Medicaid and the 2024 Election ‘Clash of two different ideologies’

Fifth of five parts of our coverage of the 2024 election and healthcare

Medicaid policy doesn’t lend itself to becoming a major national campaign issue, partly because the program is designed so each state sets its own Medicaid policy.

Still, whichever party is in power in Washington has an opportunity to shape Medicaid programs by granting waivers to states that allow them to try new approaches to the program and depart from federal rules. Moreover, the ACA created an opportunity for state officials to get federal financial support to expand eligibility for their Medicaid programs, and Medicaid expansion has been a key factor in the ACA lowering the proportion of the American population without health insurance.

Democrats and Republicans see the program very differently,
experts say.

“It’s a clash of two different ideologies of what Medicaid is about,” says Peter Shin, Ph.D., M..P..H.., Ph.D., associate professor and research director at the Milken Institute School of Public Health at George Washington University in Washington, D.C., says. “You’re looking at one side that who thinks of Medicaid as a handout, and another one that who is looking at it in terms of compassionate support.”

Shin’s characterization may be slightly overdrawn. But Republicans have favored setting work or training requirements for Medicaid. Democrats have opposed them and have pushed for Medicaid expansion under the ACA.

The Trump administration granted waivers to 13 states to impose work requirements. When Joe Biden became president in 2021, the CMS reversed most of those waiver approvals.

Georgia was one of exceptions and its “Pathways to Coverage” program started in July 2023. The goal was to have 100,000 people enrolled within a year, but it has fallen far short of that, with just 4,300 enrollees. To participate, individuals must work, attend school or volunteer for at least 80 hours a month. Members must also make have a household income of up to 100% of the federal income poverty level. Critics say the program has onerous reporting requirements and is discriminatory by not counting caregiving as work.

The mainly Repulican proponents of work requirements say that working or going to school can improve health and that Medicaid coverage should not be viewed as an entitlement. Critics say access to healthcare is a right, and also helps improves people's health so they can hold a job or go to school.

Megan B. Cole, Ph.D., M.P.H., an associate professor at the Boston University School of Public Health, says Vice President Kamala Harris is likely to continue Biden’s policies.

“If Kamala Harris wins, I think we’ll largely see a continuation of all the progress that’s been happening over the last four years,” Cole said in an email interview. “This includes expanding access to continuous Medicaid coverage, especially for postpartum people and kids; expanding access to behavioral health services and home and community-based services; systematically addressing social determinants of health within Medicaid; and implementing new and innovative Medicaid payment and delivery models that improve the value and quality of care for patients.”

A Trump victory in November could have a negative impact on many families and individuals that who depend on Medicaid, in Shin’s view. “Medicaid is largely for low-income populations. You’re looking largely at children, you’re looking largely at the poor, disabled and the elderly. I don’t want to get too dystopian, but you know, it’s, it doesn’t look like it’s going to get better in terms of what Medicaid was aiming to do.”

In a column earlier this month, Drew Altman, CEO of KFF, lamented the lack of attention on Medicaid in the election season. “Health policy can be mind-numbingly complex, but with 81 million people covered by Medicaid and proposals to drastically change it and cut spending swirling around Trump-land, Medicaid warrants greater attention,” wrote Altman.

Republicans, he said, view Medicaid as a program that politically advantages Democrats, and the party and its adjacents have floated proposals that would drastically alter how Medicaid is funded and, in the process, cut federal funds for it.

But if Trump wins the White House and Democrats, either the House or the Senates, the battle over the program is likely to devolve to smaller maneuvers over the waivers that CMS can grant to states that allow the states to depart from Medicaid rules, in Altman's view. The waivers might include work requirements like those in Georgia but also requirements that Medicaid beneficiaries pay premiums and time limits on how long people can be covered by Medicaid, Altman predicted.