Republicans, in control of the White House and both chambers of Congress, aim to cut trillions of dollars in federal spending. Despite promises from President Donald Trump and other GOP leaders not to cut widely popular entitlement programs, Medicaid—providing health care to many millions of people on low incomes—is certain to be slashed if cuts are made on anything like that scale. Among those who depend on Medicaid, millions of people who use drugs rely on it for access to treatment, medication and overdose-prevention resources.
On March 11, the House narrowly passed a stopgap spending bill. It largely maintains Biden-administration spending levels but makes certain cuts, boosts funding for immigration enforcement and the military, and gives Trump more leeway over spending. The Senate would need to approve it by March 14 to avoid a federal government shutdown; Senate Democrats plan to oppose it.
But what comes after will be far more consequential. A separate Republican budget resolution, which passed the House on February 26, is essentially the party’s wish list. As CBS reported, it sets the goal of producing legislation to cut at least $1.5 in federal spending, while cutting $4.5 trillion in taxes and raising the debt ceiling by $4 trillion.
The bill instructs the House Energy and Commerce Committee—with oversight of Medicaid—to find at least $880 billion in cuts over a decade. Republicans have avoided saying explicitly that they will cut Medicaid, knowing how many of their own constituents need the program. But the Congressional Budget Office released an analysis on March 5 confirming that there is no way to make such large spending reductions without cutting Medicaid.
“There is no way people don’t lose coverage, and you’re doing that in return for billionaires getting a tax break.”
Mona Shah, senior director of policy and strategy at Community Catalyst, a health justice organization, said that Medicaid cuts are imminent unless voters, activists and organizations can exert sufficient pressure.
“Our goal is to make this unlikely,” she told Filter. “The point [we are] making is that Medicaid is a lifeline for millions of people. Over 72 million individuals receive Medicaid, and $880 billion is a massive cut to the program. There is no way people don’t lose coverage, and you’re doing that in return for billionaires getting a tax break.”
All states participate in Medicaid, and most make households with incomes up to 138 percent of the federal poverty line eligible. According to the McCourt School of Public Policy at Georgetown University, since the Addiction Equity Act of 2008 and the Affordable Care Act (ACA) of 2010, “Medicaid has served as a workhorse to improve access to appropriate substance use care.”
People who use drugs are not a small portion of Medicaid recipients: Around one in five people on Medicaid have a diagnosed substance use disorder. The ACA, which expanded Medicaid eligibilty, increased their access to treatment and more. Services vary state by state, but many cover counseling, residential care, community-based support and mobile crisis services, as well as the overdose-reversal drug naloxone and FDA-approved medications for opioid use disorder.
“Medicaid is key to addressing substance use disorders and the overdose epidemic. It’s the single largest payer of both mental health and substance use disorder care.”
Deborah Steinberg, senior health policy attorney at the Legal Action Center, which advocates for health equity, said that in many cases, Medicaid provides better coverage for people who use drugs than Medicare or private insurance.
“Medicaid is key to addressing substance use disorders and the overdose epidemic,” she told Filter. “It’s the single largest payer of both mental health and substance use disorder care. It’s a lifeline because it provides the services people need and often to a far better degree than other insurance programs.”
“Because states can adapt it to fit their needs, we’ve seen states do such important things with Medicaid,” Steinberg continued. “They’re providing crisis services, peer support, services that address social determinants of health—all components of what people need for prevention, treatment and recovery.”
It’s therefore highly probable that slashing Medicaid would result in an increase in overdose deaths, which have been declining nationally. Such an effect would be racially disproportionate. Members of Black and Latinx communities have not shared in the national decline in overdose deaths, and are disproportionately likely to be enrolled in Medicaid, so cuts would hurt them the most.
“States won’t be able to cut back on mandatory benefits, but there are so many ‘optional benefits’—most types of providers and treatment are optional.”
Other ideas put forth by Republicans, like eliminating provider taxes, would essentially defund individual states’ Medicaid programs. Medicaid involves state and federal governments footing the bill through a cost-sharing mechanism that varies by state and the services provided. As Georgetown explains, provider taxes are collected by state governments from health care providers to help fund a state’s share of Medicaid. If the federal government restricts or eliminates use of this funding source, it could jeopardize as much as $630 billion in Medicaid spending over a decade.
“States are going to be in a really tough spot,” Steinberg said. “They either have to find a way to make up the difference, by cutting other necessary services and supports, or raising taxes, or they’ll have to make cuts to their Medicaid program to account for this reduced funding from the federal government. If they have to do that, they won’t be able to cut back on mandatory benefits, but there are so many “optional benefits”—most types of providers and treatment are optional.”
Yet another idea proposed by Republicans is to add work requirements to Medicaid, making recipients prove they have a job in order to receive health care. “It’s common sense,” said House Speaker Mike Johnson. “Little things like that make a big difference not only in the budgeting process but in the morale of the people. You know, work is good for you. You find dignity in work.”
But an analysis by KFF showed that already 92 percent of Medicaid recipients are either working, in school or caring for a dependent.
“You’ll hear conversations about adding work requirements, which is really unnecessary, burdensome reporting requirements asking individuals to report every month that they’re working,” Shah said. “Two states that tried this, Georgia and Arkansas, ended up wasting millions on consultant and administrative costs to set this up. People either unnecessarily lost coverage or didn’t enroll at all.”
A common Republican tactic is to cite the need to cut “waste, fraud and abuse,” which Johnson and other House Republicans have claimed are ruining Medicaid. Edwin Park, a health policy expert at Georgetown University’s McCourt School of Public Policy, debunked the claim in a conversation with NPR. The figure cited by Johnson, of $50 billion in Medicaid fraud annually, is untrue. That number is a measure of “improper payments,” relating to errors in documentation or procedure for payments issued. This doesn’t represent a finding of fraud or payments that shouldn’t have been made.
“The reality is there is very little fraud and abuse in Medicaid,” Shah said. “It’s one of the slowest growing health care programs, Medicaid spends less per enrollee than Medicare or even private insurance. It is already a very lean and cost-effective program.”
Photograph of House Speaker Mike Johnson by Gage Skidmore via Flickr/Creative Commons 2.0
Show Comments