Medicaid, not Medicare, Is Where the Action Is So Far in the Biden Administration

Medicare and the ACA dominate healthcare policy and political debates at the federal level but now some attention is turning to Medicaid.

Some of that focus is on what some are calling the “dirty dozen” — the 12 states that haven’t expanded Medicaid under the ACA. But there is also attention on broadening the scope of what Medicaid covers in the 38 states that have expanded the program.

Kaiser Health News (KHN) posted a story yesterday headlined, “Biden Quietly Transform Medicaid Safety Net” and The New England Journal of Medicine published an opinion piece this week by Sara Rosenbaum, J.D., of the Milken Institute of Public Health at George Washington University titled, “Health Equity and Medicaid Transformation — Operationalizing President Biden’s Agenda.”

In broad strokes, the administration is looking for ways to use Medicaid — coupled perhaps with heavily subsidized ACA exchange polices — to extend health insurance coverage to more Americans. While Democrats expended a great deal of political energy on debating “Medicare for all” proposals during last year’s presidential campaign, the Biden administration has said little about Medicare during its first year.

“They are taking very bold action,” Frank Thompson, a Rutgers University political scientist and Medicaid expert, told the Kaiser Health News reporters, referring to the Biden administration and the Medicaid program.

The Kaiser story notes that Medicaid enrollment reached 80.5 million in January, a number that includes those enrolled in the Children’s Health Insurance Program, an increase of 10 million over the enrollment before the pandemic.

As Kaiser reported, the Biden administration has moved to rescind waivers granted to Arkansas and New Hampshire by the Trump administration to put work requirements on Medicaid enrollees. Work requirements are favored by Republicans and conservatives; Democrats and many Medicaid officials see them as having the effect of reducing Medicaid eligibility and therefore increasing the number of Americans without insurance.

The Biden administration also supported a provision in the American Rescue Plan, the massive COVID-19 relief package that Biden signed in March, that allows states to extend Medicaid coverage to mothers a year after they give birth.

But, Kaiser reported, “perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push government health plan into covering services not traditionally considered health care, such as housing.” Broadening healthcare coverage to address the so-called social determinants of health is a population notion but questions about the expense and which determinants to target remain.

The administration is also entertaining proposals to extend Medicaid to incarcerated people with mental health conditions and drug dependency and to immigrants who are in the country without authorization, according to the Kaiser report.

In her piece in NEJM, Rosenbaum maps out various strategies the Biden might use to expand health insurance. Some of the possibilities that Rosenbaum discusses would bypass existing state Medicaid programs rather than try to expand them; for example, she says the administration might set up a new federally administered public insurance option for those “without a pathway to affordable insurance.”

“Recent reports indicate growing interest in pursuing such a strategy, which was raised by Biden during the 2020 election” wrote Rosenbaum, “but the current complexity of congressional politics makes this path forward a difficult one.”

Rosebaum mentions that the administration might use Section 115 waivers — the same waivers the Trump administration used to impose work requirements — to change state Medicaid programs to simplify enrollment and renewal.

She also mentions that the administration has proposed spending an additional $400 billion to expand Medicaid coverage of long-term care and the “policy and operational challenges” posed by the end of the enhanced Medicaid funding once the end of the public health emergency prompted by the pandemic is over.