Medicaid ‘at an unprecedented crossroads … progress is at risk,’ program leader says

Medicaid has become the bedrock of health coverage across the country, but the program stands “at an unprecedented crossroads,” the program’s leader said.

Dan Tsai, director of the Center for Medicaid and Children’s Health Insurance Program Services within the U.S. Centers for Medicare & Medicaid Services (CMS), was among the speakers in the Nov. 20 CMS Leadership National Call. It was to be the final call for CMS Administrator Chiquita Brooks-LaSure and her top deputies, who spent an hour describing the accomplishments of the last four years.

They did not mention President-elect Donald Trump or Mehmet Oz, MD, MBA, the president-elect’s pick to lead CMS, or Robert F. Kennedy Jr., who will oversee its governmental parent, the U.S. Department of Health and Human Services.

But Tsai’s comments were the ones that sounded most like a dire prediction for a program now covering one in five adults and roughly half the children in the country.

“The vast majority of people that we cover, we will continue to say, are working individuals and families,” he said. “And for those folks without Medicaid coverage, families, parents are faced with unthinkable choices around what a family can afford and their kids’ health. We are leaving the program so much stronger today than when we started four years ago, but that progress is at risk. Things like adding work requirements for Medicaid or block grants to the program will not only add onerous red tape that none of us would accept for ourselves and how we would expect to navigate, not only health care, but any sort of good or service provided by the public or private sector.

“But the policies, like work requirements, block grants and others that are being discussed, they're just plain bad policy, not backed up by facts and evidence,” Tsai said. “The cost would be people's lives and health across the country.”

The CMS leaders have focused on coverage and access to health care as a human right, making sure people can access providers without having to jump through a bunch of hoops or be a rocket scientist to navigate the system, Tsai said.

Medicaid a target in Washington?

Tsai’s comment about block grants recalled proposals not original to the Trump administration. President Ronald Reagan in 1981, Congress in 1995, and President George W. Bush in 2003 all proposed changing Medicaid from an entitlement to a block grant program as a means to gain control over spending, according to “Making Medicaid a Block Grant Program: An Analysis of the Implications of Past Proposals,” by analyst Jeanne M. Lambrew. The concept of Medicaid as a block grant program has prompted criticism in the past.

Tsai and the Medicare and Medicaid leaders did not reference a growing number of publications floating possibilities about new health care policies that could come out of the White House.

On the campaign trail, Trump’s “concepts of a plan” remark caught the ears of those in the health care for its vagueness, not its detail.

Since the election, Medicaid has become a subject of speculation. KFF has declared the future of Medicaid is “uncertain.”

Tens of millions of people could lose coverage, depending on which plan is implemented, according to the Center on Budget and Policy Priorities. That organization analyzed policy proposals by the Republican Study Committee, the House Budget Committee, and the Project 2025 Presidential Transition Project, which advocates for conservative policies in health care and other sectors.

The Center for Children and Families in Georgetown University’s McCourt School of Public Policy in June published, “Project 2025 Blueprint Also Includes Draconian Cuts to Medicaid,” with another roundup this week.

“I have been warning for months that Medicaid would be on the chopping block if there is a second term of the Trump Administration and if Congressional Republicans win House and Senate majorities in 2025,” wrote analyst Edwin Park, who cited reports including Politico, Bloomberg Government, the Washington Post, The New York Times and HuffPost.

Additional changes

Recounting the last four years, Tsai cited other changes to Medicaid that the leadership team supported:

• Auto-renewal rates have doubled for the number of people able to renew Medicaid coverage.
• Post-partum coverage has expanded from 60 days to 12 months of coverage for new mothers and infants, a tremendous improvement in maternal health that is part of general expansion of Medicaid.
• Children who are covered are healthier and there are rule changes making it easier for children to get and keep coverage.
• People can access a network of providers for physical and behavioral health, and home- and community-based services, that looks much more like what other people in the country have access to, in a timely way.