Since the early days of the Trump administration, it’s been clear the president and his Congressional allies have set their sights on dismantling the Medicaid program as we know it. And we are gearing up for yet another attack. After failed attempts to repeal the Affordable Care Act and limit Medicaid spending, the administration is planning to issue guidance that would allow states to implement block grants or caps using Medicaid’s Section 1115 waiver authority.
This would give states a back-door mechanism to put people and families currently enrolled in Medicaid at risk of reduced access and services, fundamentally changing Medicaid’s funding structure. Communities of color, women, LGBTQ individuals, and those who live at the intersections of these identities will face the brunt of the harm.
As the nation’s largest health coverage program, Medicaid is vital for reducing health disparities and providing a wide range of health care services to our communities, including primary and specialty care, reproductive and sexual health care, and gender-affirming care. The program provides coverage for over 75 million individuals, a significant portion of whom are people of color, women, and LGBTQ individuals. Due to systemic barriers, discrimination, and poverty, these communities rely on Medicaid as their primary source of health care coverage. And they can’t afford to lose any of the program’s critical services. Women comprise the majority of adults in the program, and coverage rates are even higher among women of color, single mothers, women with low-incomes, and women with less than a high school education. The program provides coverage to approximately 1.2 million LGBTQ adults. Medicaid is also the largest source of coverage for persons living with HIV, who are disproportionately black and Latinx.
As organizations that fight for reproductive justice values, we understand that there cannot be true equality unless everyone has access to the resources they need to make healthy decisions for themselves and their families, with dignity and self-determination. A robust Medicaid program is a key piece to attaining agency for women of color and LGBTQ individuals.
Proposals to convert Medicaid to either a block grant program, which would cap total federal spending on the program using a fixed formula, or through per capita caps, which would cap spending for each individual enrolled in Medicaid, will only exacerbate the vast health disparities experienced by women of color, LGBTQ individuals, and those living at the intersections of these identities.
Altering the Medicaid financing structure will give states the ability to limit the number of people they cover and restrict the scope of benefits they provide. A recent study commissioned by the Children’s Hospital Association estimated that states could lose up to $163 billion in federal funding just for children between fiscal years 2020 and 2029.
The study concluded that states have “limited levers to control Medicaid program costs,” and reductions in funding could force states to reduce or eliminate coverage for some enrollees and limit service use. For example, a Medicaid block grant could open the door for states to lower the income threshold of eligibility so that fewer pregnant women receive Medicaid coverage, set limits on the utilization of family planning services or gender-affirming care, and impose premiums and co-payments on families living with low incomes that will make care unaffordable. For many women of color and LGBTQ individuals, these restrictions could create an impossible choice between putting food on the table and the ability to lead healthy lives with dignity.
Four states — Tennessee, Utah, Alaska, and Georgia — have already taken steps or expressed interest in pursuing block grants or per capita caps for their Medicaid programs. Yet their efforts do not advance reproductive justice values and will only undermine the program’s primary goal of providing affordable health care for those most in need. Many states already face serious health care access challenges, including an alarming rate of rural hospital closures in Tennessee, Georgia, and other states. The combination of shortages in rural health care centers and decreased federal funding means increased risks of preterm births and less maternity care for pregnant people living in those areas.
Instead, states that have not expanded their Medicaid programs must implement full Medicaid expansion, which has already proven to reduce racial disparities in cancer treatment and increase the number of individuals utilizing preventive and primary care. State advocates must also push back on any effort to apply for Medicaid waivers that would allow this change in financing. Block grants and per capita caps in Medicaid would reduce the amount of money states currently receive to provide needed health care, thus making it harder for states to advance their goals in other areas that advance reproductive justice values such as social services, public health, and health education.
Medicaid coverage is key for many individuals to decide with dignity if, when, and how to parent. Medicaid allows many parents of color to raise healthy children while accessing the care they need. Changes to the financial structure of Medicaid will only hurt the communities that need coverage most. No state should follow the Trump administration’s destructive proposal to restructure and reduce funding for Medicaid.