The Authoritarian Project 2020 Agenda Endangers Medicaid and The Affordable Care Act
The upcoming election in November will have a significant effect on health care across the country. Candidates at the federal and states levels may propose policy proposals that could have a profound impact on health law and policies in 2025. Follow along with NHeLP through Election Day as we explore opportunities and threats to health care in the United States. Follow along with NHeLP as we explore the opportunities and threats to the health care system in the United States. This wide-ranging far-right, anti-science, and anti-democratic agenda includes numerous proposals that endanger the future of Medicaid, the Affordable Care Act (ACA), and health-related civil rights laws and policies.
Project 2025 seeks to eviscerate access to care for Medicaid beneficiaries Since 1965, Medicaid has played a crucial role in the struggle for equitable health care coverage in the United States (U.S.). By May 2024, Medicaid would have provided vital and often lifesaving coverage for more than 73.9 millions people with low incomes. This included Black, Indigenous and People of Color, people with disabilities and LGBTQI+ people. Women and young people were also covered. Project 2025’s recommendation put the future of Medicaid at risk. (
1). Project 2025’s recommendations would likely reduce Medicaid coverage for millions with low incomes in the United States.
One feature of Medicaid is that it’s an entitlement program. Federal financial assistance to states are tied to the cost of care provided by beneficiaries. Project 2025, after criticizing federal Medicaid spending, recommends that states fundamentally restructure Medicaid from an entitlement program to a block grant program or impose per capita limits (Project 2025, at 466). Policymakers have historically sought these reforms in order to severely cut Medicaid funding to states.
Project 2025 also proposes a parade of horribles for Medicaid eligibility reform. It is true that nearly all Medicaid recipients who are able to work do so. However, Project 2025 recommends allowing the states to impose Medicaid Work Requirements (467-468), a requirement that involves administrative red tape and burdensome paperwork. This would violate the Medicaid Act. According to a Congressional Budget Office estimate for 2023, these requirements will likely kick out millions of people who have low-wage jobs, putting their health and ability stay employed at risk. Many studies show that state caseworkers refuse to grant exemptions from public benefit work requirements for people who are eligible, such as pregnant women and people with disabilities. Project 2025 would also limit the time that people with low incomes could receive Medicaid coverage in their lifetimes (468). It would also allow states to “strengthen” asset tests (467), which likely would discourage savings among people concerned about losing benefits and impose burdensome paperwork verifications on people applying or renewing coverage.
Project 2025 also criticizes federal incentives for states to expand Medicaid coverage, proposing to replace enhanced federal matching funds with a “more rational match rate” (466-467). Conservatives have traditionally sought to reduce federal funding of Medicaid by cutting federal matching rates. It also recommends “flexibility” to eliminate outdated mandatory and optional benefits requirements (468). Together, these reforms could cause states to backslide in covering people who fall into optional eligibility categories. This includes Medicaid expansion, which, as of June 20, 2023, covered over 23,000,000 people with low-incomes across the country. As I discuss further below, these reforms could also prompt state backsliding on coverage of Medicaid’s current mandatory benefits, such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for kids, and optional benefits, such as prescription drugs.
Project 2025 recommends allowing states to make unilateral changes to their Medicaid programs without waivers or State plan amendments and thus, without federal oversight or public comment (468-469). Project 2025 would also allow states to contribute to a private insurance benefit for Medicaid eligible-individuals, which could leave families with low incomes without critical Medicaid protections (468).
The radical agenda also proposes to restore the Trump-era public charge rule (145), which was designed to make mixed-status immigrant families who are eligible for Medicaid under federal law afraid to apply or stay enrolled.
2). Project 2025 would eliminate sexual, reproductive and gender-affirming access to health care in Medicaid.
As a part of its overall strategy to end abortion coverage everywhere, Project 2025 suggests codifying the Hyde Amendment’s severe restrictions in Medicaid and other programs (474). It also recommends using the Comstock Act (562), and “fetal persons” (6), to criminalize abortion nationwide. The playbook suggests withholding federal Medicaid funding for states that require abortion coverage under private insurance (472,493). The playbook proposes to withdraw federal Medicaid funding for states that require abortion coverage in private insurance (472, 493). This proposal is based on the same overly broad interpretation of the Weldon Amendment used by the Trump-Pence Administration to justify withholding federal Medicaid funding for California despite its documentation and prior federal findings that it’s abortion coverage requirement complied federal law. Project 2025 would rescind a 2021 legal analysis which restored Medicaid funding to California (493).
As previously discussed, Project 2025’s recommendations could lead states to reduce or eliminate Medicaid coverage of mandatory benefits like family planning services and supplies (468) Project 2025 would also expand and exploit CDC’s abortion monitoring program, making participation by states mandatory. It recommends that despite the fact abortion is a safe and essential health care, states must report on pseudo-scientific and stigmatizing information about “abortion survivors”, “abortion related maternal deaths”, “abortion complications” and “children born alive after an abortion” (455-456). Project 2025 also endorses a federal law that would require states to comply with the new abortion surveillance regulations in order to continue receiving federal funding for Medicaid services and supplies (456). Thus, states would have to make an impossible choice: submit data that the Administration could use to bolster abortion criminalization efforts, especially for BIPOC, people with disabilities, immigrants, and other underserved communities, or lose the largest source of public funding for family planning services altogether.
Finally, federal law requires Medicaid coverage of gender-affirming care, evidence-based, clinically appropriate, safe, effective, and often life-saving health care. Project 2025, however, seeks to restrict the access to gender-affirming treatments, referring them as “experimental”, and indicating support for policies requiring parental consent for youth gender-affirming treatment (333).
3). Project 2025 endangers Medicaid coverage for people with disabilities
Project 2025’s attack on federal mandatory and optional benefit requirements (468) endangers the health and lives of people with disabilities. Medicaid’s mandatory benefits, such as nursing facility services and home health services for low-income disabled people, provide them with essential care. Similarly, Medicaid’s optional benefits, such as prescription drugs, home and community based services, and mental health services for adults, provide lifesaving care to people with disabilities.
Project 2025 also recommends redesigning eligibility, financing, and service delivery for long-term care services and supports (LTSS), which encompass the wide range of medical and personal care services that assist disabled people with critical activities of daily living (e.g., eating, bathing, dressing, medication management, meal preparation) (468). The playbook recommends restructuring the LTSS to “serve the most vulnerable and truly in needy and eliminate middle and upper-income Medicaid beneficiaries” (id.). ), implying that many disabled people who rely on Medicaid LTSS for care do not truly need access, and suggesting that they intend to drastically cut eligibility for these services.
Finally, Project 2025 recommends restoring prior regulations on Section 504 of the Rehabilitation Act (495). The U.S. Department of Health and Human Services, or HHS, finalized these regulations earlier this year for the first since 1977. They were comprehensive, vital and long overdue updates. The 2024 final rule clarifies important protections against discrimination based on disability in programs and services funded by HHS. Rolling back these reforms would be a devastating loss for disabled Medicaid beneficiaries.
Project 2025’s recommendations would gut the ACA’s protections
Project 2025 aims to gut HHS’s 2024 final rule clarifying protections under Section 1557 of the ACA, which bans health care discrimination on the basis of race, color, national origin, sex, disability, age, and any combination thereof (475). It recommends, in particular, rolling back regulations that define prohibited discrimination against women, such as discrimination on the basis of gender identity, sexuality, pregnancy or other conditions, sex stereotyping, and sex features, including intersex (id. 495-496). These regulations will prevent sex discrimination and intersectional racism in sexual, reproductive and gender-affirming health care. Project 2025 recommends the Department of Health and Human Services remove the 2022 guidance it issued to pharmacies following Dobbs. This guidance clarified Sections 1557 and Sections 504 of Rehabilitation Act protections against discriminatory post Dobbs denials of prescribed drugs for chronic conditions and sexual and reproductive healthcare (496). It also seeks exemptions from the ACA contraceptive mandate (483), which will dramatically limit contraceptive availability across the country. It would expand “junk health plans” (short-term, limited-duration plans) that don’t comply with the ACA protections (470). Project 2025 also seeks to separate unsubsidized and subsidized health plans into separate marketplaces, making it more difficult for people to compare the scope and quality of various plans (469). Project 2025 also seeks to separate unsubsidized and subsidized health plans into separate marketplaces, making it more difficult for people to compare various plans’ scope and quality (469).
Project 2025 directs the administration to reissue a 2019 Final Rule (473) that essentially made ACA’s modest protections for people to access abortion coverage meaningless, with devastating effects on health and economic futures. Project 2025’s anti-science agenda also conflates emergency contraception with abortion, and proposes to eliminate coverage of emergency contraception under the ACA’s contraceptive requirement (485). Further, the extremist playbook aims to undermine the ACA’s women’s preventive services mandate, which requires most health plans to cover recommended preventive services without cost-sharing, by narrowing coverage of evidence-based care and restoring ideologically driven and antiscience recommendations from the past (484-485).
Conclusion
This blog post previews just some of the looming federal threats to Medicaid, the Affordable Care Act, and health-related civil rights. NHeLP uses federal administrative advocacy and Congressional advocacy to fight federal attacks such as Medicaid work-requirements, block grants and per capita limits; efforts to repeal and replace the ACA and proposals to gut the health-related civil right (e.g. Section 1557 of ACA). We provide legal analysis to defend our organization’s comments, as well as template comments for partner groups and coalition sign-ons. We also develop comment portals to allow the public to tell their stories through our My Care Counts Campaign. We also fight federal threats against Medicaid, such as cuts, using litigation, administrative complaints, or other legal strategies. This work includes the Health Law Partnerships Program, where we partner with 22 experienced state-based advocates in order to strengthen their Medicaid and civil rights advocacy, enforcement, and litigation capacity, as well as provide funding to empower them to devote significant time and resource to related efforts.
