During his State of the Union address, President Biden called out Republican proposals to cut Social Security and Medicare in their quest to reduce federal spending. Republican lawmakers in the chamber protested loudly, knowing these programs are political third rails — too controversial to discuss — and they have been sparring over it ever since.
But the president and Democrats in Congress should not miss the opportunity to make Medicaid the third third rail. If they want to capitalize on the popularity of the program and protect families’ health care, Medicaid cuts must be off the table because it:
- Covers 91 million Americans, making it the largest source of health care coverage in the country
- Covers 42% of all births
- Pays for 54% of long-term care and covers 6.9 million people ages 65 and older
- Provides coverage to more than 10 million people with disabilities who rely on Medicaid for their health care
Several Republicans have said they want to use the upcoming legislative battle over raising the debt ceiling as an opportunity to cut overall spending, particularly in programs like Medicaid.
But politically savvy lawmakers would be wise to remember the health care fights of 2017 — and the results of the 2018 midterm elections that followed — proving that cutting coverage for pregnancy and childbirth, for older adults, and for people with disabilities is a pathway to political collapse. Even in deep red states like South Dakota, Idaho, and Missouri, the electorate has approved Medicaid expansion even when their elected lawmakers opposed it. That’s because Medicaid is a lifesaver for millions of families.
That’s never been clearer than over the past three years when Medicaid protected families during an enormous public health crisis. The Covid-19 pandemic upended the economy and tripled the unemployment rate. But largely because of Medicaid, the rate of uninsured reached an all-time low in 2022. That is a stark difference from the last economic upheaval during the Great Recession of 2008-2009, when 9.3 million people lost their jobs and, subsequently, their health insurance. Millions more families now know firsthand how essential Medicaid is for their health and financial well-being and they will not look favorably if their elected representatives decide to cut that lifeline.
The Medicaid program faces a daunting challenge in the coming months as the process of checking the eligibility for Medicaid of its 91 million enrollees starts back up again April 1. At the same time, 1 in 4 state Medicaid programs report staff vacancy rates greater than 20%. Millions of people are likely to lose coverage because of administrative hurdles during the eligibility determination process, and they will be hard-pressed to get someone on the phone to assist with their application. It’s political madness to cut Medicaid generally, but particularly so during this herculean lift across all state Medicaid agencies.
Republicans have floated two main strategies to cut Medicaid: per capita spending caps and bureaucratic “work requirements.” Both of these strategies are obvious efforts to disenroll people who rely on Medicaid for their health insurance.
Per capita caps change how Medicaid is paid for, increasing costs for states and giving them incentives to make cuts to their programs. These caps set a per-person ceiling on how much the federal government could pay, regardless of what people who rely on Medicaid for their health actually need. Currently, federal support can increase when families need it most, like during an economic downturn, public health emergency, opioid epidemic, or a natural disaster. It can also ensure state Medicaid programs can afford to cover a new, lifesaving expensive cancer treatment. A shift to a per capita cap would force governors to cut coverage, eliminating critical services like dental care or home- and community-based services; kick people off their insurance; make cuts to other vital programs; or raise taxes.
Work requirements are a bureaucratic way of disenrolling people from their insurance. The reality is that most people who rely on Medicaid work, and data show that Medicaid coverage can be linked with greater workforce participation — particularly among individuals with disabilities. More importantly, unemployment is at record lows at the same moment Medicaid enrollment is at an all-time high. Real-life examples over the past decade show that work requirements simply create more barriers to getting and keeping coverage without any real impact on work.
It’s time to draw a line in the sand. U.S. policymakers should be just as afraid of the political ramifications of cutting Medicaid as they are for cutting Medicare and Social Security. Ultimately, proposed cuts to Medicaid doomed the “repeal and replace” efforts in 2017, and President Biden and Democratic leadership would be remiss to not capitalize on the power of Medicaid now.
Arielle Kane is the director of Medicaid initiatives for Families USA, a nonprofit, nonpartisan consumer health advocacy and policy organization.