Defend the ACA Medicaid Expansion directly

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The Maginot Line

Forgive me for slipping into Ancient Mariner mode here, but I must again voice my obsessive plea to elected Democrats, healthcare advocates, and all those who don’t won’t to see 15-20 million Americans uninsured: Defend the ACA Medicaid Expansion! Explicitly!

As documented in my last two posts (1, 2), House Republican leadership is almost certainly coalescing on defunding the expansion — that is, ending the 90% federal match rate for low-income adults rendered eligible by the expansion’s criteria — 21 million of them at last count, as of June 2024. Since Trump ordered his troops to “cherish” Medicaid and not “touch” it while also commanding passage of a budget resolution that would cut hundreds of billions of dollars in Medicaid funding, they justify this $650 billion cut in the name of “protecting” Medicaid for children, the disabled, and elderly enrollees — those Medicaid was “originally designed for.”

By long reflex, stakeholders defending Medicaid more often than not mount their defense in the name of the same vulnerable groups Republicans are vowing to “protect.”* Here is the core defense in a letter from Families USA, co-signed by more than 300 advocacy groups, to Senate Majority Leader John Thune, asking him to reject the house budget resolution:

New Jersey may follow Texas and other states and make gold plans cheaper than silver

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I delivered this testimony today to the NJ Senate Commerce Committee in favor a bill that would put gold and silver plan pricing roughly on a par in year one and price silver at a 90% AV in year 2.  Laura Waddell of New Jersey Citizen Action also testified in favor. The bill passed out of Committee on a 5-0 vote.

TESTIMONY BEFORE SENATE COMMERCE COMMITTEE

March 24, 2025
Statement by Andrew Sprung
Health Care Committee Co-chair, BlueWaveNJ

Re:  S1971 -  An Act imposing certain rate filing requirements concerning certain health benefits plans available on the state-based exchange.

Chair Lagana, Vice Chair Cryan, and members of the Committee:

S1971 would correct a severe pricing imbalance in New Jersey’s ACA marketplace that weakens coverage for middle-income enrollees in health plans offered on GetCoveredNJ.

At a time when the fate of the enhanced premium subsidies established by the American Rescue Plan Act is uncertain, as under current law they are funded only through 2025, S1971 would also increase federal premium subsidies at no cost to the state and so partially offset the rising costs to enrollees that would result from expiration of the ARPA subsidy enhancements.

The imbalance: New Jersey is unique among U.S. state marketplaces in that in New Jersey gold-level plans – the metal choice that offers a coverage level closest to the average employer-sponsored plans – are priced out of reach for almost all enrollees.  In New Jersey in 2024, just 1.4% of on-exchange enrollees selected gold plans, versus a national average of 12.5%. Nationally, the lowest-cost gold plan premium in each state market is 4% higher than the lowest-cost silver premium in 2024. In New Jersey in 2025, the lowest-cost gold premium is priced 41% above the lowest-cost silver plan.

In Pennsylvania and Texas, two states that have taken measures similar to S1971, lowest-cost gold plans are priced well below lowest-cost silver plans, as shown below, and bronze plans are also a relative bargain.  

Democrats are fighting the last war on Medicaid

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See update at bottom for the purest expression of emerging Republican policy and messaging in the drive to cut Medicaid— from Brian Blase, Republicans’ chief ideologist on this front.

What’s wrong with this Democratic Party broadside against Republican plans to cut federal Medicaid funding?

The problem: In their likeliest path to cutting Medicaid, Republicans may well leave coverage for kids and seniors more or less untouched. They’re gunning for a different group of enrollees: 20 million low-income adults rendered eligible by the ACA Medicaid expansion.

The Tom Kean code: ACA Medicaid expansion is "waste"

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See 3/17/25 update at bottom.

A man may smile, and smile, and uninsure 20 million

I have an op-ed up this today on nj.com decoding a statement by the famously uncommunicative Rep. Tom Kean Jr. (R-NJ-7) that signals in Republican-speak that he’s on board with defunding the ACA Medicaid expansion. Below is the TLDR:

* * *

How will Republicans honor Trump’s promise not to “touch” Medicaid while reducing federal funding for the program by hundreds of billions of dollars? Leave it to purported “moderate” Rep Tom Kean Jr. (NJ-7) to channel the emerging MAGA party line. On March 6, Kean told the Record:

I support strong Social Security, Medicare, and Medicaid programs for those who depend on them. Children, seniors, and those who are disabled rely on these crucial programs…I do not support these programs being riddled with waste, fraud, and abuse — that is a direct threat to their actual missions.

While Kean vows to protect coverage for children, seniors, and the disabled, note the group of Medicaid enrollees his vow excludes: low-income adults who are not on disability. That’s the group rendered eligible for Medicaid by the Affordable Care Act. They are the “waste” Republicans propose to uninsure to help fund the resolution’s target $4.5 trillion in tax cuts for corporations and the wealthy....

WSJ editorial board: Insuring low-income "able-bodied" adults is a waste of federal money

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Providing ideological cover for Republicans who seek to cut hundreds of billions of dollars out of federal Medicaid funding, the Wall Street Journal editorial board would have you believe that federal Medicaid spending is out of control, that rich states get more than their fair share of federal Medicaid funding, that cuts to the projected spending growth rate under current law are not cuts, and that Medicaid isn’t much worth having anyway. That’s all false of course.

Let’s look at these nostrums one by one.

Undue spending in Medicaid growth. The WSJ editorialists write:

Medicaid spending as a share of federal outlays rose to 10% from 7% between 2007 and 2023, while the share of Social Security and Medicare remained stable.

Well yes, of course. The ACA Medicaid expansion, rendered optional by the Supreme Court in 2012, offered Medicaid eligibility to all lawfully present U.S. adults with income up to 138% of the Federal Poverty Level, excepting those subject to a federal 5-year bar on new immigrants. As of the program’s full launch in 2014, 24 states had enacted the expansion, and as of now, 40 states plus D.C. have done so. Medicaid enrollment has accordingly grown by 38% since 2013 (and had swelled even higher as of 2023, the year cited by the Journal, as a result of the pandemic-induced three-year moratorium on disenrollments. Medicaid enrollment has dropped 17% since the 2023 peak.)

Democratic states grab more than their fair share of federal largesse. We are asked to believe:

Democratic-run states receive disproportionately more federal Medicaid dollars. New York received $3,046 for each state resident in 2023 based on the most recent federal data. Federal Medicaid dollars also subsidize California ($2,167 per resident) and Illinois ($1,715) much more than Florida ($991) and Texas ($1,239).

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