Find and work with Allies to Protect Medicaid
Medicaid will be a major focus of the incoming Trump Administration and the 119th Congress. Republicans can make significant changes to Medicaid with a simple majority vote using the budget reconciliation procedure. Previous proposals are being discussed again, including radically restructuring Medicaid funding through block grants or cap per capita. Other proposals include reducing the federal funding for Medicaid expansion, and imposing work requirement. All of these proposals will lead to funding cuts and coverage loss. Protecting Medicaid could ultimately come down finding support from a few Members of the House or Senate who support Medicaid and its millions of enrollees. Reaching out to traditional and nontraditional allies of Medicaid is a key strategy. These important Medicaid stakeholders have considerable influence in Congress and state government, and could be key in protecting Medicaid.
Managed care companies
– More than two thirds of Medicaid enrollees nationally receive their health care services from managed care organizations (MCOs), which operate in forty-two states and the District of Columbia. In 2022, the combined revenues of three Medicaid managed care companies will total $181.8 billion. Sometimes, advocates and managed care companies are at odds. For example, over care denials. MCOs can be powerful allies in a variety of issues, from Medicaid expansion to continuous eligibility. Centene, which operates Medicaid MCOs in thirty states, has already started lobbying Republicans to preserve federal health care programs.
Advocates should reach out to MCOs in their states to discuss the harms of Medicaid funding cuts, and start strategizing. Some advocates already have good working relationships with MCOs via their state Medicaid Advisory Committees. MCOs are not only facing a loss of revenue and enrollees due to cuts in Medicaid eligibility. Health insurers are well represented in state and federal capitols. Their influence could be instrumental in defeating Medicaid funding cuts, often offered under the guise of “flexibility.”School districts
– Medicaid is an important source of funding for health care services provided in schools. Medicaid has been paying for eligible school health care services that are part of students’ Individualized Education Programs or Individualized Family Service Plans (IFSP) for more than 30 year. A survey by AASA, The School Superintendents Association found that almost 70% of school districts rely on Medicaid to pay for the salaries of health professionals who provide services to students. Medicaid funding is also used by schools to support assistive technology, and transport students with disabilities. Proposals to cut Medicaid funding could significantly impact local school districts that are already coping with budget constraints.
A study of the 2017 Republican proposals to impose Medicaid block grants or per-capita caps found that districts would lose much of their funding for Medicaid. Children with disabilities, who depend on school-based support, would feel the greatest impact. Medicaid also pays for mental health supports for children, including crisis interventions responding to school shootings.
Cuts in federal Medicaid funding could lead localities to scale back other educational services and/or increase property taxes to help offset the funding loss. Advocates should alert their local school boards and Superintendents of the looming threat of Medicaid funding. Health care professionals – State Medical Societies and other health care provider organizations are highly influential in state legislatures and state congressional delegations. The American Academy of Pediatrics has long opposed proposals for Medicaid funding cuts. The National Rural Health Association and American Hospital Association also opposed Medicaid block grants.
Advocates should reach out to their state medical societies and other health care professional organizations to urge them to oppose Medicaid funding cuts and share concerns with state and federal elected officials.
Governors and state insurance commissioners
Governors and state insurance commissioners often have significant influence with state congressional delegations. If these officials oppose proposals to cut Medicaid due to, for example, the impact of cuts on states’ budgets or health insurance rates, or at lease raise concerns, that could be enough to convince a Member of Congress or Senator to vote no.For example, in 2017, Arizona’s Republican Governor Doug Ducey raised concerns with the Republican proposal to cap Medicaid funding, writing “…
his policy change will result in the single largest transfer of risk ever from the federal government to the states.” In fact, block grants and per capita caps actually give states less flexibility in their Medicaid programs by reducing federal funds and forcing states to make up the difference.
State insurance commissioners may share concerns that Medicaid funding cuts and coverage losses would increase the number of uninsured persons, leading to uncompensated care, increased emergency department use, and greater instability in the private insurance market. Washington State’s Insurance commissioner Mike Kreidler, and Governor Jay Inslee, wrote that reform proposals “must not cause our people to be without coverage and that won’t destabilize our insurance markets, increase premiums, or drive up uncompensated costs.” If Congress does not extend more generous PTCs then premiums will increase and millions of people will lose their insurance coverage. The combination of Medicaid cuts and ACA Marketplace coverage losses could upend state health insurance markets, with potentially catastrophic results.
Advocates should reach out to their Governors and State Insurance Commissioners. As one example, in 2016, over 120 Illinois advocacy organizations joined a sign on letter to Republican Governor Rauner underscoring the importance of Medicaid and opposing proposals to cut the program.
Corrections and law enforcement
Under the federal “inmate exclusion,” states cannot use federal Medicaid funds for health care services for adults and youth who are incarcerated. In 2018, Congress authorized the Centers for Medicare and CHIP Services (CMS), to provide guidance on how to use Section 1115 waivers in order to provide transitional services to incarcerated people. At least nineteen states have approved “re-entry” waivers, while many more have waivers pending approval or in development. To date, at least nineteen states have approved “re-entry” waivers while many more have waivers pending approval or in development.[T]The availability of Medicaid funding for re-entry services has led to an important potential ally in fight to save Medicaid – law enforcement:
In a 2021 letter to Congress, National Sheriffs’ Association President Sheriff Dave Mahoney stated that Medicaid services for returning citizens “is an important part of the continuum of care for those with medical needs. This will reduce recidivism, and thus ease the budgetary burden on the jail system. Our taxpayers deserve that.”
In comments supporting their state’s Section 1115 proposal, the Massachusetts’ Sheriffs’ Association wrote, “Expanding the health coverage for eligible incarcerated individuals can and will change lives.”
Vermont’s Chief of Staff for the Department of Corrections Isaac Dayno described Medicaid as “a very cost-efficient system as opposed to private, for-profit health care, which corrections systems have relied on.”
Advocates in states with approved or pending re-entry waivers should reach out to state and local law enforcement to alert them to the potential loss of federal funding if Congress cuts the Medicaid program. Law enforcement statements opposing Medicaid funding cuts could persuade key legislators to vote no.
Medicaid enrollees/disability rights advocates
Medicaid enrollees are the most important, and most effective voices in defending the program from funding cuts. Medicaid enrollees in some states are actively organizing. One example is the Nonviolent Medicaid Army. Disability rights activists including ADAPT were instrumental in defending Medicaid when the Republican party tried to cut it. HIV/AIDS activists, people with ALS and others protested to bring the impact of Medicaid cuts into focus. Those efforts were also bolstered by anti-poverty advocacy like the Poor People’s Campaign.
- Medicaid enrollees and their caregivers can also share their stories of how important the program is. State advocacy groups are able to ethically collect stories that they can share with policymakers and media. In addition, several national health advocacy have story collection projects, including Families USA and Community Catalyst.
- Advocacy efforts to protect Medicaid should center the experiences of people enrolled in Medicaid, and their caregivers. Members of Congress often return to their districts during recess and participate in community events such as town halls. Medicaid enrollees, advocates and other stakeholders can use these opportunities to make their voices heard. It will require a concerted effort from enrollees and advocates, providers, as well as other stakeholders. Protect Medicaid!
