The clawback provision is controversial and highlights some of the tensions concerning state flexibility and national uniformity that policymakers face when designing public programs. The clawback seems to contradict the prior decision to provide states with flexibility and program design responsibilities under Medicaid. In addition, it changes the decision to use only federal funds to pay for Medicare. Given decisions made by states prior to the MMA, there are many variations among state prescription drug benefits that will be “frozen” in place with the clawback provision. At the same time, the MMA creates a uniform rule regarding how all states finance prescription drug funding in the future, and this could impact state-level decisions about dual enrollee coverage.

Is the clawback provision a good idea? Should states help pay for federal prescription drug coverage? Is there a better design?

Should states or the federal government control Medicaid prescription drug coverage that is provided to dual enrollees?

Should dual enrollees be treated differently than other Medicaid beneficiaries?