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Trump's destruction of Medicaid: Sabotage of a five-decade social contract

  • Written by Dr. John Geyman

Medicaid was enacted in 1965 under the Lyndon Johnson administration as a social insurance program to provide lower-income Americans with the health care they need. Since then it has been solidly supported by all subsequent administrations as a social contract within our society, as a matter of fairness and necessity. As poverty and inequality have increased in more recent years, it has become a mainstay assuring necessary medical care for some 74 million Americans, covering more than one in five Americans, almost one half of births, 39 percent of children, and about two-thirds of nursing home and long-term care, and more than one-quarter of mental health services. It has been described as "the backstop for America's scattershot health care system."

Not anymore. The Trump administration is out to shrink the program by whatever means, now including administrative actions by the Centers for Medicare & Medicaid Services (CMS) that bypass action by Congress. Seema Verma, Trump's appointed head of CMS, did just that in Indiana during Michael Pence's governorship. She has recently released a 10-page memo detailing how states can apply for waivers that can rein in their Medicaid programs, even in states that expanded Medicaid since 2010 under the Affordable Care Act. Through these waivers, states can exclude able-bodied adults from coverage unless they are working at least 20 hours per week. Children and disabled people are excluded from the work requirement. Ongoing reports will be required documenting that Medicaid recipients are working. If they fail to comply with these requirements, they can be locked out of coverage entirely. These new reporting requirements will greatly increase the bureaucracy involving Medicaid.

Kentucky is the first state to receive this federal waiver. It had expanded Medicaid under the ACA and now covers more than two million people. Its waiver allows it to require Medicaid recipients to work at least 20 hours per week, and to impose monthly premiums. Some people may be locked out of coverage if they fail to pay these premiums. Nine other states are lining up to request similar waivers. Waivers can also allow states to require additional eligibility redeterminations, to eliminate retroactive eligibility, and to establish lifetime limits for coverage, such as three to five years.

Government assistance to help lower income people access medical care has been a national goal for more than 50 years under an ongoing societal contract. Supporters of these new regressive policies subscribe to the unfounded belief that people needing Medicaid are lazy or otherwise undeserving of needed medical care. But such an attitude is at once unfair, uncaring, and uninformed. Most Medicaid recipients are already struggling to put food on the table and to have a place to live, so that many cannot afford to see a doctor even for urgent medical problems. Moreover, many Medicaid recipients are working or have major reasons for not being able to work. A recent report from the Kaiser Family Foundation has found that:

• almost 8 in 10 of non-elderly adults with Medicaid coverage live in working families, with a majority working themselves;

• many Medicaid enrollees work part-time and cannot find full-time work;

• almost one-half of working adult Medicaid enrollees are employed by small firms that have low rates offering full-time work;

• Most non-working adult Medicaid enrollees have major impediments to their ability to work; and

• some research has actually shown that Medicaid coverage supports work.

On the other side of the coin, a study of Medicaid expansion in Kentucky and Arkansas has documented significant gains in access to care, financial security and health. Reduction of Medicaid eligibility through CMS's new policies will reverse these gains and make a mockery of Trump's supposed claims to help people with such needs. Despite the ill-intended policies of the Trump administration, Medicaid is working, as are most of its beneficiaries, to the benefit of their communities and country.

John Geyman, M.D. is the author of Common Sense about Health Care Reform in America (2017), and Crisis in U.S. Health Care: Corporate Power vs. The Common Good, and The Human Face of ObamaCare: Promises vs. Reality and What Comes Next. He lives on San Juan Island with his wife Emily. Prior to retirement he was a physician at Inter Island Medical Center in Friday Harbor. Visit John at: http://www.johngeymanmd.org