The Biden administration is quietly engineering a series of expansions to Medicaid that may bolster protections for millions of low-income Americans and bring more people into the program.
Biden鈥檚 efforts 鈥 which have been largely overshadowed by other economic and health initiatives 鈥 represent an abrupt reversal of the Trump administration鈥檚 moves to scale back the safety-net program.
The moves, some of which were funded by the covid relief bill that passed in March, could further boost Medicaid enrollment 鈥 which the pandemic pushed to a record 80.5 million in January, including those served by the related Children鈥檚 Health Insurance Program. That鈥檚 up from 70 million before the covid crisis began. New mothers, inmates and undocumented immigrants are among those who could gain coverage. At the same time, the Biden administration is opening the door to new Medicaid-funded services such as food and housing that the government insurance plan hasn鈥檛 traditionally offered.
鈥淭here is a paradigm change underway,鈥 said Jennifer Langer Jacobs, Medicaid director in New Jersey, one of a growing number of states trying to expand home-based Medicaid services to keep enrollees out of nursing homes and other institutions.
鈥淲e鈥檝e had discussions at the federal level in the last 90 days that are completely different from where we鈥檝e ever been before,鈥 Langer Jacobs said.
Taken together, the Medicaid moves represent some of the most substantive shifts in federal health policy undertaken by the new administration.
鈥淭hey are taking very bold action,鈥 said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting, in particular, the administration鈥檚 swift reversal of Trump policies. 鈥淭here really isn鈥檛 a precedent.鈥
The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting , including Texas and Florida, to expand Medicaid coverage to low-income working-age adults through the Affordable Care Act.
And while some recent expansions 鈥 including for new mothers 鈥 were funded by close to $20 billion in new Medicaid funding in the covid relief bill Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional money.
The White House strategy has risks. Medicaid, which swelled after enactment of the 2010 health law, has expanded further during the economic downturn caused by the pandemic. The programs now cost taxpayers more than $600 billion a year. And although the federal government will cover most of the cost of the Biden-backed expansions, surging Medicaid spending is a growing burden on state budgets.
The costs of expansion are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who frequently argued for enrollment restrictions and derided Medicaid as low-quality coverage.
But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, can鈥檛 make up for all the inadequacies in government housing, food and education programs.
鈥淔ocusing on the social drivers of health 鈥 is critically important in improving the health and well-being of Medicaid beneficiaries. But that doesn鈥檛 mean that Medicaid can or should be responsible for paying for all of those services,鈥 said Matt Salo, head of the National Association of Medicaid Directors, noting that the program鈥檚 financing 鈥渋s simply not capable of sustaining those investments.鈥
However, after four years of Trump administration efforts to scale back coverage, Biden and his appointees appear intent on not only restoring federal support for Medicaid, but also boosting the program鈥檚 reach.
鈥淚 think what we learned during the repeal-and-replace debate is just how much people in this country care about the Medicaid program and how it鈥檚 a lifeline to millions,鈥 Biden鈥檚 new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN, calling the program a 鈥渂ackbone to our country.鈥
The Biden administration has already withdrawn permission the Trump administration had granted Arkansas and New Hampshire to place work requirements on some Medicaid enrollees.
In April, Biden blocked a multibillion-dollar Trump administration initiative to prop up Texas hospitals that care for uninsured patients, a policy that many critics said effectively discouraged Texas from expanding Medicaid coverage through the Affordable Care Act, often called Obamacare. Texas has the highest uninsured rate in the nation.
The moves have drawn criticism from Republicans, some of whom accuse the new administration of trampling states鈥 rights to run their Medicaid programs as they choose.
鈥淏iden is reasserting a larger federal role and not deferring to states,鈥 said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.
But Biden鈥檚 early initiatives have been widely hailed by patient advocates, public health experts and state officials in many blue states.
鈥淚t鈥檚 a breath of fresh air,鈥 said Kim Bimestefer, head of Colorado鈥檚 Department of Health Care Policy and Financing.
Chuck Ingoglia, head of the National Council for Mental Wellbeing, said: 鈥淭o be in an environment where people are talking about expanding health care access has made an enormous difference.鈥
Mounting evidence shows that expanded Medicaid coverage improves enrollees鈥 health, as surveys and mortality data in recent years have identified greater health improvements in states that expanded Medicaid through the 2010 health law versus states that did not.
In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has backed a series of expansions to broaden eligibility and add services enrollees can receive.
Biden supported a provision in the covid relief bill that gives states the option to extend Medicaid to new mothers for up to a year after they give birth. Many experts say such coverage could help reduce the U.S. maternal mortality rate, which is than rates in other wealthy nations.
Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.
The covid relief bill 鈥 which passed without Republican support 鈥 also provides additional Medicaid money to states to set up mobile crisis services for people facing mental health or substance use emergencies, further broadening Medicaid鈥檚 reach.
And states will get billions more to expand so-called home and community-based services such as help with cooking, bathing and other basic activities that can prevent Medicaid enrollees from having to be admitted to expensive nursing homes or other institutions.
Perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push the government health plan into covering services not traditionally considered health care, such as housing.
This reflects an emerging consensus among health policy experts that investments in some non-medical services can ultimately save Medicaid money by keeping patients out of the hospital.
In recent years, Medicaid officials in red and blue states 鈥 including Arizona, California, Illinois, Maryland and Washington 鈥 have begun exploring ways to provide rental assistance to select Medicaid enrollees to prevent medical complications linked to homelessness.
The Trump administration took steps to support similar efforts, clearing Medicare Advantage health plans to offer some enrollees non-medical benefits such as food, housing aid and assistance with utilities.
But state officials across the country said the new administration has signaled more support for both expanding current home-based services and adding new ones.
That has made a big difference, said Kate McEvoy, who directs Connecticut鈥檚 Medicaid program. 鈥淭here was a lot of discussion in the Trump administration,鈥 she said, 鈥渂ut not the capital to do it.鈥
Other states are looking to the new administration to back efforts to expand Medicaid to inmates with mental health conditions and drug addiction so they can connect more easily to treatment once released.
Kentucky health secretary Eric Friedlander said he is hopeful federal officials will sign off on his state鈥檚 initiative.
Still other states, such as California, say they are getting a more receptive audience in Washington for proposals to expand coverage to immigrants who are in the country without authorization, a step public health experts say can help improve community health and slow the spread of communicable diseases.
鈥淐overing all Californians is critical to our mission,鈥 said Jacey Cooper, director of California鈥檚 Medicaid program, known as Medi-Cal. 鈥淲e really feel like the new administration is helping us ensure that everyone has access.鈥
The Trump administration moved to restrict even authorized immigrants鈥 access to the health care safety net, including the 鈥減ublic charge鈥 rule that allowed immigration authorities to deny green cards to applicants if they used public programs such as Medicaid. In March, Biden abandoned that rule.
KHN correspondent Julie Rovner contributed to this report.
