Irwin Redlener is president emeritus of Children’s Health Fund and a professor of health policy and management at Columbia University’s Mailman School of Public Health.
In a Post commentary this week, Medicaid administrator Seema Verma espoused a troubling philosophy about the program she oversees. She spoke of transforming Medicaid under the Republican plans to repeal and replace the Affordable Care Act. Taking a fiscal sledgehammer to the program is more like it.
The proposal to restructure Medicaid from the Trump administration and congressional Republicans would destabilize an already fragile situation for America’s poor. Their funding scheme would end the entitlement to health coverage promised to those who qualify by placing an arbitrary dollar limit on each enrollee. That dollar figure would help determine how much money states receive from the federal government to run their Medicaid programs on a per-enrollee basis. So let’s be clear: The goal here is not to provide flexibility; it’s to limit the amount of federal funding paid to states.
It’s important to examine a fundamental point about why Medicaid exists in the first place, a point that Verma does not seem to appreciate. Medicaid is — and was designed to be — a means-tested entitlement program. In other words, it’s the federal government’s promise to provide health insurance to individuals and families who do not have the financial resources to obtain it through other means. This includes children, senior citizens, veterans and individuals with disabilities. Moreover, Medicaid was designed to meet this need in times of economic downturn, major disasters or anything else that might unexpectedly increase the number of families facing severe economic stress.
In the current, long-established system, the federal government keeps its promise by covering part of the cost of care. State and local governments cover the rest. This concept forms the foundation of one of America’s most important social safety net programs. Today, Medicaid provides coverage to 75 million people a year. Children in particular are major beneficiaries, with nearly 36 million enrolled.
Central to the arguments in favor of per-capita caps is flexibility for states. But states already have substantial flexibility to find efficiencies within their health systems and to determine how providers are paid. The federal government has also been willing to work with states through waiver programs to tailor to specific health needs, adjust to changing populations and even to seize opportunities for efficiency. Those who espouse per-capita caps should be honest about what they mean by “flexibility.” They mean that per-capita caps give states flexibility to decide who can receive coverage and who cannot. Taken further, they mean that states can determine how much coverage to provide and what to cut back.
Federal funding in capped or block-grant systems would be wholly inadequate to meet the changing and increasing health needs of our nation. That’s part of the reason why the Congressional Budget Office estimated that 15 million people would lose Medicaid coverage under the Senate’s health-care proposal.
Viewed through the lens of the impact on children, the House and Senate health bills are both deeply problematic. Children comprise more than half of the Medicaid population, and the fundamental promise of Medicaid entitles them to basic health coverage known as “early periodic screening diagnosis and treatment.” If states were forced to cut back eligibility under a per-capita-cap system, these basic benefits — which among other things guarantee immunizations, comprehensive screening and treatment for identified health issues — would be at risk.
Most concerning is the fact that without consistent access to comprehensive health care, undiagnosed or untreated medical conditions can imperil children’s overall well-being, their school performance and their prospects as adults.
I concede that Medicaid could benefit from improvements. Americans have relied on it for 50 years, and it’s reasonable to acknowledge that updates are necessary to meet future needs. But rather than radically restructuring the funding mechanism for the program — and slashing $772 billion to boot — those advocating for a Medicaid overhaul ought to first put forth specific proposals that will achieve the efficiencies they seek. The United States can improve Medicaid without breaking its promise to those most in need, and it can do so without jeopardizing the futures of millions of American children.
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