Why do conservatives hate Medicaid so much? What has Medicaid ever done to them to make them feel so threatened by its existence? Maybe what offends them so deeply about Medicaid is that it eviscerates one of the most sacred myths of their system of political values: that socialism is evil.
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Conservatives have been trying for years to cut the guts out of Medicaid, but they know they have to be sneaky about it. They can’t overtly say something stupid like, “I hate Medicaid! It makes it too hard for the health insurance companies to get rich!” They are smart enough to know that Medicaid is such a popular program that saying something like that, no matter how honest it may be, would likely make them unelectable. So when they want to attack the program, they have to sniff out opportunities to do so indirectly. They’ll take cheap shots at it when they think no one is watching. And that cowardly manner of doing things is how bullies behave.
Surely everyone remembers the great Republican stampede to repeal the Obama Administration’s Affordable Care Act (ACA) shortly after the squatter that used to occupy the White House was sworn in, in 2017. Those pieces of legislation contained provisions to convert Medicaid funding into “block grants,” which was just a fancy name for cuts.
One of the great things about Medicaid is that it is open-ended. The federal government reimburses state governments for roughly half the annual cost of providing Medicaid services for all enrolled residents of a state, regardless of what the price tag may turn out to be. But converting payments to block grants would put a cap on how much money each state receives from the federal government. If the amount isn’t enough to cover a state’s annual share of Medicaid expenses, tough luck. That state’s officials would have to figure out ways to make the allotment work—perhaps in ways they couldn’t previously get away with, such as restricting Medicaid coverage or eligibility.
That’s why disability rights activists protested against the efforts to repeal the ACA so vigorously that it resulted in several arrests. Fortunately, Republicans couldn’t muster up enough votes to repeal the ACA and severely wound Medicaid, despite holding majorities at the time in both the House and the Senate. That didn’t deter them, though, and they regrouped to repackage their shameful assault on Medicaid.
The squatter’s administration also sent a communication to state Medicaid agencies encouraging them to revamp their programs to force some recipients to meet employment requirements as a condition of eligibility. Until that time, in 2018, the federal government had never approved a state Medicaid plan that included work requirements for enrollees.
But Arkansas was one of a few states that took the squatter in chief up on the disastrous idea. Starting in June 2018, Arkansas claimed the infamous distinction of becoming the first state to implement Medicaid work requirements. Every enrollee aged thirty to forty-nine had to work eighty hours per month or participate in another qualifying community-engagement activity, such as job training or community service. Not only that, they also had to report to the state every month about how they were meeting those requirements. Anyone who failed to do so three times per year could be kicked off Medicaid.
Disabled people were among those who were exempt from Arkansas’s Medicaid work requirements. But as often as every two months, they had to file reports with the state confirming that they were still disabled. And their Medicaid enrollment could have been terminated if they failed to meet that condition three times in a year, even if they were still disabled. By December 2018, nearly 17,000 adults had been notified by mail that they had been removed from Arkansas’s Medicaid rolls.
An analysis of the state’s Medicaid work requirement conducted by the Center on Budget and Policy Priorities noted that “the number of people losing coverage exceeds the number who are already working or exempt from the work requirement.” This meant that some people who were supposed to be exempt lost coverage anyway, probably because they couldn’t keep up with the reporting burden.
In March 2019, U.S. District Judge James E. Boasberg halted the Medicaid work requirement in both Arkansas and Kentucky. In his ruling, he wrote that federal approval of the Arkansas proposal was “arbitrary and capricious because it did not address . . . whether and how the project would implicate the ‘core’ objective of Medicaid.”
When Joe Biden replaced the White House squatter in 2021, his administration swiftly revoked the permission granted by the federal government to Arkansas and other states to impose Medicaid work requirements. So when Republicans took control of the House again earlier this year, they tried to revive Medicaid work requirements through a piece of legislation called the Limit, Save, Grow Act, a bill stating their demands for raising the federal debt ceiling. The bill passed the House in April—with Republican votes only.
The Limit, Save, Grow Act would have compelled states to require certain adults between the ages of nineteen and fifty-five to work or participate in activities like community service or job training for at least eighty hours per month in order to receive Medicaid coverage. If an enrollee failed to meet or properly report fulfilling these requirements for three or more months, the federal government could stop paying for their Medicaid coverage. If state officials didn’t kick that person off Medicaid as a result, the state would have to pay the entire cost of their coverage. As putrid as the deal that was eventually reached to raise the debt ceiling turned out to be, at least that part was dropped.
We now find ourselves in the midst of what’s being referred to as the “unwinding of Medicaid.” During the pandemic, the federal government prohibited all states from disenrolling anyone from Medicaid. But that ended on March 31 of this year. After that, states began purging their Medicaid roles.
The Kaiser Family Foundation (KFF), a health policy research and news group, is keeping track of how Medicaid enrollment is shaking out during the unwinding. As of this writing, KFF reports that more than 5.4 million Medicaid recipients have been disenrolled in forty-six states and the District of Columbia. KFF says that 74 percent of them were cut off for procedural reasons, such as “when the state has outdated contact information or because the enrollee does not understand or otherwise does not complete renewal packets within a specific timeframe.”
KFF predicts that before the unwinding is said and done, seventeen million people could lose Medicaid coverage, including some “who are still eligible but face administrative barriers to renewal.”
Some states are unwinding with more zeal than others, and Arkansas is once again at the forefront. In May, twenty-two organizations issued a statement calling on the administration of Republican Governor Sarah Huckabee Sanders (remember her?) to pause Arkansas’s Medicaid eligibility redetermination process. The statement noted that a report by the Arkansas Department of Human Services showed that nearly 75,000 Arkansans lost Medicaid coverage in the first two months of the new enrollment redetermination process.
“More than 85 percent of them lost coverage for procedural reasons, not necessarily because they were no longer eligible,” the statement said. “A few of the top reasons for coverage loss listed included not receiving a notice from the state, failure to respond to that notice, or returned mail. This high rate of procedural terminations is unacceptable and cause for alarm.”
Among the signatories were the American Cancer Society Cancer Action Network, the Epilepsy Foundation, and the National Multiple Sclerosis Society.
If we don’t pay attention, they just might succeed in decimating Medicaid.
Apparently, none of this deterred Sanders, because the American Cancer Society Cancer Action Network issued a press release in July stating that approximately 77,000 more people living in Arkansas had their Medicaid coverage cut off in June, bringing the state’s total purge since the process began in April to 219,126 people. The statement again called upon the Sanders administration to pause and review the process because, according to the Arkansas Department of Human Services, more than half of the denials were for procedural reasons, not necessarily because enrollees had been found to be no longer eligible.
KFF surveyed some Medicaid recipients earlier this year and reported that 65 percent were not fully aware that states were now reviewing their Medicaid roles. Nearly half said they had not previously been through the Medicaid renewal process.
It seems like a perfect storm for conservatives bent on subtly destroying Medicaid. It’s a golden opportunity for the bullies to try to blindside their unsuspecting prey. If we don’t pay attention, they just might succeed in decimating Medicaid in a way that has never been done before.