Posts About Medicaid and Medicaid Expansion

Yesterday, House Republican leadership released another "replacement plan," the Obamacare Repeal and Replace Policy Brief and Resources. After nearly seven years, Republicans continue to call for replacement of the Affordable Care Act but have yet to put forward a plan that offers any clarity to consumers, let alone the same protections and coverage gains currently available under the Affordable Care Act (ACA). The announcement of yet another messaging document masquerading as a replacement plan continues that trend. Once again, in spite of much fanfare and self-congratulation, House Republicans still failed to present agreed-upon legislative language. The white paper released yesterday includes only high-level descriptions on some possible aspects of replacement while leaving key details missing.

Despite Republican protestations, the ACA has greatly improved the affordability of coverage available to consumers. The ACA has provided low- and moderate-income individuals and families with hundreds of billions of dollars in tax cuts to help make health insurance more affordable. And a majority of consumers using have been able to find plans with premiums below $100 after taking into account financial assistance.  Although most marketplace enrollees like their coverage, the main thing people want from health reform is lower out-of-pocket costs.

Yet instead of building on the current law, Republicans keep on releasing proposals that would undermine the coverage gains we have made under the ACA, leave families with fewer benefits and higher out-of-pocket costs, and dismantle Medicaid’s critical safety net. Rather than a detailed consensus for specific legislation, the Obamacare Repeal and Replace Policy Brief simply reiterates a grab-bag of recycled Republican policy ideas that fail to provide true protection for consumers.

For example, the tax credits offered under the Republican plan would not be adjusted based on income. Under this proposal, a family earning $150,000 would get just as much help as a family earning $25,000. People with fewer resources would likely get far less help affording premiums than they get today, which essentially amounts to a tax increase for these families and would likely put coverage out of reach for them. The proposal also encourages use of health savings accounts to supplement high-deductible health plans and the establishment of high-risk pools to aid individuals with pre-existing conditions. None of these policies makes coverage more accessible or affordable to low-income consumers and in reality would increase out-of-pocket costs when consumers can least afford it.

The GOP plan would also dismantle the Medicaid program as we know it. Their proposal to phase out Medicaid Expansion would reverse the progress made under the ACA to extend health insurance to low-income adults. And the proposal to cap and slash federal funding through per capita caps and block grants would push massive costs onto states and erode the health care safety net, putting coverage at risk for tens of millions of children, older adults and people with disabilities.

The Republican leadership's continued reliance on concept papers and rhetoric – instead of real proposals backed by concrete numbers and analysis – shows just how far they are from having a plan that can deliver on the promises they have made to replace the ACA with something that is both better and cheaper. Ultimately, these plans are a distraction from the real issue at hand – whether Congress will vote for a reconciliation bill that takes coverage away from millions and raises costs for millions more without any consensus on what, if anything, will come next.

One of the most shameful failures of our public safety net system is when structural harm goes unaddressed. The lead crisis in Flint, Michigan remains a painful reminder of when blind commitment to cost savings results in irreversible harm for an entire generation of children and families. The city of Flint is a low-income, majority black community—and it does not go unnoticed that this low-income, majority community of color, is the recipient of cost cutting efforts. The lead crisis in Flint – a crisis that is ongoing and will be for years to come—highlights the importance of public health and equitable infrastructure investment as a clear path to improving health outcomes and advancing health equity. Despite the high profile reporting on Flint, over 4 million children in the U.S.  live in homes with high levels of lead. This is heartbreaking – and unacceptable. States and communities are not without tools to demand and require lead exposure prevention programs and abatement in homes, in schools and in our water systems to ensure healthy living conditions for low-income children and families.

Cindy Mann, the former head of Medicaid at the Centers for Medicare and Medicaid Services, and her colleagues at Manatt recently highlighted a key tool in this battle: the Children’s Health Insurance Program (CHIP). Within the CHIP program, there is an opportunity for states to use a portion of their CHIP funds for a Health Services Initiative (HIS). As outlined in Manatt’s brief, it does not require a CMS waiver, it does not need to be a statewide effort and it does not require that only Medicaid- and CHIP- enrolled children benefit from the initiative. It does require a state to demonstrate need, meet program requirements that communicate how it will meet the needs of the targeted group and the program must have a clear timeline. Mann and her colleagues note that a majority of states have not yet taken up this opportunity—and have room in their CHIP budgets to do so.

Thanks to the Affordable Care Act (ACA), states are able to draw down a CHIP enhanced match through September 2019. While access to this enhanced match remains unclear beyond September (CHIP needs to be refunded by September 2017), there is opportunity now for states to address the needs of low-income communities. Advocates can play an important role in highlighting this opportunity for key decision makers and communities.  

We know that children’s health and wellness requires more than access to health insurance coverage. Children’s health is shaped by their surrounding environment—clean drinking water, stable and safe housing, nutritious foods and nurturing caregivers and community. All of these basic needs when knit together, blanket children with health opportunity. We know that for many children, this is not their reality and that the systems that serve them continue to struggle to identify needed resources, coordinate their work and reach the most vulnerable families. CHIP remains a key tool in helping states not just increase access to coverage and care but also create a healthier environment.

Congressional Republicans are executing a strategic pivot with respect to the Affordable Care Act (ACA). In the face of successful efforts to mobilize public support for maintaining coverage, they are recognizing the political difficulty of pulling health care away from millions of people (including Republican voters) and inflicting economic damage not only on those individuals but also on providers, insurers and state governments. This shift has several components.

First, they have "slowed their roll" with respect to repeal. The original congressional action plan called for sending a repeal bill to Trump on inauguration day. Plan B called for sending him a repeal bill on President's day. We are now on to Plan C, and we do not expect to even see a repeal plan, let alone a vote, before Congress returns from President's Day recess. The second component involves ramping up the rhetoric on the ACA's failures. Several congressional committees held hearings last week intended to show case failings of the law. At the same time, with help from the Trump administration, they are trying to create a self-fulfilling prophesy by undermining the operation of the ACA, creating a climate of uncertainty and confusion in order to thwart both insurer and consumer participation. Finally, in a nod to the support that most provisions of the ACA enjoy, they have made a rhetorical change from "repeal and replace" to "repair."

While the change is a welcome testament to the success of the resistance to date, it does not reflect any change in purpose on the part of most Republicans in Congress. They remain ideologically opposed to the social welfare state and to the redistribution of wealth from the top to the bottom. They are therefore unalterably opposed to the ACA or anything like it that expands the social right to health care and pays for it mainly by taxing the wealthy and big corporations.

In addition, both Ryan and McConnell probably feel that after seven years of demanding repeal, their credibility is on the line and they absolutely have to deliver on "repeal" regardless of the consequences. In addition, the far-right, as exemplified by groups like Heritage Action, remains committed to full repeal and fear of primary challenges is still a powerful motivator within Republican Party ranks. 

That said, "repeal" is not a static concept. Although support for full repeal remains strong among congressional leadership (see Senator Hatch's recent statement on repealing the ACA taxes), there is substantial dissension within the rank and file. The two critical wedge issues are the fate of the Medicaid expansion and whether the ACA-related tax revenue is preserved to pay for some kind of revised subsidy scheme. 

If congressional Republicans preserve both the Medicaid expansion and subsidy revenue it will open up room for bipartisan discussion on ACA amendments. If not, then any possibility of an acceptable replacement plan essentially vanishes. Although Republicans may try to come up with something, or, more likely, somethings that they call “replace,” in reality it will reflect a major erosion of health and economic security for low- and moderate-income people – especially for people with serious or chronic health conditions. If Democrats can resist pressure to bestow a patina of bipartisanship on any bill that undermines health security for the American people, then Republicans would be forced to either maintain many of the gains of the ACA or would be likely to pay a high political price for failing to do so.

In the wake of Republican efforts to unwind the Affordable Care Act while failing to coalesce around a replacement plan, consumers are increasingly concerned that they will lose the coverage and protections they have gained since passage of the ACA. Recent polls have found that 56 percent of U.S. adults are “extremely” or “very” concerned about losing health coverage if Republicans repeal the ACA without a replacement, and overall support of the law has jumped by 6 percent since President Trump’s inauguration.  

Since Election Day, there has been a groundswell of action among the public and within our consumer health advocacy community to protect the ACA. Advocates have been lifting the voices of concerned consumers across the country through rallies, letter-writing campaigns, op-eds and story sharing efforts. A telling example of the growing energy behind defending health care coverage was the series of rallies held throughout the country on January 15. Thousands of people gathered in cities and towns from Indianapolis, Indiana to Warren, Michigan to Richmond, Virginia to voice their support for the ACA. In Boston, a diverse coalition of providers, advocates and consumers from across Massachusetts convened at Faneuil Hall to protect the ACA. As medical students held signs such as “Patients over Politics” and “Health Care is a Human Right,” a young woman shared her story about the life-saving care that her mother received thanks to the ACA after being diagnosed with cancer.


As momentum grows, more and more consumers are telling their members of Congress that repealing the law without passing a simultaneous replacement plan that maintains the same coverage and protections as the ACA would turn their lives upside down. In Tennessee, constituents have flooded the inboxes of Senator Lamar Alexander and Senator Bob Corker with over 500 hand-written letters describing how a repeal of the ACA would affect their lives. To support these consumers and continue to grow their grassroots base of support, Tennessee Justice Center has channeled Tennesseans’ concerns by organizing letter-writing parties at people’s homes that are open to all community members. These gatherings, which have multiplied throughout the state, often coincide with the organization’s weekly webinars, where Tennessee Justice Center’s staff provides federal advocacy updates and tips to participants. And the gatherings don’t stop with writing letters: groups that have met each other through the parties are moving forward to take more actions, such as hosting town hall meetings and phone banking.

Harry Potter


Advocates in Maine are also elevating consumer concerns around the dismantling of the ACA. During the holiday season, Maine People’s Alliance organized 30 Mainers to visit Senator Susan Collins’ office in Portland to deliver holiday cards asking her to oppose the repeal of the health care law. The holiday cards included consumers’ personal stories highlighting how the ACA has saved or impacted their lives and those of their family members. Activity in the state picked up further thanks to a rally held in Portland on January 29. The multi-issue rally that attracted over a thousand Mainers included a call for Senator Collins to oppose the repeal of the ACA. Advocates have extended an invitation to Senator Collins to attend a town hall-style meeting planned to take place during the congressional recess for President’s Day, when members of Congress will be home in their states and districts.

Key Time for Action! Congressional Recess: February 20-24

In the next few weeks, Congress will deliberate on the language for the first budget reconciliation bill, which could contain language that would repeal major provisions of the ACA. Within this timeframe, members of Congress will be returning to their home districts for the President’s Day recess from February 20 to 24, providing a crucial window to make the concerns of consumers loud and clear to their policymakers.

There are a number of key activities that advocates can organize during this critical time. Set up meetings with constituents and members of Congress –specifically senators– at their in-district offices. Activate your base by organizing phone banks and making targeted calls. Organize consumers to send their members of Congress postcards or Valentine’s Day-themed cards. Continue to collect stories. Organize high visibility rallies and events, as well as petition drives. In all of these activities, be sure to engage the media.

The outpouring of stories and actions taken to defend the ACA in recent weeks demonstrates that consumers are raising their voices to be heard loud and clear. This momentum, coupled with the timing of the President’s Day recess, provides advocates a pivotal opportunity to organize and activate supporters. Lawmakers only need to open their doors and listen.

Republicans recently introduced two bills to “replace” the Affordable Care Act – one co-authored by Senators Susan Collins (R-ME) and Bill Cassidy (R-LA) and another by Senator Rand Paul (R-KY). Neither bill has been endorsed by Republican congressional leadership and both are unlikely to gain any traction. While more replacement bills may come out, it’s important to recognize that introducing a bill is not the same thing as passing a comprehensive replacement plan. Ultimately, these bill introductions are a distraction from the true issue these senators have at hand - deciding whether to vote for a reconciliation bill that takes coverage away from millions, without any consensus on what will replace it.

Even if either of these bills were the true Republican “replace” plan, they both fail to maintain, let alone build off of, the level of access, coverage and affordability currently provided by the Affordable Care Act.

Both bills repeal the most favorable parts of the ACA

While both bills purport to be better alternatives to the ACA, they gut almost all of ACA’s private insurance market reforms and consumer protections that have helped millions of individuals gain and maintain coverage, such as:

  • Online marketplaces for enrollment
  • Income-based premium subsidies and cost-sharing reductions
  • Requiring plans to cover the Essential Health Benefits, including emergency care, maternity care, coverage of mental health and substance use disorders and preventive services
  • Not allowing plans to charge individuals more based on gender and limiting how much more insurers could charge based on age
  • Eliminating annual or lifetime limits

In its place, the Senators’ “plans” offer bare-bones coverage and impose more barriers to accessing it.

Both bills would make coverage less affordable than the ACA for those with low incomes

Both bills rely heavily on the use of Health Savings Accounts, or bank accounts in which individuals can contribute pre-tax dollars and then make withdrawals to pay for the premiums and other out-of-pocket costs. But this HSA-based alternative will ultimately mean higher costs for many individuals, particularly those who need the most help.

First, the HSA-based option does away with the ACA’s income-eligibility test for financial assistance, which ensured individuals with lower incomes received more help than those with higher incomes. In addition, the ACA calculated tax credits in such a way that individuals would only pay a certain percentage of their income towards premiums, thereby protecting them from spending a majority of their income on health care costs.

In contrast, both Senators’ plans eliminate income-based eligibility tests when determining how much financial assistance someone can get, and offer fixed amounts of assistance that are not tied to the underlying cost of health insurance. For example, Senator Paul’s bill only provides $5,000 in tax credits to all eligible individuals, regardless of their income. Under the Collins/Cassidy plan, any individual earning under $90,000 or a family earning under $150,000 will get the same tax credit, adjusted for age and location only. That means a family earning $20,000 a year will get no more help affording their premiums than a family earning $140,000 a year. Therefore, under both plans, low-income individuals and families will not be receiving the type of assistance needed to be able to access coverage and care.

In addition, the Collins/Cassidy bill only provides 95 percent of the ACA’s funding levels to states to help them provide financial assistance to their residents. But because their plan expects more individuals would be eligible for HSAs than the number of individuals currently eligible for financial help under the ACA, the Collins/Cassidy bill will try to cover more individuals with less federal money. This would either put states on the hook to keep ACA levels of financial assistance or result in less help for those who need it most. 

Both plans offer skimpier coverage than the ACA

As mentioned above, both bills remove the requirement that health plans cover “Essential Health Benefits,” or 10 categories of important health services that were covered by most plans under the ACA, meaning insurers will be able to offer plans with meager coverage.  In addition, Collins and Cassidy allow states to auto-enroll uninsured individuals in a “default” plan that would have a high deductible and only cover limited services, even though the main thing people want from health reforms is lower out-of-pocket costs. States can also transition their entire Medicaid-expansion population to that “default” plan, causing this most vulnerable population to have far higher costs and weaker benefits.

Both plans impose more barriers to coverage and care than the ACA

Collins, Cassidy and Paul penalize those who experience gaps in coverage by allowing insurers to deny them coverage altogether or charge them much higher premiums. Paul’s plan adds an additional barrier to maintaining coverage: a two-year open enrollment period that limits the window of time that people can enroll before they are required to meet a continuous coverage requirement. The Collins-Cassidy plan would only allow people with pre-existing conditions who fail to maintain continuous coverage access to a skimpy high-deductible plan, and would also implement a “late enrollment” penalty and fees on HSA withdrawals. Therefore, anyone with a pre-existing condition who experiences a short coverage gap will only have meager coverage for their health needs, and coverage they may not be able to afford. 

Replacing the ACA feels like a bad game of charade

In many ways, the introduction of these plans feels more like smoke and mirrors than true policy alternatives. The Collins/Cassidy plan allows states to “keep” the ACA, but ultimately undermines that decision by capping and cutting the funding available to support it, and only providing financial assistance at 95 percent of what the state’s residents would have received under the ACA. In addition, this amount would not be adjusted for inflation or the state’s total expenditures, causing states to receive less money overall over time. So while their bill promises to offer state flexibility and freedom, in reality it offers less resources, which will make it harder for both individuals and states to enjoy the benefits of the ACA.

Although Senators Collins, Cassidy and Paul are the first “plans” released to replace the ACA in this new administration, there is no indication of broad support for either bill in the Republican caucus. Not only that, but the fact that Senators are releasing one inadequate plan after another shows they haven’t come anywhere close to reaching an agreement on what will replace the ACA. Until there is consensus on a plan that would build on - rather than tear down - the gains made under the ACA, it is imperative for all Senators to reject a reconciliation bill that takes insurance away from millions and raises costs for millions more.

This blog is part of a series to highlight the dangers of repealing the Affordable Care Act. Community Catalyst is highlighting different constituencies to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

Thanks to the Affordable Care Act (ACA), the uninsured rate in the United States declined to 8.6 percent in the first quarter of 2016, the lowest level on record. Approximately 22 million adult Americans have gained coverage through the ACA’s insurance Marketplaces and Medicaid expansion, in those states that proceeded with it. In addition, more than 3 million children have gained coverage since the ACA’s enactment, cutting in half the rate of uninsured children. Coverage gains are strong across all racial and ethnic groups, with a decline of 6 percent in the uninsured rate among whites, 10.3 percent among African-Americans, and 11.5 percent among Hispanics.

With this large decline in the number of people who are uninsured, states have seen significant budget savings and revenue gains. Over the last six years, changes deriving from the ACA have bolstered state economies and created more jobs in the health sector. According to a recent compilation of national and state-level data released by the U.S. Department of Health and Human Services, states have experienced a $7.4 billion decrease in hospital uncompensated care costs, the unreimbursed cost of the care provided by hospitals to people who are uninsured or underinsured. States that have expanded Medicaid have seen their uncompensated care costs fall by a total of $5 billion. Conversely, states that failed to expand Medicaid lost out on an estimated $4 billion in savings. In addition, Medicaid expansion states continue to report state savings in other areas, such as in behavioral health and criminal justice.

Unfortunately, despite these undeniable achievements, President Trump and the Republican-led Congress have already begun efforts to dismantle the ACA.  Through use of the budget reconciliation process, virtually all of the ACA’s coverage accomplishments (i.e., Medicaid expansion and tax credits for Marketplace coverage), and the revenue that helps fund them (i.e., the penalties associated with the individual and employer mandates), could be repealed early this year. And just a few hours after taking the oath of office at the Capitol, President Trump signed an executive order to give federal agencies the power to unwind regulations the ACA created. Up until now, the Republicans have failed to put forward a detailed replacement plan, and it could be years before they will enact a new plan. There is absolutely no doubt that eliminating the ACA’s coverage successes without a meaningful alternative approach will force millions of hard-working Americans to lose their insurance, as well as put state budgets at risk.

What states stand to lose:

States would experience a skyrocketing increase in uncompensated care spending over the next decade.

According to a new Urban Institute study, if a reconciliation bill passes, an additional 29.8 million people would be without coverage. Over 75 percent of those would become uninsured because of the elimination of Medicaid expansion, federal financial assistance for Marketplace coverage and elimination of the individual mandate, leading state and local governments as well as health care providers to experience an estimated $1.1. trillion in uncompensated care spending over the next decade.

States would lose billions of dollars in federal funding for Medicaid expansion

Although there is no consensus on a replacement plan, prior “repeal and replace” bills and proposals included elimination of Medicaid expansion. Let’s take a look at last year’s H.R. 3762, a budget reconciliation bill that was passed by both houses of Congress in 2015 but vetoed by President Obama in early 2016. This bill called for the complete elimination of Medicaid expansion for adults with incomes up to 133 percent of the federal poverty line as, well as enhanced Federal Medical Assistance Percentage (FMAP) for newly-eligible adults. According to a Manatt analysis, 31 states and Washington D.C. received an estimated $56 billion in federal funding to expand the program in calendar year 2016. Without the enhanced FMAP, the majority of expansion states would be forced to close their programs, leaving more than 11 million low-income adults without coverage. Medicaid cuts would be bad for state economies, and drastically reduce their ability to provide needed services for their most vulnerable residents (including expectant mothers, children with special health care needs and people with disabilities).

Quotes on State Budgets and the ACA

Repealing the ACA without an alternative approach would lead to state budget shortfalls as a result of a sharp reduction in federal funding. According to the Commonwealth Fund, ACA repeal would result in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs across all states. Over the next 10 years, states would see a cumulative loss of $1.5 trillion in gross products and a $2.6 trillion reduction in business output.

Governors, state Medicaid directors, and state budget officers have a lot at stake if the federal government pushes major health care cost increases onto states. Now more than ever advocates should urge state policymakers to speak out loudly against the repeal of the  ACA because of the damage that will be done to hard-working Americans and state economies.

Not even three full days into his presidency, Donald Trump is already showing he's willing to put the health of millions of older adults, children, people with disabilities and low-income people at risk. This weekend, Kellyanne Conway, a top aide to President Trump, signaled the new administration’s desire to convert funding for the Medicaid program to block grants to states, with the assertion that doing so would mean "those closest to the people in need will be administering the program." In reality though, block granting Medicaid would only ensure that those closest to the people in need will be faced with the difficult task of cutting eligible people from the program and eliminating important benefits as the total federal dollars they receive are drastically reduced.

Kellyanne ConwayThe main objective of a Medicaid block grant is to slash federal spending on the program and shift costs to states. Period. Previous proposals to shift the Medicaid program to block grants or per capita caps would have cut federal spending by $1 TRILLION over 10 years. With such drastic reductions in funding, states will have no choice but to significantly cut their Medicaid programs. And there is no way to do this that won't have terrible consequences for low-income and vulnerable people – exactly the people Medicaid is intended to serve. Eligibility reductions and cost-sharing increases will mean fewer people will have access to the coverage they rely on to manage chronic conditions and pay for lifesaving medications. Cuts to benefits will make it harder for children to access all the recommended preventive services they need to stay healthy and for older adults to receive the care they need to stay in their homes and communities and age with dignity. And cutting provider payments will mean fewer providers will accept Medicaid patients, making it difficult for low-income people, especially those in rural areas, to access the care they need.

But the hard decisions won’t be over after one round of cuts. Most block grant proposals don't adjust for increases in medical costs over time and make it difficult for states to respond to new challenges and advancements in vital areas of medical care. This means states won't have the funding necessary to effectively combat a new epidemic, such as Zika, and if they decide to cover a new drug or treatment, they may have to slash eligibility even further.

So don't be fooled by Conway's talk of flexibility and returning control to states. Block grants would do only one thing when it comes to Medicaid – cut federal spending at the expense of state budgets and the health of low-income Americans.

Photo Credit: Flickr: Creative Commons license

This blog is part of a series to highlight the dangers of the repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

Last week, Senate Republicans held hearings for Rep. Tom Price and Betsy DeVos, who respectively have been nominated to lead the U.S. Department of Health and Human Services and the U.S. Department of Education. For those of us who care about access to high-quality health care and education, each nominee has made many concerning statements. However, if we are thinking about the impact of these two departments on America’s kids, the views of the two nominees have the potential to do unique harm, in particular to children with disabilities and their families.

boy with disabilitiesFirst, let’s start with health care. Congressional Republicans are working hard to repeal the Affordable Care Act, although they are encountering resistance nationwide and substantial skepticism from many senators and governors from their own party. Rep. Price, the nominee for HHS Secretary, is fully on board with repealing the law. One of the provisions at risk of being repealed is the essential health benefits (EHB) requirement. The essential health benefits (EHB) package creates a required floor of benefits for all consumers—including children with disabilities—and set a new federal standard to ensure that all consumers have access to needed services to be healthy.

One important benefit for many children with autism, for example, is habilitative services. According to current regulation, habilitiative care is defined as “services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.” Repealing the ACA means denying children with disabilities access to these important services.

It may surprise you how many children have periods of time in their development when they need these services—and then may no longer rely on them. Think about whether a child meets specific milestones around speech, walking, talking or has difficulty with their environment—sometimes termed as “sensory issues” or “being on the spectrum.” These children need access to supports that will give them the tools that they need to succeed at school and in their communities. Access to these types of services at the right time can significantly improve both their health and education outcomes.

For kids, health and education are closely linked. A healthy child is better able to stay focused in school and participate fully in their education. Moreover, research shows that kids with coverage through Medicaid or CHIP, a program that covers over 43 percent children with special health care needs, are more likely to succeed in school and go on to higher education.

So this brings us to Betsy DeVos. Ms. DeVos is a wealthy philanthropist and advocate for school vouchers. She has no training or background in education generally or with public schools specifically—facts that became clear during her hearing to become the U.S. Secretary of Education. Most alarming was her lack of knowledge of a key federal educational reform, the Individuals with Disabilities Education Act (IDEA, 1975).

Because of IDEA, children of all abilities are included in public school classrooms; they are promised in accordance with federal law, a “free appropriate education.” Children are provided needed services and support to attend and thrive in public school settings—through individual education plans, many children also rely on health services inside schools to support their inclusion. This is key for children with disabilities who may rely on a range of services – anything from speech and occupational therapy to having an aide in a classroom to support their learning and daily needs. Ms. DeVos’ lack of understanding of IDEA and lack of support for a federal role in ensuring that the civil rights of children are protected, is an alarming signal to parents across the country who rely on these services and the law so that their children can grow up included in their communities and have healthier, more productive lives.

As we face a future that could hold the repeal of the ACA and the emergence of a Department of Education that does not stand up for the civil rights of children with disabilities, I am acutely aware of the lose-lose situation for kids and their families. As a parent with a child who relies on both school and health services to support healthy growth and development, I am baffled and dismayed at the thought of an America that could take a giant step backward in the areas of health and education, harming some of the most vulnerable among us.

Medicaid provides health insurance coverage to millions of children, older adults and people with chronic health conditions. This has meant many more kids, grandparents and people with chronic health conditions have been able to get the care they need--from well-child exams to medications to services that allow people to age with dignity in their homes and communities.

In addition to providing access to vital health care services, Medicaid has become a more flexible and dynamic program that allows states additional ways to provide more efficient and effective care that’s attuned to the needs of their population. States have been doing innovative things with their Medicaid programs for years through waivers, and the passage of the Affordable Care Act only bolstered states’ abilities to improve care delivery through their Medicaid programs. Through new funding opportunities and mechanisms for innovation, states have been testing out methods that reward value instead of volume and address the social determinants of health. For example, through its Medicaid program, Louisiana provides supportive housing services to individuals with disabilities, and Maryland helps beneficiaries find and maintain employment in their community.

Medicaid coverage and funding is the foundation for these health system transformation initiatives, but the president-elect and Congressional Republicans have proposed dismantling the Medicaid program as we know it by imposing block grants or per capita caps. Either of these options means bad news for our work to address the social determinants of health and to create even more innovative and effective Medicaid programs. The bottom line is that block grants and per capita caps would result in drastic cuts in funding and will leave states scrambling to meet even the most immediate needs of beneficiaries, without opportunities to improve the health care system to keep people healthier (and keep costs down) in the longer-term.

For example, House Speaker Paul Ryan’s proposal released this past summer would cut federal Medicaid funding per beneficiary by as much as 50 percent over 10 years through per capita caps, while block grants could slash total federal Medicaid funding by nearly a third. Rather than increasing innovation, funding cuts due to block grants and per capita caps would hinder innovation and may even prevent it altogether. These policy proposals would result in numerous negative impacts including:

  • Enormous funding cuts that would force states to cut costs dramatically in the short term. This means that states would be focused on ways to cut eligibility, benefits, and provider payments rather than ways to improve care for enrollees and lower long-term costs through innovations and investments in population health.
  • A decrease in available funds meaning that states wouldn’t be able to provide the upfront investments and incentives needed to help providers transform their practices to provide more integrated services and better care coordination.
  • Eligibility cuts that will mean any Medicaid innovations states are able to accomplish would reach even fewer people.

Finally, Medicaid cuts won’t occur in a vacuum and would likely be accompanied by other cuts to social services and supports. Limited funds on all fronts will create competition for resources and make it even harder for states to encourage collaboration with social service providers and address social needs through Medicaid.

Congress is already on its way to rolling back the important advances in the Affordable Care Act, and Congressional Republicans have their sights set on dismantling Medicaid next. In the coming days, we must ensure decision-makers understand that massive funding cuts to Medicaid will constrain – not promote – innovation. We must continue to work together to lift up the message that Medicaid is already an innovative and effective program.

This blog is part of a series to highlight the dangers of repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

Following the election of Donald Trump, immigrant communities have grown increasingly anxious about their safety and well-being. The president-elect’s hard-lined stance on anti-immigrant policies has stoked fear among undocumented immigrants and further heightened concerns about discrimination, families being separated, job security and access to health care for millions of people.

The ACA has significantly increased access to affordable health coverage for lawfully present immigrants through Medicaid expansion and health insurance Marketplaces with tax credit subsidies. For example, from 2013 to 2014, the percent of noncitizens with health care coverage jumped by 6.3 percent.

Percent Insured by Citizenship

Image Attribution: Screenshot taken from on 1/11/2017

The Affordable Care Act was built upon the success of extending (or lifting) five-year coverage to children and pregnant women through CHIPRA. In 2009, Congress Reauthorized the Children’s Health Insurance Program (CHIP), including the Legal Immigrant Children’s Health Improvement Act (ICHIA) provision allowing states the option to lift the five-year waiting period for lawfully present immigrants to enroll in Medicaid coverage. States such as Ohio, Utah and Florida recently adopted ICHIA to extend health coverage to immigrant children and pregnant women. This coverage option was critically important in ensuring that low-income immigrant women have healthy pregnancies and healthy babies. While recipients of the Deferred Action for Childhood Arrival’s (DACA) program were excluded from the Affordable Care Act’s coverage options, some states took an additional step to extend health coverage to undocumented immigrants. California, for example, deemed DACA recipients eligible for Medicaid coverage under Permanently Residing in the United States Under Color of Law (PRUCOL). The president-elect’s stance on programs benefitting immigrant communities sends a troubling signal about potential cuts and changes impacting immigrant families.

The upcoming debate around refunding CHIP should ensure that advocates maintain current eligibility criteria so that immigrant families and children continue to access the care they need. The push for Medicaid block grants and per capita caps threatens to lessen federal dollars going into states to support immigrant health programs. The movement to end programs benefitting DACA recipients and other groups under PRUCOL is yet another challenge. It’s no surprise that immigration lawyers, for example, have reported seeing a ten-fold increase in calls from immigrant clients concerned about what Donald Trump’s election means for their families. 

Consumer health, immigrant and social justice advocates can play an active role in protecting immigrants at risk of losing available health coverage options. Identify whether your state has taken up the ICHIA option. Continue educating and informing immigrant communities about available health care options and protections at local enrollment and community events. Determine how your organization can complement ongoing initiatives to educate and inform immigrants about their rights and protections. Highlight the ACA’s role in improving health care access within immigrant communities. Identify, collect and elevate the stories of immigrants whose lives have been improved by the ACA. Explore ways to partner with local groups reaching immigrant populations to support immigrant families, foster productive partnerships and further elevate the importance of the ACA for diverse constituencies across the country. All of this will go a long way for advocates to serve as a strong, vocal ally for protecting immigrant communities and their health coverage.

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