With President-elect Donald Trump's inauguration set for Monday, there's still a lot of uncertainty about what changes his administration and the new Republican Congress could usher in.
Republicans in Congress have begun discussing possible changes to Medicaid — the public health insurance program for low-income and disabled Americans that covers 80 million people. Those changes could potentially cut federal spending for the program by more than $2 trillion over the next decade and lead millions to lose their coverage.
Those proposals face a long road to being enacted — but would be a dramatic departure from the Biden administration's approach to the program.
Biden's team at the Center for Medicaid and CHIP Services — led by Dan Tsai — worked to keep people enrolled as states redetermined Americans' eligibility for the first time since before the COVID-19 pandemic. The Biden administration also encouraged states to expand what the program covers.
"Medicaid saves people's lives," Tsai told the health care podcast Tradeoffs this week, as he reflected on his time at Medicaid's helm.
Before coming to Washington in 2021, Tsai ran the Massachusetts Medicaid program during the Obama and Trump administrations.
Tsai said he saw first-hand how people in Massachusetts struggled as they tried to enroll in Medicaid. That experience motivated his work in the Biden administration.
He remembers one family in particular who showed up looking for help filling out their enrollment paperwork.
"I'm the Medicaid director, and I couldn't help them diddly squat," Tsai told Tradeoffs. "That really cast a very clear light on 'Why is it so difficult for folks to enroll in and renew their Medicaid?'"
In a wide-ranging discussion, Tsai revealed what he's learned about Medicaid during his time in Washington — and his hopes and concerns for the program's future.
The following excerpt has been edited for length and clarity.
Interview highlights:
On why he thinks Medicaid is so important
We know very clearly that having Medicaid leads to a significant reduction in kids dying. One study showed a 5% reduction in childhood mortality for kids having access to Medicaid. Medicaid expansion has been shown to reduce adult mortality by 9% over the first four years of Medicaid expansion after the Affordable Care Act. That's 15,000 deaths that could have been avoided had all states adopted Medicaid expansion in 2014. We also have a wealth of studies that show when people do have access to Medicaid coverage, they will use primary care, they will access preventative services, mental health services. And they don't forgo getting things like their prescription drugs.
I just also want to emphasize the broader economic and societal benefits from Medicaid. When I was the Medicaid director in Massachusetts, some of the most urgent phone calls I would get would be around the viability of a local hospital — the ability for Medicaid to be able to continue reimbursing that hospital, and the implication of hundreds, in some cases, thousands of jobs local to that community of having an anchor institution available. [It might determine] whether or not your teachers in the community and others could have a place to access oncology care, or whether or not there would be a hospital available for people in the community to deliver babies locally.
On why he focused on making it easier for people to enroll in Medicaid and renew their coverage.
I guarantee, if you and I were enrolled in Medicaid for our families, and my best answer to you of when you would go up for your Medicaid renewal was, "I don't know, check your mail every day for the next year and make sure you don't miss that piece of paper. And if you don't respond in the 10 days or whatever your state gives you, you're going to lose health care coverage. And your kid who relies on critical medications might not be able to get them," we would be so angry, so frustrated. We would not accept that. And that is what 1 in 4 people in the country have had to experience for far too long.
On how the Biden administration made it easier for people to stay on Medicaid
We doubled the rate of auto-renewals. The percent of people going through a renewal where a state ... can just ping up and say, "You know what? That person was at $13,000 of income last year, they were still at $13,000 of income. We should auto-renew them."
We doubled that from 25 to 53 percentage points over the course of 18 months. I have very seldom seen progress at this scale and speed, and I think this came from the entire country having this amount of absolute dedicated focus with both CMS and states rolling up their sleeves and doing a ton of work. I cannot emphasize how difficult, whether it's a blue or red state, you have dedicated public servants doing incredible things.
The experience is still too complicated, but we've made a massive dent in that. This is not an insurmountable thing. That is such deep rocket science like, how to improve the entire health of the population... This question is much simpler. And it takes very concerted, detailed work, but it can actually happen, and it can happen over a relatively compressed time frame.
On criticisms that the Biden administration kept millions of people on Medicaid who didn't need to be
I don't think that is a fair criticism. Many of the types of policies we put in are focused on how to keep eligible people enrolled. And we have seen many people that lost their coverage during the unwinding period come back very quickly. That tells us they were still eligible.
I'll give you one example. Let's say last year you were low-income, meaning under the federal poverty limit (so $15,000 for an individual or $31,200 for a family of four). And this year, the state pings up against all known electronic data sources and does not return any income. In that case, 92% of the time, you're likely still to be low-income and would qualify for Medicaid.
We know from the data a lot of those people were falling through the cracks. You have many eligible people inappropriately losing health care coverage. … This is a very surgical way of reducing red tape. And these are the types of, I think, smart, data-driven policies that actually make a difference.
On what he learned about what happens when Medicaid covers nontraditional health care services, like housing and food
You always find that a small percentage of people account for an enormously large portion of health care costs. Those individuals, almost without fail, have this incredible complexity of physical health care conditions, often mental health, behavioral health conditions, and a range of psychosocial things, including housing instability, sometimes nutritional instability. And on a Medicaid program that costs $900 billion across the country, you have to find a better way of making sure we can deliver care and not having this incredible spend for folks just to bounce in and out of acute care settings.
There are many really important questions, not least of which is, what should Medicaid pay for? Because we are a health insurance program. And after a year and a half of intense policy debate at the federal level, we came to the conclusion that, yes, Medicaid does have a role — with guardrails — in actually paying for, in certain circumstances, things like housing and nutritional supports.
One really critical thing I would say to anyone interested in this is to not underestimate how difficult it is to make this actually work on the ground. I've been in rooms with literal shouting matches between health care providers and community-based [housing and nutrition] organizations all accusing the others of bad intentions or lack of competence. And so I think it is a huge area where we need to make progress in keeping folks from cycling in and out of the system.
On the future of Medicaid under Republican control of the White House and Congress
I am both optimistic, and I think we're at a time of great risk for the program. I'm optimistic because so much of the progress that we just discussed was a ton of systems and operational work between our team and the states to actually fix things that were at the state level.
And the reason why I say progress is at risk is because the types of policies that could be considered – massive cuts to the program – will lead to more eligible people going uninsured. And I think it will be very damaging to the health of the American people.I do not think it is at all an exaggeration. You are going to have worse health outcomes and people will lose their lives as a result.
Dan Gorenstein is the executive editor of Tradeoffs, a nonprofit health policy news organization. Reporter Ryan Levi produced this story for the Tradeoffs podcast, and he and editor Deborah Franklin adapted it for the web. Tradeoffs' reporting for this story was supported, in part, by West Health.
Listen to the interview here:
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