Democrats’ push to extend health coverage to millions of very low-income people in red states has a lot working against it: It’s expensive, it’s complicated, it may invite legal challenges, and few national Democrats stand to gain politically from it.
Yes, but: The policy is being framed as a test not only of Democrats’ commitment to universal health coverage, but also their commitment to racial equity.
The big picture: Democrats are still figuring out how much money they have to spend in their massive social policy legislation, but there’s already intense competition among policies — including between health care measures.
Progressives are adamant about expanding Medicare to cover dental, vision and hearing benefits. But a handful of prominent Democrats are making the case that closing the Medicaid coverage gap is equally, if not more, important.
The gap exists in 12 Republican-controlled states that have refused to accept the Affordable Care Act’s Medicaid expansion, the majority of which are in the South.
What they’re saying: Closing the coverage gap is “very, very important to people of color. The majority of Black people in this country still live in the South,” said Rep. Jim Clyburn, one of the leading proponents of the measure.
More than 2 million adults are in the coverage gap, and 60% of them are people of color, according to the Center on Budget and Policy Priorities.
“What is the life expectancy of Black people compared to white people? I could make the argument all day that expanding Medicare at the expense of Medicaid is a racial issue, because Black people do not live as long as white people,” Clyburn added. “If we took care of Medicaid, maybe Black people would live longer.”
Between the lines: In terms of raw politics, it’s pretty easy to see why many Democrats would prioritize Medicare expansion over closing the Medicaid gap: Seniors live in every district and state in the U.S.
Only three Democratic senators represent non-expansion states, and in 2020, only ine of the 41 battleground House seats identified by Ballotpedia were in non-expansion states.
Yes, but: Sens. Jon Ossoff and Raphael Warnock, both from Georgia, are the reason that Democrats are able to consider their social policy legislation at all. Warnock is up for re-election next year.
“This is about people in this country, and I wish we’d stop this red state and blue state stuff,” Clyburn said. “Warnock and Ossoff won a runoff that nobody gave them a chance to win by promising they would close this gap.”
The catch: States that have already expanded Medicaid are covering a small portion of those costs themselves, and may question the fairness full federal funding for the holdout states.
That could create an incentive for existing expansion states to drop the ACA’s Medicaid expansion and pick up the new program instead. And any effort Congress makes to stop them could invite legal challenges.
“The case law in this domain is a bit of a moving target, and as we’ve seen over the past decade, there’s an awful lot of litigation over things pertaining to health reform,”said Nick Bagley, a professor at theUniversity of Michigan Law School.
But “if your goals are relieving health care cost burdens or expanding access to care, then it’s hard to do better on a dollar-for-dollar basis than buying coverage for uninsured people below the poverty line,” said Brookings’ Matt Fiedler.
What we’re watching: “I don’t see Medicaid as being on the radar of some of my friends in the caucus who seem to feel it’s more important to do Medicare,” Clyburn said. “I’m trying to get Medicaid on their agenda.”
“I’m tired of my party perpetuating … inequity,” he added. “Treating people according to their needs is what breaks the cycle.”
Prime Healthcare’s New Jersey hospitals announced this week they would terminate their contracts with major insurer UnitedHealthcare, citing significant underpayment compared to the rates of neighboring facilities, and lower reimbursement rates than those offered by Medicaid.
The decision impacts Saint Clare’s Health in Denville, Dover and Boonton, Saint Michael’s Medical Center in Newark, and Saint Mary’s General Hospital in Passaic.
Dr. Sonia Mehta, regional CEO and chief medical officer of Prime Healthcare New Jersey, said in a statement that the hospitals have been underpaid for years, including some rates well below that of Medicaid, and added that UnitedHealthcare’s contract proposal jeopardizes the organization’s ability to deliver quality care.
WHAT’S THE IMPACT?
Due to new disclosure requirements by the Centers for Medicare and Medicaid Services, all hospitals must now disclose their contracted rates. Prime Healthcare said it learned it had been underpaid compared to what United has been paying neighboring hospitals.
The New Jersey Hospital Association reported that Prime Healthcare hospitals provide quality healthcare services and that its cost of care is among the lowest in the State of New Jersey.
“We are patient-focused and are committed to delivering the most compassionate care by exceptional physicians using state-of-the-art technology,” said Mehta. “Undercutting our payments is unacceptable, and so we are taking the necessary step of providing notice of our intent to provide care out-of-network. We realize it is a bold move, but a necessary one to separate our hospitals from organizations that work contrary to our mission and commitment to our patients.”
Prime’s New Jersey hospitals will continue to honor the rates and services in the agreements until the end of the cooling off period, which is December 16 for the Medicaid product and December 31 for the commercial and Medicare products.
All patients can continue to use Prime’s emergency services at its New Jersey hospitals, regardless of insurance, and the hospitals are willing to negotiate single patient agreements for elective services. The hospitals will also honor all continuity of care services for United members.
UnitedHealthcare told Healthcare Finance News that Prime’s demands are unreasonable.
“Prime is demanding a 14% price hike in just one year for our employer-sponsored and individual plans, which is unsustainable and would increase healthcare costs for New Jersey residents and employers,” said spokesperson Cole Manbeck. “We hope Prime will work with us to ensure the people we serve have continued access to Prime’s hospitals at an affordable cost.
“While we have agreement on rates for our Medicare Advantage and Medicaid plans and proposed to Prime that we finalize the contract for these plans, Prime refused unless we accepted its 14% price hike demands for our employer-sponsored and individual plans,” he said.
“This unnecessarily puts thousands of New Jersey residents in the middle of our negotiation, presumably because Prime hopes the potential disruption in care for our most vulnerable members would pressure us to give in to its price hike demands.”
THE LARGER TREND
Prime Healthcare New Jersey is part of Prime Healthcare, a health system operating 45 hospitals and more than 300 outpatient locations in 14 states. In 2020, Prime successfully completed its acquisition of St. Francis Medical Center, a 384-bed Los Angeles County medical facility that had previously been owned by Verity Health.
Prime acquired St. Francis for a net of more than $350 million, including a $200 million base cash price and $60 million for accounts receivable.
Just last week, CMS blocked four Medicare Advantage plans from enrolling new members in 2022 because they didn’t spend the minimum threshold on medical benefits, with three UnitedHealthcare plans and one Anthem plan failing to hit the required 85% mark three years in a row. Medicare Advantage plans are required to spend a minimum of 85% of premium dollars on medical expenses; failure to do so for three consecutive years triggers the sanctions.
In June, UnitedHealthcare backtracked on a proposed policy retroactively rejecting emergency department claims. The policy, which was slated to take effect on July 1, meant UHC would evaluate ED claims to determine if the visits were truly necessary for commercially insured members. Claims deemed non-emergent would have been subject to “no coverage or limited coverage,” according to the insurer.
UHC rolled back the policy – for now. The insurer told The New York Times that the policy would be stalled until the end of the ongoing COVID-19 pandemic, whenever that might be.
The Democrats’ reconciliation bill includes several major health care pieces backed by different lawmakers and advocates, setting up a precarious game of policy Jenga if the massive measure needs to be scaled back.
Between the lines:Health care may be a priority for Democrats. But that doesn’t mean each member values every issue equally.
Why it matters: As the party continues to hash out the overall price tag of its giant reconciliation bill, it’s worth gaming out which policies are on the chopping block — and which could potentially take the entire reconciliation bill down with them.
There are clear winners of each pillar of Democrat’s health plan:
Seniors benefit from expanding Medicare to cover dental, vision and hearing benefits.
Low-income people — primarily in the South and disproportionately people of color — in non-expansion states benefit if the Medicaid gap is closed, giving them access to health coverage.
Affordable Care Act marketplace enrollees benefit if the increased subsidy assistance that Democrats enacted earlier this year is extended or made permanent.
Elderly and Americans with disabilities benefit from an expansion of their home-based care options, and their caretakers benefit from a pay bump.
Seniors — and potentially anyone facing high drug costs — benefit if Medicare is given the authority to negotiate drug prices, although the drug industry argues it will lead to fewer new drugs.
Yes, but:Each of these groups face real problems with health care access and affordability. But when there’s a limited amount of money on the table — which there is — even sympathetic groups can get left in the dust.
Each policy measure, however, also has powerful political advocates. And when Democrats have a razor-thin margin in both the House and the Senate, every member has a lot of power.
Seniors are disproportionately powerful on their own, due to their voting patterns. But expanding what Medicare covers is extremely important to progressives — including Sen. Bernie Sanders.
Closing the Medicaid gap is being framed as a racial justice issue, given that it disproportionately benefits people of color. And although many Democrats hail from expansion states — particularly in the Senate — some very powerful ones represent non-expansion states.
These members include Sen. Raphael Warnock, who represents Georgia and is up for re-election next year in an extremely competitive seat, and Rep. Jim Clyburn, who arguably is responsible for President Biden winning the 2020 primary.
The enhanced ACA subsidies are scheduled to expire right before next years’ midterm elections. Democrats’ hold on the House is incredibly shaky already, making extending the extra help a political no-brainer.
Expanding home-based care options was one of the only health care components of Biden’s original framework for this package. But aside from the president’s interest in the issue, unions care a lot about it as their members stand to gain a pay raise — and Democrats care a lot about what unions care about.
And finally, giving Medicare the power to negotiate drug prices has the most powerful opponents, theoretically making it vulnerable to the chopping block. But it also polls very highly, and perhaps even more importantly, produces enough government savings to help pay for these other health care policies.
The bottom line: “From a political perspective, none of these health care proposals seem very expendable,” said KFF’s Larry Levitt.
Most — if not all of them — can be scaled to save money.
But there are also powerful constituencies for the other components of the bill that address issues like child care and climate change, meaning these health care measures aren’t only competing against one another.
And, Levitt points out, “there’s always a difference between members of Congress staking out positions and being willing to go to nuclear war over them.”
On Wednesday, President Joe Biden unveiled a new plan requiring nursing homes to vaccinate their employees or lose federal funding. Industry members are concerned the mandate will exacerbate current staffing shortages and make it harder for facilities to care for their residents.
Biden ties employee vaccination to federal funding for nursing homes
Biden announced on Wednesday that nursing homes will have to require their workers be vaccinated against Covid-19 to receive Medicare and Medicaid funding, the New York Times reports.
CMS is expected to release an emergency rule covering this new requirement in September, according to Roll Call. Officials said the decision will affect more than 15,000 nursing homes with around 1.3 million workers across the country.
In a statement, CMS administrator Chiquita Brooks-LaSure said, “Keeping nursing home residents and staff safe is our priority. The data are clear that higher levels of staff vaccination are linked to fewer outbreaks among residents, many of whom are at an increased risk of infection, hospitalization, or death.”
As of Aug. 8, federal data showed that around 62% of all nursing home staff are currently vaccinated. But vaccination rates vary widely by state, with a high of 88% in some states and a low of 44% in others.
In addition, according to data from CMS, nationwide Covid-19 cases in nursing homes have increased from 319 cases on June 27 to 2,696 cases on Aug. 8. Since the beginning of the pandemic, federal data shows that around 134,000 nursing home residents and nearly 2,000 employees have died from Covid-19.
How will the vaccine mandate affect nursing homes?
According to Roll Call, divisions among nursing home staff about a vaccine mandate has some people in the industry—which has long suffered staffing shortages—concerned that even more workers will leave.
Lori Porter, CEO of the National Association of Health Care Assistants, said she is worried the industry could lose 20% to 30% of its workforce over the new vaccine requirement.
And Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living, said a broader vaccine mandate for all health care organizations, instead of just nursing homes, is necessary to prevent further staffing shortages.
“Focusing only on nursing homes will cause vaccine hesitant workers to flee to other health care providers and leave many centers without adequate staff to care for residents,” Parkinson said. “It will make an already difficult workforce shortage even worse.”
Similarly, Katie Smith Sloan, president and CEO of LeadingAge, a nonprofit that represents more than 5,000 aging services providers, said the vaccine mandate should be extended to all health care workers in all settings. She also voiced concern that cutting funding to nursing homes will further hurt facilities that have struggled financially throughout the pandemic.
“Without Medicaid and Medicare funding, nursing homes cannot provide the quality care that our nation’s most vulnerable older adults need,” Smith Sloan said. “Our mission-driven nursing home members, who operate on narrow margins in the best of times, depend on those funds alone to care for their residents.”
Separately, David Grabowski, a professor of health care policy at Harvard Medical School, said funding cuts could put some nursing homes “in a precarious position” and that he believes there will be a “tremendous amount of pushback in the industry.”
Grabowski noted that while a national vaccine mandate could “level the playing field” for nursing homes looking for employees, they may still struggle to retain employees with jobs in other areas, such as retail or hotels, offering similar pay. “I think this is a good measure, but it needs to be paired with additional resources to help pay staff and make sure these are jobs they want to stay in,” he said. (Clason, Roll Call, 8/18; LaFraniere et al., New York Times, 8/18; Christ, Modern Healthcare, 8/18)
Advisory Board’s take
This is a bold step—but it’s the right thing to do. Here’s why.
Mandating vaccinations for staff in skilled nursing facilities (SNFs) is definitely a bold step—but ensuring all staff are vaccinated is unquestionably the right thing to do. As health care leaders, it is our responsibility to care for our patients, our staff, and our communities, and during this pandemic, vaccination is the best way to do that.
Nationally, staff working in post-acute and long-term care settings have been among the groups most hesitant to take a Covid-19 vaccine. The combination of the extremely vulnerable patient populations in those settings and the lack of voluntary vaccination was likely what motivated this move.
I don’t want to imply this will be easy. Many SNFs will struggle to achieve universal vaccination, and there is understandable fear associated with having to let go of staff in what is an extremely tight staffing environment.
However, in my view, the staffing implications will be less severe than many believe. In some ways, a national mandate actually makes it easier for providers, because individual staff members can’t simply go work for another facility in order to avoid getting their shot. And as more and more employers across the country begin to mandate vaccinations—a list that so far includes large employers like Walmart and Tyson Foods—staff members will have minimal opportunities for alternate work arrangements that do not require them to get the vaccine. For many staff, even those who have refused in the past, the elimination of other options that would allow them to remain unvaccinated may give them the push they need to get the vaccine.
Some staff will refuse and leave the industry. In the short term, this will increase pressure on already tight staffing. In the medium to long term, however, a fully vaccinated workforce is better for providers. It’s better for recruiting, because it attracts potential workers who want to be in a safer environment. It’s better for the existing workforce, who will likely need to take fewer sick days. And it’s better for the reputation of the industry. In our summer consumer survey, we found that 76% of respondents would be more likely to receive care at a skilled nursing facility if all of that facility’s staff were vaccinated. Staff vaccination helps build a level of community trust in the safety of the facility, which will be critical as SNFs seek to return to growth during and after the Covid-19 pandemic.
Check out our resources for building consumer confidence in post-acute and senior care during and beyond a crisis. For help with how to prepare your staff and residents for the vaccine rollout at your facility, review our guide for long-term care leaders.
On Thursday, the Missouri Supreme Court unanimously reversed a lower court ruling that held that the state’s $1.9B Medicaid expansion, approved by voters in a 2020 ballot initiative, was unconstitutional.
The ruling clears the way for the state’s Department of Social Services to begin implementation of the expansion, which is expected to cover 275,000 low-income Missouri residents. Under the Affordable Care Act (ACA), the federal government will pay 90 percent of the cost to cover the newly eligible Medicaid beneficiaries, along with an additional bump in federal funding for Missouri’s Medicaid program, thanks to a provision in the American Rescue Plan Act passed earlier this year.
Missouri voters approved the expansion by a 53-47 margin last year, but the ballot initiative was held to be unconstitutional because it did not include a source of funding for the portion of coverage costs to be paid for by the state (and the state legislature refused to allocate money for the expansion, despite currently running a surplus). Five other states have turned to ballot initiatives to expand Medicaid under the ACA, seeking to work around state legislatures that have resisted the change. In all, a dozen states, mostly in the Southeast, have chosen not to expand their Medicaid programs, even despite the additional incentives Congress voted into law this year.
Democrats on Capitol Hill are considering legislative alternatives to provide new coverage to low-income residents in those states, as part of the $3.5T reconciliation package currently being negotiated. Numerous studies have shown the positive impact of expanding Medicaid on health and financial well-being, but state-level politics have proven to be a challenge, especially in deep-red states. Meanwhile, tax dollars continue to flow from those states to fund Medicaid expansion elsewhere—now, including Missouri.
One of the most important initiatives for President Biden since taking office in 2021 has been to pass a sweeping infrastructure bill to improve roads, bridges, water systems, and to make affordable housing more available to Americans in need, to name a few key components. While a bill has not yet been passed, initial estimates range from $2.5 – 3.5 Trillion in total spending across all sectors. How will the proposed infrastructure bill affect healthcare for Americans? Healthcare remains the largest component of household spending in the U.S. In 2019, Americans spent approximately $3.8 Trillion on healthcare, or about 18% of the Gross Domestic Product. More importantly, we learned from the pandemic that healthcare service providers are a critical infrastructure support network to our nation. What does the infrastructure bill provide to assist with this going forward? The largest healthcare components in the infrastructure bill are estimated to be:
$400 Billion for Home and Community Based care for the disabled and elderly. According to census, an estimated 20% of the U.S. population will be over 65 by
Caring for elderly relatives or living independently will become a top concern for most Americans. Home care is projected to grow by 22.6% in the next decade.
Lowering the Medicare eligibility age from 65 to 60. If it passes, this will increase the participants in the Medicare program by an estimated 20 million.
$18 Billion for needed upgrades to VA hospitals. The average age of a VA hospital is 58 years. The private-sector hospitals median age is 11 years old. There are 1,700 VA hospitals and clinics with 69% are more than 50 years old. Additionally, nearly 100 VA sites, mostly in the western part of the country, need seismic correction. Other President Biden Healthcare Priorities There are several other healthcare topics that President Biden has added to his Agenda. • Expand coverage to Medicaid at the state level to provide access to almost 5 million additional individuals • Lowering drug costs for consumers by requiring drug companies to negotiate with Medicare, limiting drug price increases and import drugs to save costs • Ending surprise billing
Expand funding for mental health care through the ACA and bring parity between mental health and other healthcare services
Tax credits for eligible families who enroll in coverage through the Marketplace
Unfortunately, while these estimates may continue to change between now and when a final bill is passed, healthcare is not a meaningful part of the infrastructure bill. Given our recent experience during the pandemic with hospital capacity being overloaded, one would have thought that the infrastructure bill would have addressed this critical shortfall.
Collection agencies held $140 billion in unpaid medical debt in 2020, according to a study published July 20 in JAMA.
Researchers examined a nationally representative panel of consumer credit reports between January 2009 and June 2020. Below are four other notable findings from their report.
An estimated 17.8 percent of Americans owed medical debt in June 2020. The average amount owed was $429.
Over the time period studied, the amount of medical debt became progressively more concentrated in states that don’t participate in the Affordable Care Act’s Medicaid expansion program.
Between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in the average flow of medical debt that was 34 percentage points greater than the average medical debt flow in states that didn’t expand Medicaid.
In the states that expanded Medicaid, the gap in the average medical debt flow between the lowest and highest ZIP code income levels decreased by $145, while the gap increased by $218 in states that did not expand Medicaid.
Senate Democrats announced a compromise budget framework to fund President Biden’s social spending plans to the tune of $3.5T, including substantial money for some of the administration’s key healthcare priorities. The framework sends instructions to several Senate committees, including the Budget and Finance panels, to craft legislative language around the central components of the deal, with the goal of passing a spending package before next month’s recess.
Many specifics remain to be ironed out in negotiations among the party’s progressive and moderate camps, but some of the main elements of the deal became clear this week. The plan includes extending theenhanced subsidies for purchasing individual coverage on the healthcare marketplaces, which were implemented earlier this year as part of the American Rescue Plan Act. It would also seek to close the so-called “Medicaid coverage gap”, by providing new coverage options for low-income adults in states that did not expand Medicaid under the Affordable Care Act (ACA).
New investments would be made in home- and community-based services for long-term care, along the lines of the $400B proposed in President Biden’s American Families Plan. And the budget deal envisions expanding benefits in the Medicare program to include dental, vision, and hearing services. Given the budgetary concerns of moderate Democratic lawmakers like Sen. Joe Manchin (WV), one critical question will be how the $3.5T deal will be paid for. One likely source of funding for the deal will be reforming the way Medicare purchases prescription drugs, making that long-time Democratic policy objective a probable part of any final package.
Notably absent from the healthcare spending proposals: lowering the eligibility age for Medicare from 65 to 60. No final decision has been reached on whether to incorporate such a move; rather, the question will be sent to the Senate Finance Committee for consideration. Given the urgency of passing as much of the Biden administration’s legislative agenda as possible before the midterm campaign season begins in earnest, we think it’s unlikely that Democrats will be willing to cross the Rubicon of Medicare expansion at this point.
The prospect of having to gain support from all 50 Democratic senators—as zero Republicans are expected to support the package—will likely temper any appetite for picking a fight with the influential hospital and physician industries, which have strongly opposed Medicare expansion.
One longer-term implication of the apparent decision to favor expansion of Medicare benefits over lowering the Medicare eligibility age now:a richer package of services in traditional Medicare might make Medicare Advantage (MA) a less attractive alternative for potential enrollees and could undermine any future efforts to create an “MA buy-in” for coverage expansion.
Expect lobbying and negotiations to reach a furious pace over the next several weeks, as lawmakers work out the final details of the $3.5T spending plan.
Hospitals in the Dallas-Fort Worth region could collectively lose $1.1 billion in funding each year without a Medicaid waiver extension, a healthcare group warned, according to CBS Local.
The group, Texas Essential Healthcare Partnerships, represents 72 hospitals in the Dallas-Fort Worth region, including those operated by Dallas-based Tenet Healthcare and Houston-based Baylor Scott & White Health.
In April, CMS rescinded approval for a Section 1115 waiver to extend reimbursement to Texas hospitals for uncompensated care through September 2030. President Joe Biden’s CMS said that under the previous administration, CMS and Texas failed to adhere to public comment period requirements in the approval process, so it should be rescinded.
Don Lee, Texas Essential Healthcare Partnerships, told CBS he’s concerned about CMS’ decision to rescind the waiver next year and that hospitals could begin feeling the effects in just three months.
“There’s about $330 million of very important mental healthcare funding for mental healthcare services for the poor that will be lost starting in September of this year,” Mr. Lee told CBS Local.
Texas plans to resubmit its application to extend the 1115 waiver soon, according to the report. However, if the new application is not approved, Mr. Lee said that some hospitals in the North Texas region may be forced to close.
“We believe it’d be catastrophic, not just for the hospitals, but for all Texans,” Mr. Lee told CBS Local.
The Biden administration is quietly engineering a series of expansions to Medicaid that may bolster protections for millions of low-income Americans and bring more people into the program.
Biden’s efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration’s moves to scale back the safety-net program.
The changes could further boost Medicaid enrollment — which the pandemic has already pushed to a record 80.5 million. Some of the expansion is funded by the COVID-19 relief bill that passed in March, including coverage for new mothers.
Others who could also gain coverage under Biden are inmates and undocumented immigrants. At the same time, the administration is opening the door to new Medicaid-funded services such as food and housing that the government insurance plan hasn’t traditionally offered.
“There is a paradigm change underway,” said Jennifer Langer Jacobs, Medicaid director in New Jersey, one of a growing number of states trying to expand home-based Medicaid services to keep enrollees out of nursing homes and other institutions.
“We’ve had discussions at the federal level in the last 90 days that are completely different from where we’ve ever been before,” Langer Jacobs said.
Taken together, the Medicaid moves represent some of the most substantive shifts in federal health policy undertaken by the new administration.
“They are taking very bold action,” said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting in particular the administration’s swift reversal of Trump policies. “There really isn’t a precedent.”
The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting 12 holdout states, including Texas and Florida, to expand Medicaid coverage to low-income working-age adults through the Affordable Care Act.
And while some of the recent expansions – including for new mothers — were funded by close to $20 billion in new Medicaid funding in the COVID relief bill Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional money.
The White House strategy has risks. Medicaid, which swelled after enactment of the 2010 health law, has expanded further during the economic downturn caused by the pandemic, pushing enrollment to a record 80.5 million, including those served by the related Children’s Health Insurance Program. That’s up from 70 million before the COVID crisis began.
The programs now cost taxpayers more than $600 billion a year. And although the federal government will cover most of the cost of the Biden-backed expansions, surging Medicaid spending is a growing burden on state budgets.
The costs of expansion are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who frequently argued for enrollment restrictions and derided Medicaid as low-quality coverage.
But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, can’t make up for all the inadequacies in government housing, food and education programs.
“Focusing on the social drivers of health … is critically important in improving the health and well-being of Medicaid beneficiaries. But that doesn’t mean that Medicaid can or should be responsible for paying for all of those services,” said Matt Salo, head of the National Association of Medicaid Directors, noting that the program’s financing “is simply not capable of sustaining those investments.”
Restoring federal support
However, after four years of Trump administration efforts to scale back coverage, Biden and his appointees appear intent on not only restoring federal support for Medicaid, but also boosting the program’s reach.
“I think what we learned during the repeal-and-replace debate is just how much people in this country care about the Medicaid program and how it’s a lifeline to millions,” Biden’s new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN, calling the program a “backbone to our country.“
The Biden administration has already withdrawn permission the Trump administration had granted Arkansas and New Hampshire to place work requirements on some Medicaid enrollees.
In April, Biden blocked a multibillion-dollar Trump administration initiative to prop up Texas hospitals that care for uninsured patients, a policy that many critics said effectively discouraged Texas from expanding Medicaid coverage through the Affordable Care Act, often called Obamacare. Texas has the highest uninsured rate in the nation.
The moves have drawn criticism from Republicans, some of whom accuse the new administration of trampling states’ rights to run their Medicaid programs as they choose.
“Biden is reasserting a larger federal role and not deferring to states,” said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.
But Biden’s early initiatives have been widely hailed by patient advocates, public health experts and state officials in many blue states.
“It’s a breath of fresh air,” said Kim Bimestefer, head of Colorado’s Department of Health Care Policy and Financing.
Chuck Ingoglia, head of the National Council for Mental Wellbeing, said: “To be in an environment where people are talking about expanding health care access has made an enormous difference.”
Mounting evidence shows that expanded Medicaid coverage improves enrollees’ health, as surveys and mortality data in recent years have identified greater health improvements in states that expanded Medicaid through the 2010 health law versus states that did not.
In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has backed a series of expansions to broaden eligibility and add services enrollees can receive.
Biden supported a provision in the COVID relief bill that gives states the option to extend Medicaid to new mothers for up to a year after they give birth. Many experts say such coverage could help reduce the U.S. maternal mortality rate, which is far higher than rates in other wealthy nations.
Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.
The COVID relief bill — which passed without Republican support — also provides additional Medicaid money to states to set up mobile crisis services for people facing mental health or substance use emergencies, further broadening Medicaid’s reach.
And states will get billions more to expand so-called home and community-based services such as help with cooking, bathing and other basic activities that can prevent Medicaid enrollees from having to be admitted to expensive nursing homes or other institutions.
Perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push the government health plan into covering services not traditionally considered health care, such as housing.
This reflects an emerging consensus among health policy experts that investments in some non-medical services can ultimately save Medicaid money by keeping patients out of the hospital.
In recent years, Medicaid officials in red and blue states — including Arizona, California, Illinois, Maryland and Washington — have begun exploring ways to provide rental assistance to select Medicaid enrollees to prevent medical complications linked to homelessness.
The Trump administration took steps to support similar efforts, clearing Medicare Advantage health plans to offer some enrollees non-medical benefits such as food, housing aid and assistance with utilities.
But state officials across the country said the new administration has signaled more support for both expanding current home-based services and adding new ones.
That has made a big difference, said Kate McEvoy, who directs Connecticut’s Medicaid program. “There was a lot of discussion in the Trump administration,” she said, “but not the capital to do it.”
Other states are looking to the new administration to back efforts to expand Medicaid to inmates with mental health conditions and drug addiction so they can connect more easily to treatment once released.
Kentucky health secretary Eric Friedlander said he is hopeful federal officials will sign off on his state’s initiative.
Still other states, such as California, say they are getting a more receptive audience in Washington for proposals to expand coverage to immigrants who are in the country without authorization, a step public health experts say can help improve community health and slow the spread of communicable diseases.
“Covering all Californians is critical to our mission,” said Jacey Cooper, director of California’s Medicaid program, known as Medi-Cal. “We really feel like the new administration is helping us ensure that everyone has access.”
The Trump administration moved to restrict even authorized immigrants’ access to the health care safety net, including the “public charge” rule that allowed immigration authorities to deny green cards to applicants if they used public programs such as Medicaid.In March, Biden abandoned that rule.