We Already Know How This Medicaid Story Is Going To End
Spoiler alert: terribly for kids and families
Note: I also have a piece out this morning in Fast Company that may be of interest, entitled “Here’s why Trump’s plan to gut Head Start will hurt you, even if you don’t have kids.”
As you probably know by now, Congressional Republicans have put Medicaid squarely in their sights in order to pay for their huge tax cuts that will disproportionately benefit the rich. Targeting Medicaid is in some ways an imperative for them. Even as they play fast and loose with budget math1, there’s likely no way for the GOP to get to the level of offsets they need through nickel and dime cuts (in the context of the whole federal budget) like slashing the Institute for Education Sciences or yanking free child care and early education from more than 700,000 families. Yet we don’t need to project how bad Medicaid cuts will be for kids and families, because we have a very recent example that no one in either party particularly wants to talk about: come with me to revisit the insanity that was the Great Medicaid Unwinding.
Here’s how I explained the background to this story for The Atlantic back in August 2023:
The problem stems from the ending of a pandemic-era rule requiring states to maintain continuous Medicaid coverage for everyone on their rolls. Eligibility for Medicaid is primarily determined by income, and normally requires periodic verification. Now states have ceased providing continuous coverage. But that involves reestablishing the eligibility of all their enrollees in just six to 14 months, which means reaching a population that sometimes moves frequently because of housing instability and that hasn’t had to deal with the verification process since 2020.
This process became known as “Medicaid unwinding,” because the system was “unwinding” itself from continuous coverage. While this surely needed to happen at some point, the rushed timeline (agreed to by Congressional leaders of both parties as part of an appropriations deal in December 2022) was a choice. And boy oh boy did it reveal how terribly new paperwork requirements around Medicaid go.
Forms were sent to the wrong addresses. Online systems were inaccessible or threw error messages. Call centers in many states were understaffed, overburdened, and/or unable to provide support in multiple languages. Close to 70 percent of eligibility denials were due to “procedural reasons,” i.e. paperwork issues and not an actual finding of ineligibility. And of course, lots of people were just plain confused. After all, Medicaid covers a definitionally lower-income population where individuals are frequently transient and working themselves ragged to put food on the table; it’s understandable if some were not closely following the shifting sands of eligibility paperwork.
While some states eventually got their act together, the damage was done -- especially to kids. Upon the completion of the unwinding process, more than five million children had lost access to Medicaid, a huge swath of whom were almost assuredly still eligible (as children generally have higher eligibility thresholds than adults) but fell prey to red tape.2 Five million. 5,000,000. That’s a shocking, damning number of kids who were dropped from their health insurance -- as in, the thing you need to realistically access health care in this country -- to say nothing of how many of their parents lost their insurance. You can imagine the human cost: childrens’ needed therapies and treatments were delayed, important doctor’s visits were skipped, prescriptions went unretrieved. And, to echo a theme in my work, all of this introduced unneeded stress and chaos and a time suck that disrupted families’ lives.3
One of the worst offenders was Texas -- a state where 1 in 10 American children live. In February of this year, the Texas Tribune ran an in-depth piece entitled, “Texas has the highest rate of uninsured children, and it’s getting worse.” The article notes:
Among the issues is a backlog of thousands of families who applied for Medicaid or the Children’s Health Insurance Program, known as CHIP. For most of 2024, the average waiting time for a decision by the state was well over two months, which triggered a federal probe under the Biden administration. The application process remains tedious and confusing, requiring families to sometimes round up dozens of documents to prove they’re eligible. Some give up.
The state has booted more than 1 million children from Medicaid since it began reviewing recipients’ eligibility again in 2023 after a pause during the COVID-19 pandemic. Many were dropped not because they were ineligible, but for procedural reasons, such as their parents’ failure to submit a renewal packet.
So, back to present day. How are Republicans angling to get those Medicaid savings, seeing as they probably can’t just take a hedge trimmer to benefit levels, politically speaking? Politico reported on April 14th that:
Even some Republicans worry Medicaid benefits will take a hit to accommodate demands from GOP fiscal hawks. As Johnson tried to seal his agreement with conservative hard-liners over the budget framework last week, he dashed onto the House floor to reassure a half-dozen moderate Republicans that he would not take away Medicaid benefits.
“We made it very clear once again that we would not vote for anything that takes away benefits from legally eligible recipients,” Rep. Nicole Malliotakis (R-N.Y.) said.
But [House Energy and Commerce Chair Rep.] Guthrie insists $170 billion alone in savings could come from making sure people receiving Medicaid benefits are actually eligible — kicking only those off the rolls who truly do not qualify. Rep. Mike Lawler (R-N.Y.) said during a CNN town hall Thursday night that such policies could include making eligibility checks required every quarter.
More than $200 billion could come from instituting new Medicaid work requirements, according to Guthrie, along with added savings from lowering the share of federal payments for certain beneficiaries in states that have expanded Medicaid.
So we’re back to trying to draw water from the eligibility well -- which, by the way, was dug adjacent to the work-requirement well that also basically just functions to throw eligible people off Medicaid. As Arkansas found out when they piloted Medicaid work requirements in 2018, in just nine months, “More than 18,000 people lost coverage, or about 25% of the population subject to the requirement, primarily due to failure to regularly report work status or document eligibility for an exemption. Researchers found work and reporting requirements in Arkansas were associated with losses in Medicaid coverage, an increase in the percentage of adults who were uninsured, and no significant change in employment—as nearly everyone targeted by the policy met the requirements already or qualified for an exemption. More recent research looking at two-year impacts of Arkansas’s work and reporting requirements found disenrollment was also associated with poorer medication adherence, delays in care, and medical debt.”4
I don’t know any other way to say this, and I am someone who tries very hard to believe those who I disagree with are acting in good faith: Congressional Republicans are looking for excuses to throw eligible people off of their health insurance because they can’t find any other way to pay for tax cuts that mainly benefit the rich. Increased eligibility checks and work requirements for Medicaid don’t work. We know they don’t work. Republican-led states proved they don’t work! To move forward with such a plan requires actively turning a blind eye to the harm that will be caused not as an unintended consequence but as a predictable if not desired consequence. To promote such a plan should be anathema to anyone claiming to champion children and families.
Because again, who will bear those consequences? Let the Texas Tribune answer:
Children face the brunt of such cuts, said Edwin Park, a Medicaid researcher at Georgetown University’s Center for Children and Families. As of October 2024, about 75% of Texas Medicaid’s 3.8 million enrollees were kids.
“In Texas, it’s mostly kids, seniors and people with disabilities on Medicaid,” Park said. “That’s where the cuts would hit. There isn’t anywhere else.”
There isn’t anywhere else.
So let’s be clear: when you hear Republicans talking about Medicaid reforms, what you should hear is “our plan means many, many fewer children get to see a doctor.”
I know politics is politics, but the fact so many so-called conservative deficit hawks have been willing to go along with the ridiculous notion that you can pretend extending previously passed tax cuts costs zero dollars still leaves me shaking my head.
Prior to unwinding, researchers at the Department of Health and Human Services estimated that ~72%(!) of children who might lose their access would in reality still be eligible
A fair number of eligible individuals who lost coverage through the unwinding process were eventually able to “churn” back on, and you can imagine how much fun it is to suddenly lose your health insurance for no good reason and then have to spend the time fighting to get it back, particularly if you have a medical condition that requires consistent care. All of this chaos also understandably strained Medicaid offices, causing delays in service reimbursements for providers and backlogs for new applications.
Watch out for this narrative sleight-of-hand as the debate intensifies, by the way. Some House Republicans are making noise about ensuring that any reconciliation package “preserves” Medicaid, but their letter to Speaker Mike Johnson leaves lots of wiggle room for “preserve” to mean “impose strict and frequent eligibility redeterminations and proof-of-work requirements.”