A version of this op-ed originally appeared in the National Review Online on January 19, 2017.

By Ellen Weaver and Caleb Crosby

As the 115th Congress convenes and President-elect Trump prepares to take office tomorrow, our nation faces incredible challenges and opportunities. On health care in particular, the stakes couldn’t be higher, nor the path forward more clear.

As leaders working on state-based policy solutions across the country, we have seen the impact of Obamacare on our communities up close.

screen-shot-2017-01-19-at-10-19-06-amGiven the focus on the disastrous launch of the law’s insurance exchanges in 2013, many people don’t know that most of Obamacare’s coverage gains have come not through those exchanges, but through its new expansion of Medicaid to able-bodied, working-age adults. Medicaid was intended to provide important safety-net coverage to vulnerable populations such as individuals with disabilities, low-income children, and the elderly. But Obamacare’s massive expansion of this entitlement to able-bodied adults has placed added strain on an already overextended program in many states.

Even prior to Obamacare, Medicaid stood in desperate need of reform. In many states, low physician-reimbursement rates result in poor access for beneficiaries. Medicaid beneficiaries have higher rates of emergency-room usage than uninsured patients, and a landmark study from Oregon found that they showed no measurable improvement in health outcomes after gaining Medicaid coverage.

With enrollment in the program skyrocketing beyond most states’ wildest expectations after Obamacare’s expansion, states now face difficult fiscal choices. The law provided three years of 100 percent federal funding for states that expanded Medicaid to the able-bodied. But beginning this month, states that expanded will have to start paying a portion of those costs—5 percent this year, rising to 10 percent in 2020. Even Democratic state legislators have publicly mused that the high costs their states will face due to Medicaid expansion will crowd out other important priorities such as education for children and care for the disabled.

Obamacare’s Medicaid expansion has already prompted states to take actions that effectively discriminate against the most vulnerable in our society. Because Obamacare provides a 90-100 percent federal match to states covering the able-bodied, but only a 50-75 percent match to those covering individuals with disabilities, many states have chosen to prioritize coverage of the able-bodied. In some cases, they have gone so far as to cut coverage for the most vulnerable even while expanding it elsewhere. There are nearly 600,000 individuals with disabilities stuck—and in some cases, dying—on waiting lists, unable to access the care they need through Medicaid. It’s long past time to reorient our priorities.

Thankfully, the Supreme Court found Obamacare’s mandatory expansion of Medicaid unconstitutionally coercive in 2012, ruling that states could opt out of the expansion if they wished. Leaders in our states wisely saw through the false promises of expansion and declined to embrace this massive new entitlement for the able-bodied.

Having witnessed other states’ difficulties with Obamacare, and our own states’ desire for true reform of Medicaid, we would like to wholeheartedly emphasize the need for a new, and better, approach. Reforming Medicaid must start with unwinding Obamacare—and with three basic principles.

First, any Obamacare-repeal measure Congress enacts should freeze enrollment in this massive new entitlement. Individuals currently enrolled in Medicaid expansion should be held harmless and not face coverage disruptions. But states and the federal government need to begin unwinding the massive, unsustainable spending associated with Obamacare.

Second, repeal legislation should also, after an appropriate transition period, end the enhanced federal match for states expanding Medicaid to able-bodied populations, which has distorted states’ behavior, encouraging them to discriminate against the most vulnerable.

Third, Congress, the states, and the federal Centers for Medicare and Medicaid Services (CMS) should work together to reorient Medicaid toward the vulnerable populations for which it was originally designed. Seema Verma, the new CMS Administrator-designee, has indicated her willingness to provide more flexibility to states, as have the new majorities in Congress.

The tasks ahead of the new president and Congress are many. But so are the possibilities. By unwinding Obamacare’s Medicaid expansion the right way, the new Republican government can slow the gusher of spending that has jeopardized state and federal budgets, treat fiscally prudent states fairly, and focus on restoring the safety net for the most vulnerable. We would urge lawmakers and the president-elect to make these goals a top priority.

MORE ON Fiscal Policy

Learning fiscal responsibility from the fall of MoviePass

One year ago, a relatively-unknown company announced that, for a monthly fee of $9.95, subscribers could see one movie a day without paying anything at the box office. That’s right – even though the average movie ticket in the U.S. is $9 – a $9.95 monthly subscription could get you into 31 movies. Since last […]

Tax Incentives: Not Always the Answer for Alabama’s Economic Struggles

Last month, the state rejoiced with news that Alabama would be the home of a new Toyota-Mazda plant. The plant is expected to bring over 4,000 jobs and billions of dollars in net revenue to the state. With the execution of this deal, known as Project New World, state and local governments will give the […]

MORE ON Health Care

API Joins 36 Conservative Groups and Activists: Congress Must Stop New Obamacare Taxes

Lawmakers must act to prevent Obamacare taxes from going into effect next year, 36 conservative groups and activists wrote in a letter addressed to House Speaker Paul Ryan (R-Wis.) and Senate Majority Leader Mitch McConnell (R-Ky.). Absent Congressional action, the Obamacare health insurance tax and medical device tax will both go into effect in 2018. […]

Obamacare Repeal Must Roll Back the Medicaid Expansion

A version of this op-ed originally appeared in the National Review Online on January 19, 2017. By Ellen Weaver and Caleb Crosby As the 115th Congress convenes and President-elect Trump prepares to take office tomorrow, our nation faces incredible challenges and opportunities. On health care in particular, the stakes couldn’t be higher, nor the path […]

MORE ON The Forum

HUNTSVILLE RADIO: Alabama should shine the light on asset forfeiture

API Senior Fellow J. Pepper Bryars recently discussed civil asset forfeiture on the Fred Holland Show, 105.3 FM WTKI in Huntsville. The two spent an hour discussing the issue, including how it’s done in Alabama, its pros and cons, and why law enforcement should make the process more easily available to public scrutiny. Listen to […]

While the Supreme Court deliberates, Alabama should shine the light on asset forfeiture

The U.S. Supreme Court recently signaled that it’s ready to limit the government’s power to confiscate things like cars, houses, and cash that prosecutors have proven, or maybe just reasonably suspect, were involved in crimes. The court heard oral arguments related to Indiana’s use of the power, known as asset forfeiture, to confiscate a $42,000 vehicle — […]

MORE FROM The Alabama Policy Institute

Our Evaluation of Michael Sentance

The Alabama State Board of Education will meet tomorrow in Montgomery for a special meeting abruptly called last week. The stated purpose is to evaluate Superintendent Michael Sentance. The rumored purpose is to fire him. We trust that the latter is just that—a rumor—as there is absolutely no justification for firing Mr. Sentance. Indeed, allow […]

API Joins National Coalition of Education Choice Advocates and Releases Letter Applauding Education Secretary Betsy DeVos

Letter Encourages Trump Administration to Champion Constitutionally Focused Education Choice Agenda Yesterday, Alabama Policy Institute (API) joined 12 other leading state and national organizations in sending a letter to Secretary of Education Betsy DeVos praising her outspoken commitment to parental choice in education. The letter outlines the importance of state-led efforts on education choice, emphasizing […]

Statement on the Alabama Child Placing Agency Inclusion Act

The Alabama Pro-Life Coalition (APLC) commends Governor Kay Ivey for signing the Alabama Child Placing Agency Inclusion Act into law on May 3, 2017. By her signature, the rights of religion based adoption agencies are protected. APLC also commends the sponsors of the legislation, Senator Bill Hightower (R-Mobile) and Representative Rich Wingo (R-Tuscaloosa). Their understanding, […]