Biden wants to strengthen Medicaid, but Trump left major hurdles for him

In rural Clay County, Georgia, access to health care is not always easy to come by. So when an area hospital that had long been on the financial brink closed in October because of the pandemic, Dr. Karen Kinsell, the only doctor in the county, was left with even fewer resources to treat her neighbors.

It’s rare that Kinsell’s patients have insurance or are even covered by Medicaid, the federal and state program aimed to help the country’s poorest receive medical care. In this southwest corner of Georgia, one of the dozen states that still hasn’t expanded Medicaid, it’s typical for her patients to have no health care coverage at all.

So Kinsell charges $10 for a doctor’s visit, less if patients can’t afford it.

“Everybody is born, everybody dies, and most people get sick in between,” Kinsell said. “For one of the richest countries in the world, one of the most medically advanced, to just be leaving out 10 to 20 percent of their population from participating in that service is just wrong. It’s immoral and not sustainable. It hurts the entire system.”

It hurts particularly bad in Georgia, which has the third highest rate of uninsured people in the country, according to the Census Bureau. It’s also a state where lawmakers have forgone billions of federal dollars that would have helped provide hundreds of thousands of Georgians with health care coverage by expanding Medicaid enrollment.

The Biden administration hopes to quickly help those uninsured in Georgia, as well as in 11 other states, by providing incentives to expand Medicaid. The efforts won’t be easy, however: Some state leaders, like Gov. Brain Kemp last year, pursued a variation of Medicaid expansion pushed by the Trump administration — a version that undercuts the federal insurance program, implements work requirements and leaves hundreds of thousands of people without access to coverage.

Republican lawmakers maintain that expansion is too heavy a financial burden for states to take on, even though the federal government will pay for 90 percent of it. There is also ideological opposition to the program, especially as it was formed under the umbrella of Obamacare.

The governor’s office did not respond to a request for comment.

So far, 38 states have expanded Medicaid; Georgia, Mississippi, Tennessee, Alabama, Florida, North Carolina, South Carolina, Texas, Wyoming, Kansas, South Dakota and Wisconsin have not. That has left millions of people without coverage more than a decade after states were eligible to enroll in Medicaid expansion through the Affordable Care Act.

Hours after Joe Biden took the oath of office as president, the White House dedicated last Thursday to the signing of an executive order to take steps to “strengthen Medicaid and initiate an open enrollment period under the ACA,” also known as the Affordable Care Act or Obamacare.

The White House declined multiple requests to provide more specifics about the order and how it would strengthen Medicaid, but many policy experts say it will address the numerous waivers provided by the Trump administration.

During the Trump administration, the Centers for Medicare & Medicaid Services, or CMS, provided a series of waivers — in essence, agreements between states and the federal governments about the implementation of Medicaid — for states to pursue their own goals with the program.

Most notably, the Trump White House pushed to provide waivers to allow states to enact work requirements to receive state Medicaid benefits, which no administration had done before and which Congress had voted down in 2017.

Now many wonder what it will take for the Biden administration to unwind some of those policies and expand access to health care as he promised.

“Each administration does have some discretion and flexibility, but given all the litigation we saw, that discretion is not unlimited,” said Robin Rudowitz, vice president of the Kaiser Family Foundation’s Program on Medicaid and the Uninsured. “It certainly is still being tested in the courts, but I think it’s not disputed that there’s flexibility for a new administration to rescind and issue new guidance on what waivers they’d like to promote and encourage. For anything that’s pending, those are negotiations between the administration and the state.”

That has, in essence, left behind a political bomb for Biden and the new administration to defuse, most likely at the cost of political capital, while increasing tension between states and the federal government.

“The fact that during a pandemic, when Medicaid is a first responder, they were spending so much time trying to booby-trap the program and handcuff the Biden administration when they walked in the door is abhorrent,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

Nineteen states have approved or pending work requirement waivers, which critics say damaged Americans’ access to a vital safety net program and could cause quite a bit of trouble for the Biden administration to dismantle.

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