Even as litigation and rulemaking threatens the nation’s progress under the Affordable Care Act (ACA), the 2020 presidential campaign has put proposals for the future of health care coverage front and center. The New York Times, CBS News, and National Public Radio were among the news media who led their coverage of the September 12 debate by featuring the Democratic candidates’ clashes over their competing approaches. These include adding a public option to the ACA marketplace framework,  “Medicare for choice” or “for all who want it,” and “Medicare for All” either single payer or preserving a role for employer-paid insurance. Cost estimates range from $740 billion to $30 trillion over ten years. 

But Medicaid – the national health coverage program for low-income individuals – was mentioned just once in the latest debate, when former Vice President Biden said that someone who qualifies for Medicaid would be automatically enrolled in his “Medicare for choice” plan. But that would mean eliminating Medicaid, a program that provides coverage to millions of Americans. Why aren’t more people talking about the problems this could create? 

Drew Altman of the Kaiser Family Foundation criticizes the “radio silence about eliminating Medicaid,” and George Washington University Law Professor Sara Rosenbaum and attorney Stephen Warnke lament in an op-ed that the consequences for Medicaid have “gone virtually undiscussed” even though “the future of Medicaid — regardless of how people are insured — is as serious a health policy issue as they come.” What’s so important about Medicaid?

Why Medicaid is vital.

Medicare covers about 14% of Americans – those who are over age 65, are blind, or have disabilities and  who qualify based on their Social Security earnings record. Medicare enrollees must pay  monthly premiums, annual deductibles, and cost-sharing that can be expensive. Medicaid, on the other hand, covers 21% of Americans. It is available to low income individuals and imposes minimal out-of-pocket costs.  Rosenbaum and Warnke highlight the too-little-acknowledged benefits of Medicaid not just to its recipients, but to the health care system as a whole, including:

• Medicaid serves disproportionately people of color in the most vulnerable communities with higher health risks and shortages of services.
  
• “Countless studies” have shown that Medicaid improves access and outcomes, reducing health inequities between the rich and the poor.
  
• Medicaid is able to adapt to local conditions and respond quickly during crises. “It is in all states a public health first responder,” for example, providing extra resources to communities hit by mass shootings, the Zika virus, and the opioid epidemic.
  
• “Medicaid investments underpin the healthcare infrastructure in at-risk communities, keeping their clinics and hospitals stable and able to function. In these respects, every insurer, including Medicare, relies on Medicaid as the foundation for its operations.”
  
• Uniquely, Medicaid allows people to enroll when they need care, and get some retroactive coverage.

How might Medicaid change under the various Democratic proposals?

The Kaiser Family Foundation (KFF) offers a detailed side-by-side comparison of the ten bills introduced so far in this Congress, including a review of how each might affect Medicaid 

• Single-payer or Medicare-for-All bills introduced by Sen. Sanders and Rep. Jayapal would completely or nearly completely replace Medicaid.
• Reps. DeLauro and Schakowsky’s Medicare for America public plan with opt out would “gradually” replace Medicaid by steps that include requiring states to enroll all individuals on their waiting lists for Medicaid home and community-based services and increasing federal matching payments to bring states’ Medicaid reimbursement rates up to Medicare for America levels.
• Several bills adding a public option to the ACA marketplace would not make any changes in Medicaid.
• Sen. Schatz and Rep. Lujan’s State Public Option bill would extend 100% federal funding for three years to states newly adopting the Medicaid expansion, allow states to “buy in” to Medicaid (charging premiums based on income) uninsured individuals with above Medicaid-expansion level incomes, requires states to raise Medicaid reimbursement levels to Medicare levels, improve standards for access to Medicaid providers, and mandate comprehensive reproductive coverage including abortion.

KFF’s Issue Brief summarizes how the Sanders and Jayapal bills (endorsed by three other candidates, and Senator Harris’s approach to Medicare for All would or might affect people who get Medicaid.  

What’s vital to retain?

KFF’s issue brief reminds us that “there will be trade-offs” in any eventual reform, and the National Health Law Program’s (NHeLP’s) Jennifer Lav and Hector Hernandez Delgado emphasize the essential elements of today’s Medicaid that any new legislation must include so as not to sacrifice the distinct needs of low-income and underserved people. They begin by linking to NHeLP’s series of deeper explanations of “What Makes Medicaid, Medicaid?”:

• More comprehensive benefits than in Medicare and most private insurance, such as long-term care, outpatient prescription drugs, reproductive services, and enhanced screening, diagnostic, and treatment for children
  
• Strict affordability protections limiting all out-of-pocket costs
  
• Rights to due process, which includes benefits “sufficient in amount, duration, and scope to reasonably achieve their purpose,” delivered “reasonably promptly,” and fairly to people with similar needs; consumer rights in managed care; written notice of decisions about eligibility and services; hearings to contest adverse decisions and keep benefits going during that process; and the right to ultimately seek remedies in court.
• Non-emergency transportation to medical appointments, “practically unheard of in employer-sponsored insurance. …For most people, a two-dollar bus fare is not a barrier to health care; but for those without two dollars, it is–and can result in delay or postponement of necessary services.”

Then, to guard against losing what makes Medicaid Medicaid, they cite NHeLP’s Guideposts and Principles for evaluating new health care proposals, encouraging other advocates to use them. These guideposts and principles go well beyond preserving the core of Medicaid, to expanding coverage, reducing health disparities, protecting against discrimination, ensuring language services, addressing social determinants of health, promoting quality and accountability, and enhancing the rights to pursue remedies in court. And they conclude with the reminder: “Protecting people’s health must override market incentives, profit interests, or any other factor.”

No major positive reform has a chance of being enacted during this Congress and presidential term, and while not highlighting their effects on Medicaid, the initial versions of Medicare for All and the public option bills all appear fairly careful not to weaken it. If an Appeals Court were to strike down the ACA,  that could spur the Democratic-majority House to advance a bill. NoHLA will monitor signs of movement, and we recommend that advocates use the resources cited here to raise the visibility of Medicaid at opportune times with candidates, their supporters, news media, and every interested audience.  We can help lay the groundwork to prevent any trade-offs that could undermine the elements that make Medicaid indispensable to low-income people as we move toward a just, effective health care system for all.

– Charlie Mitchell, NoHLA Senior Staff Attorney