The raging battle over Medicaid funding is really a fight about the soul of Medicaid and our progress as a society. The broader objective of the House legislation is clear – to reverse decades of progress and take us back to 1965, when health care was welfare, and many people simply were considered undeserving of access to health care. That is what this legislation is all about. As my colleagues Adam Searing and Joan Alker have written, it is an attack on the progress we’ve made toward building a health care system that works for everyone.
Yes, the recently passed House Reconciliation bill (bill and amendments) would make the largest Medicaid cut in history (around $800 billion in federal funding alone, which when combined with corresponding state funding will be a cut of about $1.2 trillion to Medicaid in states) and combined policies would take health insurance away from some 16 million people – wreaking unspeakable havoc and harm on families, providers, and states across this country. But if you take a step back and look at how health care in America has evolved, you will see the bill is about much more than numbers can convey. It is an attack on who we have become as a country – who we are in blue, red and purple states. Here’s a very brief timeline on the evolution of Medicaid and how the bill would take us backwards.
Timeline on Medicaid’s Evolution
I’ll divide the timeline into six phases. Phase one starts in 1965, the birth of Medicaid. When Medicaid started in 1965, eligibility for women and children was linked to cash assistance, then known as AFDC (Aid to Families with Dependent Children). Medicaid eligibility was very limited, as was AFDC, in the belief that only a small set of the poor were worthy of help.
During phase two, from the 1970s to mid-1990s, an incredible transformation began. While eligibility for AFDC remained constrained to a relatively limited set of worthy groups, eligibility for Medicaid grew through numerous piecemeal expansions, and for good reason. For example, when Medicaid started in 1965 some children living in poverty and some people with disabilities in extreme poverty were ineligible. In the period up to the mid-1990s, widespread recognition that more people were worthy of health coverage led Congress to repeatedly expand eligibility for Medicaid. Step-by-step the program progressed. The program’s slow but steady growth to new populations (both before and after the 1990s) is superbly illustrated by this graphic from KFF, included below, and available in their Medicaid overview report. These improvements ushered in a decline in the uninsured rate.
In 1996 came phase three; more a decisive moment for Medicaid than a phase, but let’s not quibble. After seeing Medicaid’s evolution to a program covering so many worthy groups, Congress in 1996 recognized the undeniable and inevitable truth that Medicaid is not a “welfare” program. Congress redesigned AFDC (morphing it into TANF, Temporary Assistance for Needy Families) and de-linked Medicaid eligibility from AFDC/TANF. Medicaid was now on its own track as a health care program. It’s not this blog’s purpose to explain why cash assistance and health care are different, but just consider that health care isn’t edible, doesn’t pay your rent, but does help families work—it doesn’t replace work nor the need to work to survive.
During phase four, from 1996 until 2010, there is a continuation of the phase two trend – more group-by-group expansions of Medicaid identifying more and more worthy groups. For example, Congress added a category to cover workers with disabilities. (In 1997, Congress also established CHIP, the Children’s Health Insurance Program.) More step-by-step progress.
Phase five takes us to 2010, the passage of the Affordable Care Act (ACA) and its Medicaid Expansion—a watershed moment for health care in the United States. By 2010, both Congress and the American public had come to the inescapable conclusion that everyone should have access to health care. So, Congress did something interesting. It didn’t upend the category-by-category approach, but it added one new category that effectively reads: “everyone else who has been left out of Medicaid and is poor.” That is Medicaid Expansion in a nutshell. And by doing so, Congress took the last step of the (at that point) 45-year Medicaid marathon, crossing the proverbial finish line and ending (or so we thought) the anachronistic classifications of worthy and unworthy poor. Medicaid expansion, in conjunction with the ACA Marketplace (with subsidies available for lower income people), would bring accessible coverage to everyone.
This leads us to our sixth and final phase – the post-ACA era political (and judicial) backlash. Although a large majority of Americans view Medicaid favorably (including 63% of Republicans), a political minority unleashed an attack on the progress made in Medicaid, which has led to some regression and the possibility of more. As soon as the ACA passed, lawsuits to stop it were filed. Many were unsuccessful. However, in a case commonly known as NFIB, the Supreme Court reviewed the ACA’s Medicaid expansion and somewhat absurdly ruled (for the first time ever) that the Congressional spending power was used coercively upon states, and therefore the expansion could not be mandatory for states. Nonetheless, it is such a sensible and non-coercive policy that 41 states including DC have voluntarily taken it up. But Congress, too, has attempted to attack the Medicaid expansion, from numerous (failed) legislative proposals to defund it, to the current House-passed bill that takes a “death by a thousand cuts” approach.
Legislative Proposal to Reverse Progress
The House-passed Reconciliation bill currently being considered by the Senate (bill and amendments) represents a gargantuan cut on Medicaid generally, but concentrates a lot of its firepower directly at Medicaid expansion, launching a coordinated attack on Medicaid Expansion through numerous provisions. I’ll number them to help you keep count. (1) It proposes work reporting requirements (a policy that has already failed) which is an at-least-$344 billion dollar cut, forced on Medicaid expansion states, that will lead to five million or so people losing expansion coverage. (2) It proposes to double the renewal requirements for people enrolled in Medicaid expansion coverage, in a thinly-veiled attempt to force disenrollments by drowning families in paperwork. (3) It would end incentives that are currently in place to encourage new states to opt into Medicaid expansion. (4) It forces states to increase cost-sharing for Medicaid Expansion enrollees. (5) Perhaps most astoundingly (and unlawfully), it would double Medicaid Expansion costs for states that offer programs covering some lawful immigrants under existing federal options or that cover immigrants (lawfully residing or undocumented) in state programs that use only state dollars. (6) And in a last-minute change, the House added a provision punishing states that accepted Medicaid expansion by setting lower hospital reimbursement limits for them compared to non-expansion states. Do you see a pattern here? These cuts are nearly half of the total cuts in the House-passed reconciliation bill. Long story short, the House Republicans really, really hate Medicaid expansion.
The funny thing is, do you know who doesn’t hate expansion? The American public. Even in the non-expansion states, two-thirds of the people want their states to expand. And when Medicaid expansion has been put on the ballot in states, state citizens have voted in favor of expansion over and over again, including in red states such Idaho, Missouri, Nebraska, Oklahoma, South Dakota, and Utah. So why is the House so out of step with the American public?
The answer can be gleaned from the statements made by House and administration leadership. They talk about “young men who need to be out working instead of playing video games all day.” They talk about Medicaid as “welfare” and “handouts.” All the while ignoring the reality of millions of blue collar workers that simply do not get health care from their jobs and rely on Medicaid. But their larger purpose is simple: to bring back the exclusion of poor people they deem “unworthy.” At this point, House leaders may realize that—given its popularity—a frontal attack to repeal Medicaid Expansion would fail, so they are attempting to bleed it dry, by making it hard to enroll, erecting barriers to using coverage, and punishing states that have chosen or choose to expand. The unmistakable intent in attacking the Medicaid expansion, and the ACA more broadly, is to reverse the decades of progress and take us back to 1965 (or maybe even 1552?). If the legislation had a slogan, it would be: Make Medicaid Welfare Again.
It remains to be seen whether Congress wants to take us backwards to a dysfunctional past or accept the reality that Medicaid has evolved, and the American public wants it that way.