Updated on June 26, 2017
For over 50 years, Medicaid has provided cost-effective coverage for medically necessary services to millions of low-income children, pregnant women, people living with disabilities, and seniors. Today, Congressional Republicans and the President propose dramatic changes to end Medicaid as we know it, to instead give wealthy people tax cuts. Their plans would lead to 23 million uninsured people by 2026 — in large part by eliminating Medicaid coverage for 14 million people.
As public health professionals, we’re uniquely positioned to advocate against these devastating changes: we know the importance of having access to health care when someone is ill or injured, and the value of getting services and advice that help families stay healthy. We believe that all people — especially children and disadvantaged adults — should have access to health care regardless of their income. Let’s use our voices to protect health care for all children and adults!
This resource, produced by Public Health Awakened, is intended to help health department staff and other public health professionals protect health and equity in the face of devastating changes to Medicaid.
In here, you will find:
Medicaid works — and it works well. Today, 81 million people in the US get health coverage through Medicaid, the state-federal partnership that ensures access to life-saving health care for low-income children and adults, as well as people with disabilities and seniors (Medicaid and CHIP Payment and Access Commission, 2017). This includes nearly 2 in 5 children in the US, 36 million children in households that already struggle to make ends meet, as well as children and adults with disabilities. Medicaid covers almost half of all births in the US (Kaiser Family Foundation, 2017). It also covers seniors for costs that Medicare may not cover — such as nursing homes. Nearly 1 in 10 people using Medicaid is a senior (Kaiser Family Foundation, 2016).
Currently, a person who is eligible for health care coverage through Medicaid can get that coverage. This includes people who the federal government says must be covered and those whom states have the option to cover (Centers for Medicare and Medicaid Services, 2017). This idea that people who are eligible have a right to coverage is the same in Medicare, which along with Medicaid supports elderly Americans (Medicaid and CHIP Payment and Access Commission, 2017). To pay for Medicaid, state and federal governments jointly fund the program. The amount of federal funding to states can increase or decrease along with health care costs, as the population ages, or as more or fewer people need coverage, such as during times of economic downturn (Kaiser Family Foundation, 2017).
Instead of strengthening the current Medicaid program, Republicans are suggesting drastic changes to cut it. These changes will effectively take away coverage from people who already have it and/or will force states to limit the services they provide. The proposals cap the amount of money the federal government provides to states, instead of the current system that is responsive to what people living in those states need.
Proposals being considered use two mechanisms — per capita caps and block grants. Both would drastically reduce coverage, benefits, and affordability for millions of at-risk children and adults by setting limits to what the federal government contributes to state Medicaid programs, regardless of need or changes in health care costs (Center on Budget and Policy Priorities, 2016; Congressional Budget Office, 2012; Families USA, 2017). Instead of saving money, it will shift the burden from the federal government to states or even the people who use the programs.
See the last section of this resource, “Nuts and Bolts: What are Republicans Proposing?” for specifics on how Medicaid is funded and proposed changes to that funding.
Changes to Medicaid will happen through 2 main routes: healthcare “reform” and federal budget cuts.
Educate your community and elected officials about potential health impacts of proposed changes to Medicaid for your state — or more locally if you can access that data.
For example, using Kaiser Family Foundation identify the number of people in your state covered by Medicaid — including children, pregnant women, people living with disabilities, seniors, and people with chronic illnesses. Or cite info on Medicaid use by Congressional district. If you can access local data and stories, do it! Use these data and stories to highlight: benefits of expansion if your state expanded Medicaid under ACA, how dismantling Medicaid would affect the health of individuals and families, and how undoing it undercuts the health care system (e.g., community health clinics, rural hospitals).
Encourage elected officials to whom you report to take a position on the proposed changes to Medicaid. Once they have, see if your health department can speak publicly about its position.
Talk with your jurisdiction’s legislative/policy staff and/or elected officials to ensure policy makers hear the department’s concern about the proposed changes to Medicaid. Encourage them to take a formal position on the proposals. If they do take a formal position, use your platform at the health department to ensure people know about it and amplify the message.
Mobilize professional associations and advocates to take a position and provide them with data.
Work with professional associations like national, state, and local chapters of the American Public Health Association or the National Association of City and County Health Officials to communicate the impacts of the proposals to legislators. Provide local advocacy organizations with data, helping them understand how to request data from the health department as necessary, so they can make the case to local elected officials.
Hold workshops for community members.
Public health departments can host public workshops that help people to understand Medicaid and the AHCA. Host a workshop so community members know how changes may affect them.
Attend Congressional Town Hall events and community meetings.
When members of Congress host town hall events and community meetings in home districts, ask about their plans for Medicaid and the AHCA. Visit Organizing for Action’s Toolkit for guidance on doing this during Congressional recesses. Identify yourself as a public health professional, share information from this document or information about local impacts, and ask how elected officials are protecting health.
Reach out to elected officials — repeatedly and often.
Write letters with health colleagues through professional organizations like the American Medical Association and American Public Health Association or call and visit the offices of Congressional and local elected officials. Inform them on how pending decisions will change health and equity. This resource can be a starting point.
Get proactive — call for strengthening Medicaid.
Read the evidence, join the discussion, and help advocate for strengthening instead of dismantling Medicaid. Put another choice on the table. Look for opportunities to partner with other groups or agencies with similar goals.
Start with values — for example, you can say:
“No matter our differences, most of us want pretty similar things — to go through our lives in good health and to get quick, effective, compassionate care if we’re ever sick or injured.”
“Most of us can agree on the basic principle that we all should be able to see a doctor, be treated for an illness, or get care to prevent us from being sick in the first place — regardless of how much money we earn. All children should have health care, and people with disabilities, people with chronic conditions, seniors, and those in great need should get the care that is essential to helping them live.“
“Medicaid embodies these principles. And it works well.”
Here are some key points you can make about what Medicaid looks like today:
Proposed changes to Medicaid will lead to:
The rationale for radically changing Medicaid does not stand up to scrutiny. There are 2 main and misguided criticisms:
First, critics suggest that Medicaid “does not work” because reimbursement is too low and many health providers will not treat Medicaid patients. That is incorrect — reimbursement rates are currently set by states, not the federal government. Further, compared with similar people without coverage, people with Medicaid are more likely to have a regular source of care, receive needed health care services, and have better health outcomes (Center on Budget and Policy Priorities, 2017).
Second, critics suggest that the federal government takes a “one size fits all” approach to Medicaid, while states need flexibility to meet local needs. Again, this is a misrepresentation — states already have a lot of flexibility about whom they cover, what benefits they provide and how health care services are delivered. The federal government sets minimum standards in these areas. States are free to set their own rules as long as they meet the minimum standards. As a result, Medicaid eligibility and benefits vary substantially from state to state. In addition, states can obtain waivers from certain minimum standards to implement other alternative approaches to meeting the needs of their low-income children and at-risk adults. So states already have a large degree of flexibility. Federal standards are important, however, for ensuring that state programs provide a minimum benefit level to participants and cover the people who are most at-risk.
Congress created the Medicaid program in 1965 with legislation supported by both sides of the political aisle, but attempts to overhaul Medicaid began under President Reagan in the 1980s. Starting in 2010 and every year since then, Republican majorities in the House have proposed major changes to Medicaid, starting with Rep. Paul Ryan’s suggestion to slash spending for Medicaid and similar programs in his “Roadmap to Prosperity.” Often, the motivation is to cut taxes significantly for the wealthy — the 1%, the 0.1% — and for corporations. Since those tax cuts mean an out-of-balance budget, many Republicans have suggested instead taking away services like Medicaid for people who earn low incomes.
Currently, states and the federal government jointly fund Medicaid. The federal government pays at least 50% of the cost, and beyond that it varies by state, with the federal government paying a larger share in states with more low-income residents (Center on Budget and Policy Priorities, 2016; Kaiser Family Foundation, 2017). Medicaid is better able to control healthcare costs than private insurance, providing more comprehensive benefits at 22% lower costs. Over the past 30 years, Medicaid’s annual cost growth rates have been 40% lower than for private insurers. Moreover, people who get health coverage through Medicaid — including lower-income people who often have worse health and greater health care needs than higher-income people — are overwhelmingly satisfied with their coverage, and are more satisfied than people covered with private insurance (Center on Budget and Policy Priorities, 2016; America’s Health Insurance Plans, 2016).
Many Republicans are proposing to change Medicaid’s financing structure from guaranteeing federal money that covers medically necessary services to instead capping how much the federal government gives to states. There are 2 possible ways to do this that are being discussed: through what is known as a “block grant” or a “per capita cap”. There are nuances and differences to each, but the two options share many harms to health. Both block grants and per capita caps are forms of “caps” that would drastically reduce coverage, benefits, and affordability for millions of at-risk children and adults by setting limits on what the federal government can contribute to state Medicaid programs, regardless of need or changes in health care costs. The caps would be based on 2016 average rates.
Although increasing with overall inflation, they would not rise with health care cost inflation (which is higher than regular inflation) — meaning the federal government would be forced to contribute less and less to states relative to the states’ rising costs.
The block grant program proposed in the House’s AHCA bill gives states the option to shift low-income children and adults (but not senior citizens and other Medicaid enrollees with disabilities) to a new Medicaid block grant. This is incredibly harmful to residents. States would no longer have to cover the comprehensive pediatric benefit that federal law currently requires (known as EPSDT, Early and Periodic Screening, Diagnostic, and Treatment, including developmental and preventive screenings, like lead testing); they could charge people unlimited premiums, deductibles, and copayments; and they could limit the number of children or adults who enroll (Sharfstein, 2017).
Because the federal government would be forced to limit its contributions to states, and not increase at the same rate as health care costs nor grow as the population ages and its health care needs increase, states would have to either find other funds to cover the shortfall or, as is most likely given state budgets, cut services or the number of people covered, or charge participants more. (Center for Budget and Policy Priorities, 2017; Park & Solomon, 2016; Holahan, et al., 2017). States may also cut back on Medicaid funding for school-based health services, which were $4 billion in 2015 that funded staff such as school nurses, school counselors, and speech therapists.
Starting in 2020, the AHCA in particular also would end enhanced federal Medicaid payments that let states expand Medicaid as part of ACA under the Obama administration. The non-partisan Congressional Budget Office estimates that 95% of people enrolled in Medicaid through the ACA would lose coverage by the end of 2024 (Congressional Budget Office, 2017).
Together the capped federal payments, block grant option, and abrupt ending of enhanced Medicaid payments would lead to an estimated 14 million people would have Medicaid coverage taken away — a large chunk of the estimated 23 million more people who would be uninsured under the House’s proposed AHCA bill — and millions more people experiencing reductions in coverage and/or increases in out of pocket costs specifically because of Medicaid changes (Kaiser Family Foundation, 2017; Congressional Budget Office, 2017).
If you have questions or edits, please email: email@example.com. Our thanks to Anat Shenker-Osorio for messaging suggestions included in this brief.