Proposed Cuts to Medicaid Could Mean Proposed Cuts to Sexual and Reproductive Health

Medicaid, the United States’ largest public health insurance program, currently insures over 72 million people with low incomes. Medicaid covers a host of health needs, including those related to sexual and reproductive health (SRH). Madeline Morcelle, Senior Attorney at the National Health Law Program (NHeLP) and co-chair of the National Coalition for Gender Justice in Health Policy, sits down to talk with us about how Medicaid is indispensable for SRH coverage and how recent proposed cuts would impact those who are enrolled.

Medicaid plays an essential role in securing SRH for those with low incomes and other underserved communities, including Black, indigenous, and other people of color, people with disabilities, women and LGBTQI+ people, young people, and people with limited English proficiency. States are required to cover family planning services and supplies, pregnancy-related care, and abortion within the Hyde Amendment’s exceptions. The House recently passed a budget resolution that requires at least a minimum of $880 billion in budgetary cuts from the Energy and Commerce Committee—who’s vast majority of financial jurisdiction is centered in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Assuredly, proposed cuts would cause states to limit eligibility for Medicaid insurance and impact million’s access to SRH care.

Links from this episode

NHeLP on Bluesky
NHeLP on Facebook
NHeLP’s Medicaid defense resources and analysis
National Coalition for Gender Justice in Health Policy Letter to Congress Opposing Medicaid Cuts
Protect Medicaid Funding Issue #7: Access to Sexual and Reproductive Health Care
Protect Medicaid Funding Issue #8: Pregnant People
Protect Medicaid Funding #9: People with HIV
World AIDS Day 2024 - Fight AIDS! Protect Medicaid!
Proposed Medicaid Work Requirements Are Another Dangerous Attack on Sexual and Reproductive Health Care Access

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Transcript

Jennie: Welcome to rePROs Fight Back, a podcast on all things related to sexual and reproductive health, rights, and justice. [music intro]

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Jennie: Hi rePROs. How's everybody doing? I'm your host Jennie Wetter and my pronouns are she/her. So y'all, I still feel like I'm in this big ball of chaos and stress. We have our new report card that's coming out next week and I'm very excited to get it out into the world, but there's just been a bajillion and one things that have needed to happen to get it ready to go. We have some new things that we're releasing this year and I'm so excited for y'all to see them. But it has added like this whole extra layer of work and it's just been a lot. It's been a lot y'all. And that is on top of all of the chaos the administration is suing and other work-related things that are still going on and need to be done even while I am desperately trying to get this report ready for a release next week. So it's just, it's been a lot and my body has started to, like, really absorb all of that stress and is, you can feel, I can feel it, I can feel the way that my body is taking on all of that stress. I have like one of those big stress balls on my shoulder, like on my shoulder blade and it's, it hurts and I just, I need to be better about meditating. I've really fallen off on that and have not been good about it. So, putting this out into the universe so y'all hear it and maybe it'll help hold me accountable to myself by saying it: I need to get better about finding time to meditate, to get rid of some of that stress. If you have any great recommendations for how you are dealing with all of the stress of everything happening, I would love to hear it. I'm sure we all would like we could all use recommendations for how to release some of that and not internalize it. Not good for my body and I need to be better about dealing with it in ways that are not just holding onto it. That is my goal for right now. Let's see. I don't feel like I've had a ton going on. I feel I've been so focused on all of this work stuff that I feel like there's not been a ton of other things happening. I mean my birthday, the last episode came out after my birthday, but it was recorded before my birthday so it was lovely. I had a really chill day, lots of sweet messages from friends and, you know, getting together with some people. Some people who know I love cheesecakes sent me cheesecakes. Unfortunately that meant I had two big cheesecakes—while they were both delightful and delicious and everything I wanted, two cheesecakes for one person was a lot. Luckily, I was able to freeze some so I will have some more later. But yeah, it was a lovely day and you know, just made me think of looking forward to the year ahead. Like I said, I have some big trips coming up this year that I am very much looking forward to. So, trying to focus on those things to get me through this little ball of chaos and stress that I am finding myself in right now. I don't really feel like talking about administrative chaos right now. There's a lot going on and a lot to take in, but the episode is gonna be focusing on some, some of it. So, let's not do that right now. Maybe let's just turn to the episode.

Jennie: One of the things that is happening is House Republicans have put forth their budget resolution that would slash a huge part of Medicaid. So, it felt like a good time to revisit conversation, a conversation about Medicaid and talk about what it is, why it's such an important sexual and reproductive health program and what these proposed cuts would look like and how it would be absolutely devastating if these cuts were to take place. And I couldn't think of a better person to have with me to talk about this than Madeline Morcelle with the National health law Program to talk all about Medicaid and why we need to care about what is happening right now and get involved and take action because it is all hands on deck y'all. It is time to get loud. Okay, with that, let's go to my interview with Madeline.

Jennie: Hi Madeline, thank you so much for being here today.

Madeline: Thanks for having me on, Jennie.

Jennie: I'm so excited to talk to you. But before we get started, do you wanna take a second and introduce yourself and include your pronouns?

Madeline: Sure. My name is Madeline Morcelle, my pronouns are she/her. I’m a senior attorney at the National Health Law Program and I work on a range of sexual and reproductive health equity issues in Medicaid and non-discrimination rights.

Jennie: So, there is so much happening around Medicaid right now so I'm very excited to have you here to talk about it. But I thought it was really important to maybe take a step back first for people who aren't as familiar with Medicaid and just talk about what Medicaid is real quick.

Madeline: Yeah, so Medicaid is our country's largest public health insurance program. Currently over 72 million people with low incomes are enrolled in Medicaid's free or low cost coverage. The program covers one in five people in the US including four in 10 kids, over eight in 10 kids in poverty, almost half of adults in poverty. And because of structural barriers to wealth, it covers a higher share of people of color and people with disabilities. It's worth noting some states have their own names for Medicaid. For example, when I was in grad school I was covered by MassHealth, which is Massachusetts' Medicaid program. Wisconsin calls Medicaid BadgerCare, Tennessee calls it TennCare, California calls it Medi-Cal and so on. Medicaid is jointly financed by the federal government and the states but administered by the states within broad federal rules, states are currently guaranteed federal matching funds called a Federal Medical Assistance Percentage or FMAP. Without any cap for qualified services provided to eligible enrollees, states receive a base FMAP and then enhanced FMAPs for certain populations and services. For example, under the ACA, the federal government picks up 90% of the cost of covering Medicaid expansion enrollees. Medicaid covers a broad range of services including: preventive services, prescription drugs, outpatient and inpatient care, long-term care—it's actually the leading payer of long-term care services in the US—disability services and much more. Coverage facilitates access to care, improves health outcomes, lowers the risk of premature mortality, narrows health inequities, and provides financial protection from medical debt. And it's worth noting that Medicaid is popular. In recent nationally representative polling from KFF, more than three quarters of the public supported Medicaid including six in 10 Republicans and at least eight in 10 Independents and Democrats. Both Trump and terrorist voters want policymakers to focus on improving Medicaid instead of cutting it. And among those enrolled in Medicaid, both Trump and Harris voters value their Medicaid coverage and the access to health services and medications for themselves and their children that it provides. They also value Medicaid because it helps protect them from financial disaster, alleviates stress, improves health health outcomes, and often supports their ability to work. People say that losing Medicaid would be devastating and lead to serious consequences for their physical and mental health and exasperate preexisting financial challenges.

Jennie: There are so many things that Medicaid covers, and I think people really think of like broader healthcare, but Medicaid is actually also a really big sexual and reproductive health program. Do we wanna talk about some of the ways that Medicaid is covering things to do with sexual and reproductive health?

Madeline: Yeah, so Medicaid plays an essential role in the struggle for equitable sexual and reproductive health care access for people with low incomes and many underserved communities including Black, Indigenous and other people of color, people with disabilities, women and LGBTQI+ people, people with limited English proficiency, and young people. States are required to cover family planning services and supplies, pregnancy related care and abortions within the Hyde Amendment's exceptions under Medicaid. Medicaid also includes a number of special protections to ensure that people can access family planning services and supplies such as giving people freedom of choice to visit any Medicaid provider and to obtain those services. And also providing states with an enhanced FMAP rate for those services, which gives states a strong incentive to provide these services. Medicaid also allows states to provide family planning services and supplies to many individuals who are not otherwise eligible to receive Medicaid coverage. That limited-scope Medicaid coverage is especially important in states that have not yet expanded Medicaid. And in addition to family planning services, all states provide access to life-saving breast and cervical cancer treatment via Medicaid and many programs cover aspects of gender-affirming care. Some are starting to cover fertility preservation services and Medicaid also covers critical preventive and treatment services for HIV in every state. In practical terms, Medicaid covers more than 40% of US births and 65% of Black women's births. Medicaid expansion has lowered maternal mortality and narrowed racial maternal health inequities. It's the leading source of family planning coverage in the United States. It covers 40% of non-elderly adults with HIV. It has been critical in the fight to end the HIV epidemic. And its critical sexual and reproductive health coverage makes it a strategic target for those who wish to restrict access for millions across the country.

Jennie: I love, like, how much I think I know about all these things but every time I get to talk to an expert, like I always learn like new nuggets of things that Medicaid covers or people that are impacted by its programs. Like, it is amazing how many people are benefiting from these services and what a big role it plays in combating the really high maternal mortality rate in this country.

Madeline: Yeah, absolutely. It plays a crucial role in ending the epidemic and, as I noted, states that have expanded Medicaid have witnessed reduced maternal mortality and lowered inequities across racial lines. So, really profound effects for reproductive health equity.

Jennie: I was really amazed last year for our 50-state report card we started to measure, we added on the maternal health expansion where they could expand coverage postpartum for one year and I expected to see variation, like, I expected to see, like, a bunch of states deciding not to do it like in other parts of Medicaid. And I was shocked this year as we're getting ready for the report card to come out next week, like, there were only two states that have not expanded. And first of all, I have to say: shame on Wisconsin. I am from Wisconsin. Come on y'all. But it was amazing to me that there were only two states.

Madeline: Yeah, the uptake of the American Rescue Plan Act state plan option to extend Medicaid coverage after pregnancy from the statutorily required roughly 60 days after pregnancy ends to a full year after pregnancy ends has been spectacular. It's been wonderful to see almost every state adopt the option in a short number of years including states like Mississippi and other states that have not yet expanded Medicaid. And those reforms unfortunately are that uptake of that optional expansion and extension of coverage is unfortunately now on the line as Congress faces the prospect of severe cuts to the program.

Jennie: Okay. I guess that means we have to turn to, like, the bad news. Now that we know all of the great things that Medicaid covers and how important it is, let's talk about these proposed cuts that were in the House budget and what it would mean to people.

Madeline: Yeah, so I think now is a good time to take a deep breath. Yeah, we're dealing with so much heaviness in our movement right now, so many attacks on a daily basis from all fronts and so I just want to, like, pause and take a breath before we dive in 'cause this too is heavy stuff. So, the House recently passed a budget resolution that requires at least a minimum of $880 billion in budgetary cuts from the energy and commerce committee. President Trump endorsed this resolution and many of us...[Jennie's cat walks by] hello, kitty!

Jennie: She apparently has strong thoughts on Medicaid cuts.

Madeline: We, we all should.

Jennie: [Chuckles]

Madeline: Many of us have heard Republicans say there is no mention of Medicaid in the budget resolution or there will be no Medicaid cuts or my favorite the Senate will fix it. But as the congressional budget office made clear in its response to ranking members, there are only $135 billion in E and C's jurisdiction outside of Medicare, Medicaid, and CHIP, the Children's Health Insurance Program. Even if Republicans zero these programs out entirely, that's less than one sixth of the minimum $880 billion in cuts required by the house budget resolution confirming what we all know which is that the only way to meet their target for the Energy and Commerce Committee is through deep damaging cuts to Medicaid. We're still waiting on bill text but there are some policy proposals floating around for how we get there and some of the cuts we're likely to see are Medicaid work requirements, cuts to federal matching funds or the FMAP that I mentioned before, provider tax cuts, per capita caps, and attacks on Biden-era regulatory reforms that improved access to care for Medicaid beneficiaries. I can't stress enough that we cannot take at face value Speaker Johnson's comments on certain Medicaid cuts being off the table. It's clear that the situation is fluid, and that decisions are still being made, and that chair Guthrie continues to push for per capita caps and FMAP cuts to be included in reconciliation. So, what are some of these proposals? The first of these is per capita caps. Under the current federal state Medicaid financing model, the federal government pays a fixed percentage of state's Medicaid costs, whatever those costs may be. And those costs can fluctuate a lot from beneficiary to beneficiary depending on what an individual's health needs are. They can fluctuate across geography, depending on what access to care looks like in a particular location. And a per capita cap would radically restructure Medicaid financing so that states would receive only a fixed amount of federal Medicaid funding per beneficiary regardless of state's actual costs, capping the possible funding that states can receive for covering their enrollees. Congress has estimated that this proposal would cut federal spending by up to $900 billion over 10 years. The second proposal floating around is FMAP cuts. FMAP cuts would cut the amount of federal matching funds that states receive for Medicaid coverage. So for example, before I mentioned that states receive 90% FMAP for Medicaid expansion enrollees. This means that the federal government picks up 90% of the cost of covering those beneficiaries. Several states have trigger laws in place that require them to unwind Medicaid expansion if that FMAP bump goes away. So, FMAP cuts are both a direct cut to Medicaid and a cost shift to states that will lead to cuts in Medicaid eligibility and services. This would include cuts to access to key services for people with disabilities, cuts to sexual and reproductive healthcare services—and Congress estimates that FMAP cuts could cut federal spending by up to $561 billion over 10 years, provider tax cuts—under current law all states except Alaska institute taxes and assessments on hospitals, nursing homes and other healthcare providers—as well as Medicaid managed care plans to help finance their share of Medicaid spending. These taxes help states cover more people and services, which in turn helps providers and managed care companies because they're able to get reimbursed for coverage or care for more enrollees. One of the options for cutting Medicaid is to restrict your end provider taxes. This would reduce federal spending because states can't possibly make up the revenues raised by provider taxes with other sources such as income taxes and sales taxes. So, states would have to cut their Medicaid programs and because of that federal state Medicaid financing model, this would reduce federal Medicaid spending as well and Congress estimates it would do so by about $175 billion in federal spending over a 10 year period. And before I move on to some of the other proposals on the table, I just wanna talk about how these cuts to Medicaid funding would impact SRH. So, all of these would reduce the amount of federal funding available to states to help provide essential sexual and reproductive health coverage. With less funding, states would likely scale back eligibility for their Medicaid programs. States that expanded Medicaid might reverse course while states considering expanding that small number of holdout states might halt those efforts. States might also lower their income eligibility thresholds for pregnancy coverage or drop critical optional programs such as coverage for people with breast and cervical cancer or limited-scope family planning coverage, causing millions to lose their health insurance. Funding caps could lead states to reduce the availability of critical services. States struggling to fund their Medicaid budgets would likely reduce the services available to people who remain eligible. And for example, states could narrow the list of covered pregnancy related services. They might attempt to drop outpatient prescription drug benefits or limit the number of prescriptions enrollees can fill per month, leaving people with HIV, endometriosis, and other chronic conditions without essential and potentially life-saving medications. And these cuts could lead to weakened protections for pregnant people and their families. For example, we just talked about the American rescue plan option to extend pregnancy related coverage to a full year after pregnancy ends and how, since 2021, nearly all states have taken up that option but that extension remains optional. And so, if states no longer have adequate funding, then they might drop those coverage extensions for people that are so critical to ending the maternal mortality crisis. These cuts could also weaken contraceptive access. Under the financial pressure from funding cuts, states could seek to roll back or request exceptions to federal standards that ensure access to contraceptive care and federal regulators might choose to waive the freedom of choice requirement that allows people to visit any family planning provider of their choice.

Jennie: I think it's so easy to get lost in, like, the big numbers we're talking about of funding to, like, forget that these are people's lives and health we're talking about and the millions of people that are gonna be impacted by these cuts—it's not just these big numbers that get thrown around like it's just money we're talking about but it's health coverage for people who need these services. And I just wanna make sure that, like, we're standing on that because it is going to be devastating to so many people if these cuts go through.

Madeline: Yeah, I mean again we're talking about coverage for 72 million people, many people who access sexual and reproductive healthcare through this program. So, there's a lot at stake and, unfortunately, that's not all that Congress is considering, there's more. Medicaid work requirements have long been a cornerstone in efforts to end access to affordable health coverage for low income and underserved communities and they're one of the most insidious strategies to cut Medicaid because they do so by triggering coverage losses rather than appear directly as a funding cut to states. Nearly three decades of evidence across public benefits programs demonstrate that work requirements don't improve employment outcomes, their purported purpose and instead trip people up and then blame them for falling. Work requirements are excessive, intrusive and unnecessary government bureaucracy. We know that the vast majority of Medicaid enrollees who can work already do so and people, because of work requirements, many people would lose the health insurance coverage that allows them to access the health services that allow them to work—directly undercutting and destabilizing our workforce. So, it's an interesting strategy to promote work when it actually does the opposite. Work requirements also force individuals to either navigate red tape to prove they're already working or qualify for an exemption or lose their health insurance coverage. And we know from decades of experience with work requirements in SNAP and TANF [Temporary Assistance for Needy Families], as well as the short period of time that our Arkansas tested work requirements during in Medicaid during the first Trump administration, that exemptions to these requirements for certain populations don't work as intended and are extremely difficult to obtain. People who are pregnant, have disabilities, or have parenting or other caregiving responsibilities are often purported to be exempt under public benefits work requirements. But we know from experience they often struggle to prove that they qualify for exemptions or maybe discriminatorily denied them often based on race or ethnicity. Beneficiaries also often experience significant power differentials with program caseworkers who have a great deal of discretion in whether they grant work requirement exemptions and often arbitrarily refuse them. For example, there is a 2022 study on TANF work requirement exemptions for intimate partner violence that shows that even when women documented and showed evidence and recounted their experiences of interpersonal violence to caseworkers, many caseworkers still chose to deny these exemptions because they just didn't believe in the exemptions or across racial lines. So, we can't count on exemptions. So ultimately, Medicaid work requirements truly would only serve to further efforts to all but eliminate sexual and reproductive healthcare access for low income and underserved communities and further reproductive oppression in the US and really truly are just Medicaid cuts by another name.

Jennie: Yeah, I feel like I remember hearing so many stories when—I guess it must have been when the Arkansas one was in place—of people like trying to meet the work requirements and like having to show up and like them losing their job because they had to have all this time to, like, go in weekly to show that they were working to keep their Medicaid and it was a barrier for people to actually have those jobs.

Madeline: Yeah, that's absolutely right. It has been shown to be an employment barrier, to worsen people's health, to increase medical debt. Work requirements are tied to all kinds of really horrible outcomes. We also know right now Georgia is testing work requirements under a program that was approved by the first Trump administration and of the estimated 300,000 people who should have been able to access coverage through Medicaid expansion, only 6,500 people have been able to enroll in Medicaid coverage under the Georgia Pathways program. And we know, looking at North Carolina, which recently implemented Medicaid expansion and is a similarly sized, a state with like a similar makeup, that that 300,000 person estimate for Georgia is actually probably half of what Georgia would actually see in Medicaid expansion.

Jennie: Wow.

Madeline: So, it's really probably like 6,500 people of really, like, 600,000 people that would probably be able to get coverage in Georgia under actual Medicaid expansion. So, work requirements really can keep the front door closed from health insurance coverage. Or depending on how they're designed, kick thousands of people out. In just a seven-month period of testing work requirements in Arkansas, roughly 20,000 people were kicked out of the program.

Jennie: Okay, this is all very depressing and the fight is just beginning 'cause I'm sure even if it's not successful this time around, it's not going anywhere. As I feel like we keep reliving some of these things. What can we do to protect Medicaid?

Madeline: So, we're living under not just a Republican trifecta, but a far-right trifecta amid severe democratic backsliding. I don't know if you saw Jennie, but just last week the US was deemed a non-democracy. So, that's a heavy thing to bear witness to. And while administrative advocacy is going to be critical for Medicaid defense, changes to the underlying statute, the Medicaid Act, the Affordable Care Act, these underlying statutes are generally far more dangerous because they're far harder to undo. So first and foremost, we have to stop Congressional attempts to cut Medicaid and interrelated civil rights.

Jennie: Okay. So, that's what we need to do. How can the audience get involved? Like what can the audience do to make this happen?

Madeline: So, it's not hyperbole to say that the threats facing the Medicaid program are imminent and we need everyone in this fight, including those who care about sexual and reproductive health, rights, and justice. So, please if you're listening, take a few minutes to contact your members of Congress and urge them to save Medicaid. Urge them to oppose any Medicaid cuts through budget reconciliation or other legislation. Remind them that Medicaid cuts would devastate your community by taking health insurance away from millions, including kids, people in nursing homes and those living with a disability or chronic conditions. If your Representative or Senators are supportive of reproductive rights, you can also stress that any cut to Medicaid is a cut to sexual and reproductive healthcare access. I think that message is important depending on who your audience is and no matter who you're represented by in Congress, you should tell them, remind them that Medicaid cuts would increase healthcare costs for everyone, including medical debt for millions. It would just stabilize hospitals, health centers and other providers that we all rely on, especially in rural communities and just like really keep beating the drum, keep calling. It's really, really important that your members of Congress hear from you and you can reach them by calling a dashboard that health advocates have set up. That number is 866-426-2631. Again, that's 866-426-2631. And please help spread the word. If you've never been covered by Medicaid, it's very likely that you know folks who have. I certainly have, a lot of us in this movement have. And you can also learn more by visiting the National Health Law Program's website. We have a Medicaid defense landing page with dozens and dozens of resources on what these cuts would mean with a lot of explainers on the various options, which I'm happy to share in follow up. We have a number of materials on how Medicaid cuts would affect sexual and reproductive health in particular.

Jennie: We will make sure to include links to all of those in our show notes to make sure that y'all are able to access them and take action. Madeline, thank you so much for being here. It was so wonderful to talk to you about what an important program Medicaid is and the huge threat it is under.

Madeline: Thank you so much for having me, Jennie. And yeah, as I said, this truly is an all hands-on-deck moment. We need every voice loudly saying: save Medicaid. So please, if you're listening, consider getting involved.

Jennie: Okay y'all, I hope you enjoyed my conversation with Madeline. It was so great to get to talk to her about everything related to Medicaid. There is so much happening right now and it is really important that we raise our voices and make sure that our Congress people know that we support Medicaid, we think Medicaid funding is important and that we save this program. Millions of lives are counting on it. We need to make sure that the Medicaid program stays strong and stays safe to ensure that all of these people who rely on it are able to keep their healthcare. So with that, get loud. Make sure that everyone knows that you support Medicaid and that we need to save this program. And with that, I will see everybody next week.[music outro] If you have any questions, comments, or topics you would like us to cover, always feel free to shoot me an email. You can reach me at jennie@reprosfightback.com or you can find us on social media. We're at @RePROsFightBack on Facebook and Twitter or @reprosfb on Instagram. If you love our podcast and wanna make sure more people find it, take the time to rate and review us on your favorite podcast platform. Or if you wanna make sure to support the podcast, you can also donate on our website at reprosfightback.com. Thanks all!