Medicaid: The (Almost) Great Unraveling

On Thursday, May 25, 2017, the Philip R. Lee Institute for Health Policy Studies and the UCSF/UC Hastings Consortium in Law, Science and Policy co-hosted an event, titled, “Medicaid: The (Almost) Great Unraveling” held at UC San Francisco.  The event featured Sara Rosenbaum, J.D., who is the Harold and Jane Hirsh Professor of Health Law and Policy and Founding Chair of the Department of Health Policy at the Milken Institute School of Public Health, George Washington University.  She also holds professorships in the Schools of Law and Medicine and Health Sciences and the Trachtenberg School of Public Policy and Public Administration.



Professor Thomas Greaney of UC Hastings, moderator for the event, held a public conversation with Ms. Rosenbaum about ongoing efforts to change the Medicaid program.  The session was held just a couple of weeks after the House of Representatives passed the American Health Care Act (“AHCA”), the bill that would repeal and replace the Affordable Care Act (“ACA”).  At the time, Senator Majority Leader Mitch McConnell had promised to introduce a bill to the Senate that would not mirror the deeply unpopular AHCA.


Ms. Rosenbaum began the event by explaining that Medicaid, on the whole, is working exactly as it should be.  The program provides health coverage to millions of Americans, including low-income adults, children, pregnant women, elderly adults, and those with disabilities.  It provides a safety net for many working-class adults who are unable to afford insurance on the individual market.  Ms. Rosenbaum conceded that there were some issues in the Medicaid program, largely related to access to specialty programs and because it is overburdened in many areas.  However, she maintained that Medicaid is “a marvel of public policy.”


She predicted that the Senate bill would go into the legal architecture of Medicaid and alter it so drastically that it would essentially be eliminated.  For example, if the Senate bill reflected the AHCA in any way, it would take away essentially 25% of Medicaid funding through the employment of per capita caps and block grants.  As a result, states would be forced to limit their benefits for Medicaid enrollees.  Rosenbaum criticized the AHCA for taking away the ability for states to implement their own approaches to healthcare, despite the Republican Party’s promises that any ACA Repeal and Replace bill would do just the opposite.


California would be “ground zero” in the event of such a major change.  Ms. Rosenbaum explained that the state did not simply expand Medicaid, it set up its own Marketplaces, codified parts of the ACA into its laws, and went above and beyond the ACA in many areas.  California also built and implemented its own mechanisms for delivering healthcare through these programs, which was not easy to do, and would not be easy to replace.  If a bill like the AHCA were to cut funding, California would be forced to dismantle many of these mechanisms, which would cost even more money.


Ms. Rosenbaum further argued that insurance companies are not equipped to handle the cases that the Medicaid program handles.  Insurers work on a theory of risk, and Medicaid recipients fall outside the scope of what companies are willing to take on.  From a public health policy perspective, harming Medicaid would do untold damage to the population.  Ms. Rosenbaum explained that the government will not recognize the extent to which our infrastructure relies on Medicaid until the program is mortally wounded.


Additionally, she asserted that Congress does not have a firm understanding of the policies they are trying to enact.  For example, in the AHCA, the House included provisions that would force Medicaid to mirror the Temporary Assistance for Needy Families (“TANF”) program.  Like TANF, the bill would allow states to introduce a work requirement for Medicaid recipients under the theory that assistance is supposed to be temporary, and getting people to work will get them insurance.  However, Ms. Rosenbaum points out that two-thirds of Medicaid recipients are already working, and those that are not working typically have special circumstances where they cannot work, such as having a serious medical condition or taking care of an adult with a disability.  Ms. Rosenbaum says this highlights the serious misunderstanding that the Republican Party holds about Medicaid recipients.


On a final note, Rosenbaum encouraged the public to speak up about their needs for the Medicaid program.  Californians, in particular, have much at stake, and should remain vigilant and informed as the Senate releases its bill to repeal and replace the ACA.


This event was supported in part by the California Health Care Foundation.