The per capita cap and block-granting scheme would certainly save the federal government money. The main appeal of universal spending caps is not only that they promote thrift among states, but that pegging them to economic factors, at the start of a prescribed “base year,” basically underfunds them in the future. But this scheme might also work against the ability of Medicaid to effectively cover people. A report from the Kaiser Family Foundation shows that such a policy could “lock in” funding to states based on their position in the base year, and would create long-term “winners” and “losers” in states. States would no longer be able to react in real time to crises like drug epidemics, disasters, or job crunches, and funding would not respond to demographic changes. In essence, people might be blocked from receiving care simply based on where they live. That this problem recreates the geographic incoherence of the current Obamacare Medicaid expansion—where people covered under the expansion in some states will lose coverage if they move to non-expansion states—is no small irony.

The logic behind block grants and per capita caps on federal funding is that they force states to be efficient with Medicaid dollars since they’re on the hook after that money is gone. But there are no guarantees that states wouldn’t simply create that “efficiency” by dropping people from coverage, diminishing the services covered, or reducing payments to providers. In fact, the House plan appears to encourage just that, as it only specifies coverage of mandatory services for disabled and elderly people in its requirements for block grants. The ensuing system, then, would no longer be a safety-net entitlement for all people who need care, but one where many of the riskiest patients with the most pressing issues might simply be forced to do without. That’s a strong departure from the underlying logic of the program, outlined when President Lyndon Johnson railed against “the injustice which denies the miracle of healing to the old and to the poor” when he signed the amendment to the Social Security Act, which gave the country Medicare and Medicaid in 1965.

The prospects of the House Republican plan are murky at the moment, as the Senate still appears to be much more cautious in its approach to repealing or replacing Obamacare, and the actual coverage details when released might not bode well at district town halls. Still, the structural changes to Medicaid have endured a decade or more as the dominant Republican health-reform strategy, and seem one of the likeliest changes to occur at some point over the next few years if they maintain control in Congress. Unfortunately, the losers of that strategy will tend to be the people for whom the country built the safety net in the first place.