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:

Medicaid is a lifeline for communities across the country. It provides affordable health insurance to almost 80 million Americans—1 in 5 people living in the United States—and serves as a financial backbone of the health care system, including for the clinics and hospitals on which we all rely. Medicaid delivers essential care to 37 million children, 14 million people living in rural areas and more than 8 million people with disabilities. It supports 7 million seniors and 12 million Medicare enrollees. It also covers more than 40 percent of all births and is the single largest payer to community clinics, for long-term care, and for mental health and substance use disorder services in the country.

I love and honor Families USA, which was a driving force in getting the ACA passed and in staving off repeal in 2017. And so I plead: you can’t defend the expansion by subtraction! (80 - 37 - 8 - 12…). Republicans are out there proclaiming that “able-bodied” adults don’t deserve coverage, that the 90% federal match rate for the expansion that made it financially viable for states sucks resources from “traditional” Medicaid beneficiaries (it doesn’t), that defunding the expansion is just cutting “waste, fraud, and abuse” — that is, that low-income adults without affordable access to employer insurance are effectively human waste. The copious benefits to expansion beneficiaries themselves and to state healthcare systems and finances stemming from the expansion need to be defended directly.

A statement in defense of Medicaid signed by 167 advocacy groups in Pennsylvania does include “low-wage workers” — but backloads them (my emphasis):

Medicaid works for Pennsylvania. It’s a proven, efficient, and effective program that keeps Pennsylvanians healthy. Three million Pennsylvanians rely on Medicaid for health coverage; of those, 42% are children and 33% are seniors, pregnant, or people with disabilities. Medicaid is a top funder for critical services that communities across Pennsylvania rely on, like mental and behavioral health care, school nurses, substance use disorder treatment, community health centers, rural hospitals, in-home care, and nursing homes. Medicaid is an investment that keeps low-wage workers working, creates local jobs, boosts small businesses, and generates economic growth for Pennsylvania.

Expansion funding is key to many of the Medicaid functions named between my italics above — e.g., mental and behavioral healthcare, substance abuse treatment, funding for health centers and rural hospitals. Again, though, the impulse is to lead with children, seniors, pregnant mothers, and people with disabilities. The PA letter offers no numerical marker for the expansion population — those at greatest risk of being uninsured by Republican cuts. As of June 2024, 830,000 Medicaid enrollees in the Pennsylvania were in the expansion group — 28% of the state’s 3 million enrollees.

To be fair, sign-on letters have diverse constituencies — e.g., groups directly serving children, nursing care recipients, and people with various types of disabilities. It makes sense to include the full spectrum of Medicaid benefits and beneficiary groups in the defense. The problem is one of emphasis and omission.

One more snippet example. Here is New Jersey Citizen Action recounting a well-attended, successful empty-chair Town Hall NJCA sponsored in Rep. Chris Smith’s district (NJ-3) (my emphasis, natch):

Speakers highlighted the dire consequences of Smith’s support for a budget that slashes $880 billion from healthcare services, gutting Medicaid, SNAP, and other programs millions rely on—all while giving tax breaks to billionaires and corporations. In Smith’s district alone, 147,000 Medicaid recipients, including 67,500 children and 9,700 people with disabilities, stand to lose coverage.

Smith’s district also includes more than 50,000 expansion enrollees — and as I noted in my last post, Smith, unlike many Republicans, has defined Medicaid for “low-income families” (i.e., the expansion population) as “vital.” Why not urge him to resist expansion defunding particularly?

There is not guarantee that Republicans will write bills targeting the expansion’s 90% match rate specifically. But that cut, estimated at $651 billion over ten years by CBO, is the most viable path to meeting the spending reduction target for the Energy and Commerce Committee ($880 billion/ten years) in the House budget resolution). If Republicans do back off a cut on that scale, it will likely be because of pressure exerted now, before the Senate signs off on the House target for E&C or something close to it.

Perhaps when (if) Republicans actually write bills defunding the expansion, advocates will rise to a more explicit and focused defense. By then, however, it may be too late. Republicans will be locked into defining the expansion as “waste, fraud and abuse” and a perversion of Medicaid’s original intent — as the hard right has done since the ACA’s drafting. The time to defend the expansion is now — while Republican senators still waver over whether to sign onto the House spending reduction targets.

UPDATE, 3/28/25: To sharpen the sense of what defenders of the ACA Medicaid expansion are up against, here is House Energy and Commerce Chair Brett Guthrie (KY-2), lying through his teeth about not cutting Medicaid benefits while defunding the expansion:

“There’s an opportunity to preserve benefits, to make sure people have the benefits they’ve been promised but also get a handle on the large growth … and not take away any benefits,” Guthrie said.

That could come from changes to taxes that states levy on doctors and hospitals to help pay for their share of Medicaid expenditures, rather than using their general funds, Guthrie explained. He also said Republicans could reduce the federal share for states that have chosen to expand Medicaid through the Affordable Care Act, and enact new policies to ensure beneficiaries are actually eligible.

“If a disabled child goes to the doctor in Kentucky, the federal government pays 72 cents. If a healthy adult goes to the doctor, the federal government pays 90 cents. We think that’s just unfair and takes away money, because the states are incentivized to take care of this population because it’s more money,” Guthrie said. “What we want to do is make it fairer.”

In Guthrie’s home state of Kentucky, that “unfair” 90% FMAP for the expansion population swiftly cut the state’s uninsured population in half following enactment in 2014. In 2013, Kentucky’s uninsured rate was 14.5%. In 2015, it was 6.1% — and more than 400,000 Kentuckians were enrolled in Medicaid via the expansion (while 92,000 had enrolled in the ACA’s private-plan marketplace). As of 2014, only 24 states had opted into the expansion, which the Supreme Court rendered optional for states in 2012. Bright-red Kentucky was wise and lucky enough to have a Democratic governor in 2014, Steve Beshear, who opted in. The 90% FMAP for low-income adults was and remains necessary to make the expansion financially viable for states, and it takes nothing from that “disabled child” drawing Guthrie’s crocodile tears. Stripping it away will double Kentucky’s uninsured population. Guthrie doesn’t care. 

P.S. In 2018 I noted the effect of the expansion in those of the nation’s poorest states (including Kentucky) that enacted it. Note that uninsured rates are for adults age 18-64, not the whole population.

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* Defunding the expansion, along with likely cuts to other Medicaid funding streams, will certainly harm “traditional” Medicaid enrollment groups as well.

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