skeptical.
POLLACK: And when we're talking about really critical services for people, that's a heck of a gamble to run.
ROVNER: By contrast, President Obama's Affordable Care Act originally required states to expand Medicaid to most non-disabled adults with incomes under 133 percent of poverty. That's about $15,000 for an individual. Pollack says that's important for more than just those getting the new coverage.
POLLACK: It also allows the people who are taking care of that individual to get reliable payment, which is a really important issue for public hospitals and for many other organizations that just desperately need that support right now.
ROVNER: But the Supreme Court this summer made that expansion optional for the states. Health and Human Services Secretary Kathleen Sebelius thinks eventually most states will opt in, if only because the federal government will pay nearly all the costs.
KATHLEEN SEBELIUS: We think at the end of the day this is a deal that states won't want to turn down.
ROVNER: But as with few other programs, the fate of Medicaid will be very different, depending on who the next president is. Julie Rovner, NPR News, Washington.
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