As noted previously, the budget adopted by House Budget Committee Republicans does two important things to Medicaid:
a) It enacts draconian reductions in the federal government's commitment to financing health care for the disabled, the elderly, and the poor.
b) It substantially devolves power over how those dollars are spent.
That, to my eye, is an unconscienable set of policy priorities that seems to me to be driven by its architect Paul Ryan's devotion to the philosophy of Ayn Rand and the general principle that taking resources from those who have a lot to give to those who have great needs is immoral. Ross Douthat, however, argues that "the projected dollar figures for Medicaid spending in 2021 or 2031 matter less than the budget’s proposal to devolve control over Medicaid to state governments and allow more room for policy experimentation at that level."
Ezra Klein offers a long response, but my short response would be that the way to enact a program whose intended purpose is to decentralize control over Medicaid would be to write a bill that decentralized control over Medicaid! What Ryan wrote, and what his colleagues on the Budget Committee voted for, was a bill that decentralizes control over Medicaid and enacts draconian reductions in the federal government's commitment to financing health care for the disabled, the elderly, and the poor. If they'd written and voted for a different bill, we could have a different debate about it. But they didn't, so we can't.