Restore Medicaid's intent: Prioritize the most vulnerable over able-bodied childless adults
As Republicans unveil proposed cuts to government programs, they should take this opportunity to reform a program that is the fourth-largest driver of spending: Medicaid.
Congress should refocus the program on its original intent: vulnerable Americans, especially those with disabilities who have nowhere else to turn for health coverage.
Nearly 700,000 people with disabilities are sitting on Medicaid waitlists for vital home and community-based care, and they will wait an average of three years to get it. People like Whit Downing in Kansas, who wrote in the Kansas City Star about spending eight desperate years waiting.
Downing said during his time on the list, “I experienced more psychiatric hospital stays than I can count or even remember. I survived a suicide attempt. I wore my family out emotionally and physically as they tried to help me navigate a world that often felt unaccommodating and overwhelming.”
“I’ve spent countless hours sitting in emergency rooms, waiting for help that often felt out of reach,” he added.
When Congress created the Medicaid program in 1965, they could have never envisioned that it would become the largest single source of health coverage in the U.S.
Medicaid now represents $1 out of every $5 spent on health care. The original intent was to pay medical expenses and nursing home care for vulnerable Americans: low-income children, individuals with disabilities and seniors.
The Medicaid program changed in 2010 with the passage of the Affordable Care Act, which expanded Medicaid to work-capable, able-bodied childless adults. This shifted resources away from those who need it most. The Affordable Care Act overwhelmed the Medicaid system with nearly 17 million new work-capable, non-disabled adult enrollees under Medicaid expansion. In some states, expansion increased enrollment by more than 30 percent.
Adding to the incongruity, people with disabilities must continue to comply with the $2,000 asset limitation in Medicaid, whereas the expansion population does not. The number of health care providers that serve Medicaid enrollees has not kept pace. As a result, access to care for traditional enrollees has disintegrated. We’ve learned that increased coverage is not the same as better care.
Compounding this problem, the act incentivizes states to shift their priority to the expansion population over those with disabilities. States receive a higher federal dollar amount, called the enhanced federal matching rate, which reimburses 9 out of every 10 state dollars spent on able-bodied adults while only reimbursing 5.7 out of 10 state dollars spent on the traditional population.
People with disabilities, like Downing, are left waiting for years to receive vital long-term care services through Medicaid home and community-based services.
According to a 2018 Congressional Revenue Service report, total Medicaid long-term service spending was $154.4 billion in 2016, making Medicaid the largest single-payer of long-term care. Private insurance usually does not cover this kind of care, as it can run from $50,000-$200,000 per year in the private market.
It is unfair to prioritize work-capable, non-disabled Medicaid enrollees and leave people with disabilities with worse or no care.
As Republicans in Congress and the Department of Government Efficiency look to reform Medicaid, they should do three things to ensure that the program retains its integrity and serves those who truly need it.
First, Congress should shift resources from the expansion population to the traditional population by ending the enhanced federal match. Next, they should reallocate Medicaid funding formulas to boost Medicaid home and community-based services funding in states to increase long-term services and eliminate their wait lists.
States have led by example. Virginia’s Republican governor, Glenn Youngkin, announced an additional $300 million to fund waivers for every Virginian with a developmental disability on the waitlist. Kansas has introduced a similar plan in its legislature.
Congress should follow their lead and prioritize funding for Medicaid’s intended enrollees. It would be a mistake to implement broad across-the-board Medicaid cuts that apply equally to an enrollee with a disability as it would an able-bodied adult enrollee.
Lastly, the DOGE effort should require the Centers for Medicare and Medicaid Service to audit state programs and end fraudulent enrollment, which steals resources from those who truly need it.
DOGE could also ensure Medicaid implements Sen. Eric Schmitt’s (R-Mo.) Think Differently Database Act to bring lasting transparency. This requires Medicaid to establish a website database of all of its services and resources for people with disabilities.
This effort is sorely needed, as demonstrated when Able American’s Project Access sought to catalog all the programs and policies at the Department of Health and Human Services meant to serve those with disabilities. Project Access found 2,605 initiatives across 22 disability categories throughout Medicaid and the Department of Health and Human Services. Many of these are duplicative programs or difficult to access.
Congress and DOGE have a huge opportunity to prioritize Medicaid services for the vulnerable, bring transparency to the program and eliminate waste and fraud. By doing this, we can accomplish the true intent of Medicaid to achieve better health outcomes for people with disabilities and the vulnerable in our nation.
Rachel Barkley is the director of the National Center for Public Policy Research’s Able Americans program.
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