Biden is quietly transforming the Medicaid safety net

The Biden administration is quietly developing a series of Medicaid extensions that could strengthen protections for millions of low-income Americans and attract more people to the program.

Biden’s efforts – which have been largely overshadowed by other economic and health initiatives – represent a brutal reversal of measures taken by the Trump administration to reduce the safety net program.

The measures, some of which were funded by the COVID relief bill that was passed in March, could further boost Medicaid enrollment – something the pandemic pushed to a record 80.5 million in January, including those served by the Children’s Medicare program. That’s against 70 million before the start of the COVID crisis. New mothers, prisoners and undocumented migrants are among those who could benefit from coverage. At the same time, the Biden administration is opening the door to new Medicaid-funded services, such as food and shelter, that the government insurance plan has not traditionally offered.

“A paradigm shift is underway,” said Jennifer Langer Jacobs, director of Medicaid in New Jersey, one of the many states trying to expand Medicaid services at home to prevent nursing home registrants and other institutions.

“We’ve had discussions at the federal level over the past 90 days that are completely different from what we’ve ever been before,” said Langer Jacobs.

Taken together, the Medicaid measures represent some of the most significant changes in federal health policy undertaken by the new administration.

“They are taking very bold steps,” said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting, in particular, the administration’s rapid overthrow of Trump’s policies. “There really is no precedent.

The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting 12 blocking states, including Texas and Florida, to extend Medicaid coverage to low-income working-age adults through the Affordable Care Act.

And while some recent expansions – including for new mothers – have been funded by nearly $ 20 billion in new Medicaid funding in the COVID relief bill that Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional funds.

The White House strategy carries risks. Medicaid, which swelled after the enactment of the 2010 health law, expanded further during the economic downturn caused by the pandemic. The programs now cost taxpayers over $ 600 billion a year. And while the federal government will cover most of the cost of Biden-backed expansions, soaring Medicaid spending is a growing burden on state budgets.

Expansion costs are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who has often advocated for enrollment restrictions and ridiculed Medicaid as poor quality coverage.

But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, cannot make up for all of the inadequacies in government housing, food, and education programs.

“Focusing on the social drivers of health… is critically important to improving the health and well-being of Medicaid recipients. But that doesn’t mean that Medicaid can or should be responsible for paying for all of these services, ”said Matt Salo, head of the National Association of Medicaid Directors, noting that funding for the program“ just isn’t capable. to support these investments. “

However, after four years of efforts by the Trump administration to reduce coverage, Biden and his appointees appear determined not only to restore federal support for Medicaid, but also to increase the program’s reach.

“I think what we learned during the repeal and replacement debate is how much the people of this country care about the Medicaid program and how it is a lifeline for millions of people. people, “Biden’s new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN. , calling the program “the backbone of our country”.

The Biden administration has already withdrawn the Trump administration’s permission for Arkansas and New Hampshire to impose work requirements on some Medicaid registrants.

In April, Biden blocked a multibillion-dollar Trump administration initiative to support Texas hospitals that treat uninsured patients, a policy that many critics say has effectively discouraged Texas from expanding coverage. Medicaid through the Affordable Care Act, often referred to as Obamacare. Texas has the highest uninsured rate in the country.

The measures have drawn criticism from Republicans, some of whom accuse the new administration of trampling on states’ rights to run their Medicaid programs as they see fit.

“Biden is reaffirming a larger federal role and not relying on states,” said Josh Archambault, senior researcher at the Conservative Foundation for Government Accountability.

But Biden’s early initiatives have been widely praised by patient advocates, public health experts and state officials in many blue states.

“It’s a breath of fresh air,” said Kim Bimestefer, chief of Colorado’s health care policy and funding department.

Chuck Ingoglia, head of the National Council for Mental Wellness, said: “Being in an environment where people are talking about expanding access to health care has made a huge difference.

Growing evidence shows that extended Medicaid coverage improves the health of enrollees, as surveys and mortality data in recent years have identified greater health improvements in states that have extended Medicaid through law. 2010 health compared to states that did not.

In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has supported a series of extensions to expand eligibility and add services that registrants can receive.

Biden supported a provision of the COVID relief bill that gives states the ability to extend Medicaid to new mothers for up to one year after giving birth. Many experts claim that such coverage could help reduce the maternal mortality rate in the United States, which is much higher than rates in other rich countries.

Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.

The COVID relief bill – which passed without Republicans backing – also provides additional Medicaid funds for states to set up mobile crisis services for people facing mental health or substance abuse emergencies, expanding still the reach of Medicaid.

And states will receive billions more to expand so-called home and community services such as help with cooking, bathing, and other basic activities that may prevent Medicaid registrants from having to be admitted to the hospital. nursing homes or other expensive institutions.

Perhaps the more ambitious Medicaid extensions envisioned by the Biden administration would push the government’s health plan to cover services that are not traditionally considered health care, such as housing.

This reflects an emerging consensus among health policy experts that investments in certain non-medical services can ultimately save Medicaid money by keeping patients out of hospital.

In recent years, Medicaid officials in the Red and Blue states – including Arizona, California, Illinois, Maryland, and Washington – have begun to explore ways to provide rental assistance to some Medicaid registrants. to prevent the medical complications of homelessness.

The Trump administration has taken steps to support similar efforts, releasing Medicare Advantage health plans to provide some registrants with non-medical benefits such as food, housing assistance, and assistance with utilities.

But state officials across the country said the new administration had signaled more support for both expanding current home services and adding new ones.

It made a big difference, said Kate McEvoy, who heads Connecticut’s Medicaid program. “There has been a lot of talk within the Trump administration,” she said, “but not the capital to do it”.

Other states are looking to the new administration to support efforts to extend Medicaid to inmates with mental health and addiction issues so they can more easily connect to treatment once released.

Kentucky Health Secretary Eric Friedlander said he hoped federal officials would approve his state’s initiative.

Still other states, like California, say they are getting a more receptive audience in Washington for proposals to extend coverage to immigrants who are in the country without permission, a step according to public health experts who may help improve community health and slow the spread of communicable diseases. diseases.

“Covering all Californians is essential to our mission,” said Jacey Cooper, director of the California Medicaid program, known as Medi-Cal. “We really feel that the new administration is helping us ensure that everyone has access.”

The Trump administration decided to restrict even authorized immigrants’ access to the health care safety net, including the “public charge” rule that allowed immigration authorities to deny green cards to applicants. they were using public programs such as Medicaid. In March, Biden abandoned this rule.

KHN correspondent Julie Rovner contributed to this report.

Kaiser Santé news is a national health policy information service. It is an independent editorial program of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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