The Washington PostDemocracy Dies in Darkness

The Health 202: Trump tried to shrink Medicaid. Here's how Biden will try to expand it.

with Paige Winfield Cunningham

The Trump administration spent four years trying to reshape Medicaid to make it fit conservative priorities. 

But now the Biden administration is trying to pull it in a different direction. 

President Trump pushed states to weed out ineligible enrollees and greenlit work requirements in exchange for benefits. But President Biden – and, if confirmed, his nominee to lead the Centers for Medicare and Medicaid Services Chiquita Brooks-LaSure -- are expected to push to get more people on the Medicaid rolls.

Medicaid provides coverage to around 72 million Americans — about 22 percent of the population — and those numbers have risen during the coronavirus pandemic. The program is central to Biden’s promise to get more people insurance by building on Obamacare and existing programs. 

 “Medicaid is a tremendously powerful tool,” said Eliot Fishman, the senior director of health policy at the health-care advocacy group Families USA. “In many states, it is by far the largest source of federal funds for health and human services.”

There are some changes already in the works: 

Work requirements are on the way out.

The Biden administration has sent letters to Arkansas, New Hampshire, Michigan and Wisconsin revoking their authority to mandate that Medicaid recipients work or attend educational programs to qualify for benefits. 

CMS told states the requirements don’t align with the goals of the safety net program to provide medical care to vulnerable and low-income populations, especially in the middle of a pandemic forcing many out of their jobs. 

It’s a major departure from the approach of former CMS administrator Seema Verma, who frequently argued that work requirements would provide an incentive for people to get jobs and get out of poverty.

But the immediate practical effects may be minimal: Arkansas is the only state that actually started to enforce work requirements under the Trump administration, in 2018. A court halted the program the following year, by which time 18,000 adults had lost coverage.  

Holdout states have more incentives to expand Medicaid.

Obamacare was supposed to ensure that everyone making under 138 percent of the federal poverty line would be eligible for the safety net program. That’s not how it worked out: A 2012 Supreme Court decision let states reject Medicaid expansion. 

A decade later, generous federal incentives and popular pressure have pushed many states to expand coverage, but a dozen states continue to hold out. About 4 million Americans who would otherwise be eligible live in those states. 

Now, Democrats have sweetened the deal to get them on board, offering as part of their economic stimulus bill a 5 percent funding increase for non-expansion enrollees if states expand.

That extra money would more than offset the cost to the states of expansion for those two years, according to the Kaiser Family Foundation. In Texas, the biggest holdout state, it would mean an extra $6 billion. 

“I think this incentive is probably the most powerful card that the federal government has to play to get states to take up expansion,” said Jesse Cross-Call, a senior analyst with the Center on Budget and Policy Priorities. 

Women may get extended coverage after giving birth.

The American Rescue Plan also gives states the option to extend Medicaid coverage for women after they give birth to a full year, up from 60 days. 

If states opt in, the change could make it easier for women to maintain their insurance coverage during a particularly critical time for their health. The Urban Institute found that if every state adopts the new policy, 123,000 new mothers could be eligible. 

Several states, including some that have not expanded Medicaid, already are looking at options to extend coverage. 

Beyond these initial steps by the Biden administration, more changes to the Medicaid program could be on the horizon:

Funding for home-based care could increase dramatically.  

The Biden administration has said that it intends to include $400 billion in an upcoming infrastructure package toward expanding Medicaid coverage of home- and community-based care for the elderly and those with disabilities. 

The proposal comes as institutional long-term care settings are still reeling from the ravages of the coronavirus. Nursing home residents account for less than 1 percent of the population but around one-third of all coronavirus deaths

The president’s plan would expand a program that encourages states to develop Medicaid-covered alternatives to nursing homes and other institutional settings. More funding could also cut into long wait times to qualify for care in many states. 

Democrats say the proposal is crucial as the baby boomer generation ages and the number of frail elderly needing care rapidly expands. Republicans have balked at the cost and questioned whether it counts as real infrastructure. 

Biden could make Medicaid more generous and enrollment easier. 

Medicaid enrollment declined from 2017 to 2019 — in part, researchers believe, because of the Trump administration’s encouragement of frequent eligibility checks and more onerous renewal requirements. 

In Missouri, for instance, enrollment declined by 70,000 individuals in 2018. According to media reports, the state sent mailed letters asking for people to verify their information. Many of the people who lost coverage were those who did not receive or did not understand the letters, even if they still qualified for the program. 

The Biden administration may move in the other direction. 

Experts say there are lots of small changes that the federal government can make so that it’s easier to enroll in Medicaid and stay enrolled, if eligible. Many states, for instance, have reduced documentation requirements and turned to more automated renewals. 

“It could become a big part of moving towards a more universal and automatic system of health coverage,” Fishman said. 

The administration could push to restructure Medicaid in Puerto Rico.

Unlike in the states and Washington, Medicaid funding for Puerto Rico and other U.S. territories — American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto Rico and the U.S. Virgin Islands — is capped at a fixed amount. 

 The money set aside for Medicaid in the territories is rarely enough, and lawmakers have passed a series of measures over the years temporarily increasing allotments. The latest increase was approved in 2019 and is set to expire in September, and some lawmakers are pushing for a more permanent fix.  

Prisoners and recent immigrants could see increased coverage. 

 There is bipartisan support in Congress for legislation that would allow states to restart Medicaid coverage for individuals in jail or prison 30 days before their release date. Current law does not allow incarcerated people to qualify for the program. Supporters say this change would help eliminate coverage gaps post-release and facilitate access to mental health and substance abuse treatment.   

Congress could also lift restrictions that prevent states from using federal funds to offer Medicaid coverage to immigrants within five years after their arrival in the country with exceptions only for pregnant women and children. 

Ahh, oof and ouch

AHH: The pause on the Johnson & Johnson vaccine could be lifted Friday.

In interviews on political talk shows on Sunday, Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said that he expected officials would come to a determination about the vaccine’s future by the end of the week, The Post’s Amy B Wang reports.

“My estimate is that we will continue to use it in some form. I doubt very seriously if they just cancel it. I don’t think that’s going to happen,” Fauci said on NBC News’s “Meet the Press.” “I do think that there will likely be some sort of warning or restriction or risk assessment.”

CDC Director Rochelle Walensky on April 14 detailed why there was a call for pause in the use of the Johnson & Johnson vaccine. (Video: The Washington Post)

The Food and Drug Administration called for a temporary halt on the use of the Johnson & Johnson vaccine on April 13 after reports of rare blood clots among six U.S. recipients of the shot. The decision was criticized by some experts who characterized it as an overreaction that could contribute to vaccine hesitancy.

All of the six cases of blood clots were in women between the ages of 18 and 48, but Fauci said there was not enough information to determine whether the vaccine only affected women in that age group.

Despite the Johnson & Johnson pause, the government announced a vaccine milestone Sunday: More that 50 percent of adults have now received at least one dose of the vaccine. Nearly a third of the population is fully vaccinated. 

OOF: The Department of Veterans Affairs is waging a battle against vaccine hesitancy.

“Even as the Biden administration’s campaign to inoculate the country accelerates each day, the agency has struggled to persuade a vulnerable population to protect itself and help the country get to herd immunity,” The Post’s Lisa Rein reports

One VA crew in the rural West is trying to change minds one by one: The VA hospital in Spokane, Wash., has logged 2,500 miles in its mobile medical unit, a 45-foot bus previously used as a primary care clinic, in an effort to get vaccines to the roughly 46,000 veterans under the hospital’s care, especially those who live beyond driving distance of the city. 

Nationally, about three out of four Americans say they are willing to get a vaccine. But only around one out of four of those contacted by the Spokane VA for an appointment on the bus say yes.

“In many cities and suburbs, millions are lining up for shots they have waited more than a year to get. Here, the political and cultural currents are pulling in the other direction, against the federal government, public health experts and a new president many of these veterans distrust. VA’s halting and labor-intensive effort may be a warning for the country as vaccine advocates seek to persuade unwilling Americans to sign up,” Lisa writes.

OUCH: Some people are selling fake vaccination cards.

On eBay customers can buy an “Authentic CDC Vaccination Record Card” for $10.99 from a user who goes by “asianjackson.” The account has sold 100 blank vaccination cards in the past two weeks, The Post’s Dan Diamond reports.

“At least 129.5 million Americans have gotten at least one or both doses of a coronavirus vaccine and have received a free proof-of-vaccination card with the logo of the Centers for Disease Control and Prevention, as officials push to inoculate the nation,” Dan writes. “But that vaccination drive has pitted people like asianjackson, selling blank or fake credentials, against law enforcement officials rushing to stop them — and warning that the full scope of the problem is impossible to grasp.”

The burgeoning vaccine card scams come as some businesses and universities have said that the cards could be required to return to classrooms, board cruises or enter some stores.

CDC officials initially had discussed using digital systems to track vaccinations, but technical setbacks and time pressures forced the agency to rely on paper cards, which can be easily photocopied or printed off a template. The FBI has warned that making or buying vaccine cards is against the law. 

A 400-day lockdown

At the D.C. jail, the coronavirus lockdown has lasted more than a year.

“More than a year ago, about 1,500 men and women at the D.C. jail were locked in their cells for 23 hours a day to halt the spread of the coronavirus,” The Post’s Peter Jamison reports. “Such extreme confinement has been adopted at other jails and prisons during the pandemic as a temporary, last-ditch measure. But the District’s lockdown differed in a crucial way: It never ended.”

Experts say that the 400 days of lockdown essentially constitute a form of mass solitary that can lead to serious physical and psychological harm. Some men have been forced to grow long beards because they don’t have access to a barber, and until recently inmates were prevented from going outdoors, even during the one hour a day when their confinement was eased. Jail officials say that the measures have prevented the type of coronavirus outbreaks seen in other facilities.

More in coronavirus news

  • Sen. Bernie Sanders (I-Vt.) and nine Democratic senators sent a letter calling on President Biden to support a waiver of vaccine patents at the World Trade Organization. The lawmakers argue that the waiver would allow poorer countries to ramp up production of the vaccine and would help restore American public health leadership, the Hill’s Peter Sullivan reports.
  • The Biden administration will spend $1.7 billion to track coronavirus variants. The money, which comes from the American Rescue Plan, will be used to sequence coronavirus samples, create six new centers specialized in genomic epidemiology, and build a national bioinformatics infrastructure, The Post’s Tyler Pager and Joel Achenbach report.

Health officials stretched at the border

HHS abruptly closed an emergency shelter set up to care for unaccompanied migrant children in Houston.

The agency is transfering several hundred children being housed there to other facilities. The announcement came after an HHS IT specialist working at the Houston site died on Friday evening, although HHS officials said there was no connection between the death and the decision to close the site, Dan reports.

The Biden administration has spent weeks calling for volunteers to help respond to a surge of unaccompanied children at the border, appealing to staffers even in far-flung divisions with little health care or human services expertise. Politico reported on Friday that the administration is weighing whether to assign more staff to HHS to support its efforts at the border. Officials note that 100,000 additional unaccompanied children are expected to arrive at the border this year and enter HHS custody.

Sugar rush