The 2024 Election Could Have Massive Impacts on Medicaid Coverage

A decade ago, an old work injury put Fred Blackman II in the hospital with a slipped spinal disc that threatened to paralyze him.

The Austin, Texas, minister spent the next five months there, enduring five back surgeries, extreme pain and a brain infection. He almost died.

After discharge, he returned to a life he didn’t recognize. He’d lost his job at an insurance company, his health coverage and his house, and his marriage was falling apart. He could barely walk and owed more than $500,000 in medical bills.

He got emergency Medicaid coverage with the hospital’s help, but it lapsed after a few months. He was in desperate need of health care and therapy. “I had nothing,” he says.

The minister, now 51, would eventually emerge from the crisis, but the health and financial effects persist. And Blackman says he came to better understand the importance of having access to affordable care — and the government’s role in providing it. He’s now a public advocate of expanding health-care access in Texas and the nation.

If Texas had expanded Medicaid eligibility for low-income adults under the Affordable Care Act, as 40 other states and Washington, D.C., have done, Blackman would have easily qualified for coverage of the care he needed.

More Americans could find themselves in Blackman’s position — uninsured, in financial stress and locked out of the largest federal safety net for health care — if leading conservative visions for the program come to fruition.

Three notable blueprints — the Heritage Foundation’s Project 2025 report, the fiscal year 2025 Republican Study Committee budget plan and the FY 2025 House budget resolution — all propose Medicaid cuts and changes that are more likely to happen under a Trump administration and a Republican Congress. Some researchers say all three plans would slash federal Medicaid dollars and scrap the 90% federal matching rate for Medicaid expansion enrollees.

In interviews with Public Health Watch, health economists and policy experts said the plans would drive up the uninsured rate and financially strain hospitals and health providers that care for uninsured and Medicaid patients.

The people most likely to be affected would be those with the fewest resources to obtain health insurance elsewhere, such as from private employers and the federal marketplace.

Some of the proposals, such as cutting federal Medicaid funds and imposing work requirements on beneficiaries, have been Republican staples for years. The latter was tried and struck down in federal court during the first Trump administration.

In his current run for the White House, Donald Trump has not talked specifically about his plans for Medicaid and denied any association with Project 2025. A New York Times report found numerous ties between the project and his campaign. Based on actions during his first term — including attempts to repeal both the ACA and Medicaid expansion — political observers believe that Medicaid will again be a target if Trump is elected Nov. 5.

“I think they may use the same playbook they did during the first Trump administration,” said Nicole Huberfeld, a professor of health law at Boston University School of Law and School of Public Health. “It could just happen faster this time around because they already have a blueprint for the policies they want.”

The trio of conservative plans assert that Medicaid’s financing is in need of reform to address a substantial rise in federal Medicaid spending.

“This unrestrained growth in Medicaid spending is unsustainable,” states the House budget resolution. The Congressional Budget Office projects that Medicaid spending will rise by more than 60% over the next decade, to $898 billion, or 2.2% of gross domestic product.

The GOP plans also cite a few studies that have found, in some cases, Medicaid patients are more likely to have poor health outcomes than the uninsured, and health-care expansions have minimal effects on health. A review of nearly 200 studies by KFF, a nonprofit research group, found instead that Medicaid expansion benefits patients with many conditions, from cancer to mental health.

Asked how Project 2025 and the GOP plans would affect uninsured rates, the Heritage Foundation declined to comment. A spokeswoman said it doesn’t comment on coverage related to an election because, as a 501(c)(3) nonprofit, it is prohibited from involvement in campaigns.

A spokeswoman for the Republican Study Committee and its chairman, U.S. Rep Kevin Hern, R-Oklahoma, did not respond to requests for comment.

The stakes are high. As of June, almost 73 million adults and children, or more than one in five Americans, relied on Medicaid for affordable health care. The federal-state insurance program pays for more than 40% of U.S. births, provides supplemental coverage to 7.2 million poor seniors and insures more than 10 million people with disabilities.

Nearly 60 years old, Medicaid covers more Americans than Medicare, the insurance program for people aged 65 and older.

Some experts say that conservatives’ plans would likely result in a radical downsizing of Medicaid and destabilize a critical piece of the country’s health care infrastructure.

“Tens of millions of people could either become uninsured entirely or lose access to the care they need,” said Edwin Park, a research professor at Georgetown University’s Center for Children and Families.

Capping Medicaid Dollars

After COVID-19 sent the country into recession, state Medicaid rolls ballooned to record highs, catching millions of Americans who suddenly were jobless and couldn’t afford health insurance.

The jump in enrollment wasn’t a surprise. Medicaid numbers typically surge during severe economic downturns, such as during the Great Recession in the late 2000s.

State Medicaid programs can respond quickly in economic crises because states have a deal with the federal government: It pays a percentage of state Medicaid costs regardless of how many people enroll. States are guaranteed a certain share.

The percentage for traditional Medicaid varies by state, ranging from 50% to 78%, according to the Kaiser Family Foundation. For people covered by expansion — low-income, nonpregnant adults without dependents or disabilities — the federal government pays 90% of costs.

Park said that flexibility could fade under conservative proposals because they would use block grants or per-capita caps to limit federal Medicaid dollars.

Block grants would give Medicaid programs a fixed amount of federal funds instead of a percentage of overall costs. A risk is that if states faced unexpected Medicaid demands — such as from a natural disaster or an expensive new drug therapy — they could be on the hook for 100% of costs.

Per-capita caps are similar, with states getting a fixed amount of federal dollars per beneficiary. The Project 2025 plan also includes lifetime limits on Medicaid benefits.

Park said the GOP plans don’t detail how the grants or caps would be implemented. But such measures are typically designed to generate large savings over years, he said, as states see a diminishing flow of federal Medicaid dollars.

The three plans also would slash the 90% federal rate for people covered by Medicaid expansion, which as of February this year insured more than 23 million people.

“That’s a huge cut,” Park said. “Eventually, most states would likely have to drop expansion because it’s such a big cost shift.”

The Trump administration tried to cut Medicaid funding using budget legislation and the Medicaid waiver process but didn’t succeed. Park said if a major cut is made, states could face stark choices: Increase state funding, perhaps by raising taxes, or reduce Medicaid services and eligibility.

How some states might react could be seen in the recent Medicaid “unwinding,” in which states began removing enrollees again after a suspension of the process during the pandemic, said Benjamin Sommers, a professor of health care economics and medicine at Harvard.

Texas, for example, was aggressive in its approach to unwinding, removing more than 2 million people from the Medicaid rolls, most of them children. A Texas Tribune/ProPublica investigation found the state ignored federal guidance meant to prevent eligible Texans from being disenrolled.

“I imagine, in some states, it would be a race to the bottom,” Sommers said. “Those who are eager to have small Medicaid programs will move fast.”

Federal cuts could also cause a surge in uninsured rates. Medicaid expansion alone covers tens of millions of people.

The newly uninsured can turn to already-strained safety-net programs, such as federally qualified health centers, or FQHCs. But research shows that having health insurance is associated with better health outcomes and longer life. A wave of coverage loss would likely worsen all kinds of health measures, Sommers said.

After Blackman, the Austin minister, lost his health insurance, his providers recommended that he visit the People’s Community Clinic, a local FQHC that serves uninsured residents.

He credits the clinic, where he now serves as board chair, with saving his life and pulling him out of a deep depression. But it can’t provide all of the complex specialty care Blackman needs.

After two years of going uninsured and failed attempts to qualify for Texas Medicaid, he qualified for Medicare because of his new disabilities. But it doesn’t cover his costs as much as Medicaid would, so he depends on family, friends and his church to help fill the gap.

He’s lucky. In 2020, they raised $10,000 for his latest back surgery. His bones had finally healed enough so doctors could insert the metal screws and plates to keep his spine intact. He’d put the surgery off for more than a year because he couldn’t afford the out-of-pocket Medicare costs.

“How many people are in my position?” Blackman asked. “I see homeless people in wheelchairs and I think, ‘Could that have been me if I didn’t have family or church?’”

Impact in Every State

Medicaid is the single largest source of health coverage in the U.S. If Republican and right-leaning Medicaid proposals were to become reality, no state or community would be left unaffected.

Timothy McBride, a health economist and professor at Washington University in St. Louis, put it bluntly: Turning Medicaid into a block grant would cause states to run out of money.

“Is it the fault of the Medicaid program that health care costs are rising so much?” he said. “I don’t think it is.”

Rural areas, which generally have higher uninsured rates than urban ones, could be especially hard hit, McBride said. Almost half of children and 1 in 5 adults in small towns and rural areas depend on Medicaid or CHIP, according to a Georgetown University report.

Shifting to block grants wouldn’t be an easy lift. Republican Presidents Ronald Reagan and George W. Bush proposed such a change, but the efforts failed. During Trump’s first term, GOP lawmakers supported bills to repeal the Affordable Care Act that also included measures to block-grant or cap federal Medicaid dollars.

Huberfeld, the health law professor in Boston, said the federal-state funding arrangement for Medicaid is enshrined in statute, and to alter it, Republicans would need enough votes in Congress and a president willing to sign the bill.

In her view, the way the Medicaid Act is written, “this is not a waive-able feature of the program.”

But another Trump administration might try to go around Congress, using tactics it tried in his first term.

Under Medicaid, states can apply for federal waivers, which gives them the flexibility to try different approaches in carrying out the program. Near the end of Trump’s term, the U.S. Centers for Medicare and Medicaid Services used its waiver authority to approve a demonstration project in Tennessee that capped nearly all of the state’s federal Medicaid dollars for a decade.

The Biden administration renegotiated the Tennessee waiver, scrapping the block-grant plan.

Also in Trump’s first term, the CMS used waivers to approve work requirements for Medicaid beneficiaries. Only one state, Arkansas, implemented those, which data show resulted in large coverage losses and didn’t increase employment.

A federal court struck down the requirements in 2020, calling the administration’s decision to approve them “arbitrary and capricious.” Project 2025, the Republican committee budget plan and the House budget resolution call for Medicaid work requirements.

It’s unclear exactly how another Trump term would target Medicaid. But Park, at Georgetown, said that cutting the program could be floated as a way to offset the costs of extending the Trump-era tax cuts, which expire in 2025.

“Ultimately, I think the goal is to dramatically shrink Medicaid,” Park said of conservatives’ efforts over years.

Blackman, the Austin minister, knows more than most what it’s like to live in a state with a bare-bones Medicaid program.

In Texas, low-income adults who are not pregnant or in postpartum or don’t have dependents or disabilities don’t qualify for Medicaid. Parents in a household of four don’t qualify if they make more than $4,000 a year. Republican state leaders oppose Medicaid expansion.

Texas has the highest uninsured rate in the nation — which Blackman considers a badge of shame.

His own experiences have turned him into an outspoken advocate for improving health care access in the state where generations of his family have lived. He meets with lawmakers in Austin and travels to Washington, D.C., to tell his story.

At the state Capitol, he said, the words “Medicaid expansion” are a nonstarter these days, despite polls showing most Texans support it.

He works around this, undeterred, drawing strength from his favorite Bible verse, which says that “old things have passed away; behold all things have become new.”

“I know I’m on the right path,” Blackman said. “I know that advocating for health care for God’s people is something that needs to be done.”

The story is part of “Uninsured in America,” a collaborative project led by Public Health Watch that focuses on those with little or no health insurance and the 10 states that haven’t expanded Medicaid under the Affordable Care Act.

Kim Krisberg, who co-leads the project, is a contributing writer for Public Health Watch who has covered public health policy and science for two decades.