Medicaid’s Narrow Escapes: The Ongoing Fight to Protect Our Children’s Health
As a child growing up in El Paso, Texas, I witnessed firsthand the harsh realities of being uninsured. At times, the uninsured rate for children was as high as 40%. Even in 1999, after Texas finally committed to participating in the Children’s Health Insurance Program (CHIP), it is estimated that over 30% of the children in El Paso were still uninsured.
I vividly recall classmates who worrying they might not be able to play on our junior and high school sports teams because they couldn’t get the required physical exams. But the most heartbreaking memory is of a classmate who tragically died from cancer because he was uninsured and could not access the timely medical care that might have saved his life.
Although Texas has made some progress since those days, the Lone Star State continues to lag far behind and today has the highest uninsured rate for children in this country. Gov. Greg Abbott and the Texas Legislature, where I once worked, should and must do better by its children.
Our nation should aspire to the goal of ensuring that all children have health coverage and access to quality health care.
The Success Story of Medicaid and the Children’s Health Insurance Program (CHIP)
Fortunately, other states have taken some significant steps toward the goal of guaranteeing health coverage to cover children, pregnant women, people with disabilities through Medicaid and CHIP, and more recently, uninsured adults under the Affordable Care Act (ACA), also known as Obamacare.
For children, the partnership between Medicaid and CHIP, which was enacted in 1997, has proven to be a national success story.
These programs provide a lifeline of comprehensive coverage of health care to tens of millions of kids across this country. Over two decades, they have played a leading role in reducing the uninsured rate for children from around 15% in 1996 to less than 5% in 2015 and 2016 – a 70% reduction in the uninsured rate for children.
When the uninsured rate for kids dropped to record lows below 5% in 2015 and 2016, the gap between coverage rates for White and Black children was eliminated. Studies have shown that these investments in child health not only improve the short- and long-term well-being of children but also enhance educational outcomes and save lives. Thans to timely prevention and medical treatment, millions of children are healthier today.
Unfortunately, after two decades of progress, the uninsured rate for children began to rise in 2017 during the Trump Administration. This was due, in part, to the imposition of new bureaucratic barriers to health coverage.
Fortunately, the American people have recognized the importance of Medicaid and have remained widely supportive of the insurance coverage program. In a Kaiser Family Foundation survey earlier this year, 71% of the public agree with the statement:
Medicaid should largely continue as it is today, with the federal government guaranteeing coverage for low-income people, setting standards for who states cover and what benefits people get, and matching state Medicaid spending as the number of people on the program goes up or down.
In contrast, only 28% agree with the idea that Medicaid should be transformed and cut:
Medicaid should be changed so that instead of matching state Medicaid spending and setting certain requirements for health coverage, the federal government limits how much it gives states to help pay for Medicaid and states have greater flexibility to decide which groups of people to cover without federal guarantees.
Medicaid Has Withstood Decades of Ongoing Attacks
And yet, in every decade (1981, 1995-1996, 2003 and 2005, and 2017), Medicaid has been subjected to recurring zombie attacks. These attacks are attempts by opponents to limit, cap, cut, and devastate the program through mechanisms such as block grants.
In 1981, President Ronald Reagan proposed drastic cuts to federal programs, including the block granting of Medicaid. Fortunately, Congress blocked the measure. A later analysis found that Reagan’s proposal had been enacted, it would have cut federal Medicaid spending by 26%, or $77 billion, below actual spending levels between 1982 and 1991.
In the mid-1990s, House Speaker Newt Gingrich resurrected the Medicaid block grant idea (e.g., Medigrant) as part of a larger package that also cut Medicare, reduced education funding, and rolled back environmental policies.
I was working for Sen. Bob Graham (D-FL) in 1995 when a bipartisan group in the Senate came together in opposition to the Gingrich plan. For example, in a series of Senate floor speeches, Sen. Graham highlighted how arbitrarily capped funding, which does not adjust for need during events like population growth, economic recessions, natural disasters, epidemics, terrorist attacks, medical innovations, or inflation.
As Sen. Bob Graham (D-FL) explained:
I have a warning for [governors], or more accurately a proverb for them. The proverb goes as follows: Fish see the worm, not the hook.
Those governors who are salivating, who are so anxious to gobble up block grants being proposed, will feel the hook when their economies stumble, when an epidemic strikes, when a natural disaster hits, when inflation creeps up again, or when their population grows. Worst of all, they will be held accountable in history for killing a program that actually had achieved its objectives and nurtured a national pride in providing basic health care for fragile and vulnerable citizens.
Under block grants, a State that is knocked down to its knees by a flood, earthquake, hurricane, would not find a helping hand from the Federal Government at the time it needed help to get back on its feet. No, Mr. President, acts of God and block grants do not mix.
Sen. John Chafee (R-RI) insightfully observed that children would likely be the first to be forsaken in Gingrich’s plan to slash Medicaid. Chafee explained:
As states are forced to ration finite resources under a block grant, governors and legislators would be forced to choose among three very compelling groups of beneficiaries.
Who are they? Children, the elderly, and the disabled. They are the groups that primarily they would have to choose amongst. Unfortunately, I suspect that children would be the ones that would lose out.
This fight over the Gingrich package led to a government shutdown and a veto of the Gingrich proposal by President Bill Clinton, who said:
The [Gingrich] plan would end the guarantee of quality medical care that now exists for 26 million Americans, a guarantee that has been on the books for three decades now… All told, if current patterns of coverage prevail, some 8 million people could be denied health care coverage under Medicaid; nearly half of them children. No one would want to do this in any state, but many states would have no choice under the budget now pending.
So I just want to be clear about this… I will not permit the repeal of guaranteed medical coverage for senior citizens, for disabled people, for poor children and pregnant women. That would violate our values, it is not necessary, and therefore, if it continues to be a part of the budget, if necessary I would veto it again.
Clinton’s firm stance against cuts to Medicaid, Medicare, education, and the environment – referred to as “M2E2” – was central to his re-election campaign and effectively ended efforts to block grant Medicaid during his Administration.
In his State of the Union speech in Jan. 1996, Clinton said he would oppose undermining “our fundamental obligations to our parents, our children, and our future, by endangering Medicare, or Medicaid, or education, or the environment, or by raising taxes on working families.”
But being a zombie idea that just never seems to die, the proposal resurfaced a few years later (in 2003 and again in 2005) when President George W. Bush’s administration attempted to slash Medicaid and covert it into a block grant. In the early 2000s, I was working with Sen. Jeff Bingaman (D-NM), who took a leadership role with Sen. Gordon Smith (R-OR) to protect Medicaid.
As Sen. Bingaman said after President Bush proposed block granting Medicaid in 2003:
…States would get a fixed amount of Federal money for the millions of people who States have voluntarily decided to cover under Medicaid, and, as a result, Federal funding would be limited and not responsive to those items that it is now responsive to, such as economic recessions, epidemics, terrorist attacks, population growth, changes in the State's health care environment, or the growth in our Nation's elderly that we expect in the next decade. Nor would it be available to States wishing to expand coverage, as I indicated before, States wishing to reduce the uninsured rate.
In 2005, $15 billion in Medicaid cuts were proposed and passed by the House of Representatives. Although some Medicaid advocates were concerned about having a Senate vote on Medicaid in 2005 because Republicans controlled the chamber by a 55-45 margin, Sens. Smith and Bingaman worked together to secure the full support of all Democratic senators and seven Republican senators to successfully strip the billions of proposed cuts to Medicaid through a block grant out of the budget by a 52-48 vote.
This two-vote Senate margin averted a crisis and quelled other Medicaid attacks from taking center stage for more than a decade.
The Trump Administration’s Attack on Medicaid and the ACA
That changed in 2017 when President Donald Trump proposed to simultaneously dismantle the Affordable Care Act and slash Medicaid by hundreds of billions of dollars through his American Health Care Act (AHCA) proposal.
Once again, the health coverage of millions of children hung in the balance, and disaster was averted by the narrowest of margins in the U.S. Senate – this time by just one single, solitary vote.
In a Senate with a 52-48 Republican majority, Sens. Lisa Murkowski (R-AK) and Susan Collins (R-ME) had already expressed opposition to the Senate bill, which was estimated would cause the uninsured rate to rise by 23 million.
In the end, the fate of Medicaid and the ACA was eventually decided by the last vote cast by Sen. John McCain (R-AZ) against the proposal at in the wee hours of the morning on July 28, 2017.
For children, although protecting the ACA was crucial, the proposed cuts to Medicaid by the Senate bill would have been devastating.
But zombie ideas die hard, so there was one last-ditch effort in 2017 to scale back the ACA and Medicaid via the “skinny repeal” proposal by Sens. Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI) in Sept. 2017.
This “scaled-back” version of ACA repeal, however, was anything but “skinny” when it came to cuts to Medicaid. In fact, an analysis by Avalere Health estimated that the Graham-Cassidy-Heller-Johnson proposal's Medicaid cuts to children had ballooned to an estimated 31.4%.
Fortunately, the child advocacy community rallied, and slashing child health proved unpopular with the American people. As a result, the underlying bill was not revived.
Why the Threat Lives On
While seven Republican senators and their Democratic colleagues saved Medicaid in 2005 and Sens. Murkowski, Collins, and McCain and their Democratic colleagues saved Medicaid and the ACA from being gutted in 2017, the narrow margins by which those efforts were defeated (2-vote and 1-vote Senate margins, respectively) highlight how vulnerable Medicaid and children's health care remain.
These votes are a stark reminder that the protections Medicaid offers to children, pregnant women, other adults, people with disabilities, and low-income senior citizens can be dismantled by a single legislative decision.
Unfortunately, the zombie ideas of Medicaid block grants, per capita caps, and deep cuts to the program are once again resurfacing. As Axios reporter Maya Goldman writes:
…conservative groups from the Republican Study Committee to the Paragon Health Institute to the Heritage Foundation want to turn Medicaid into block grants, impose work requirements or reduce the federal share of program costs for states where coverage has been extended.
My colleague at First Focus on Children, Abuko Estrada, details how Project 2025 “proposes converting Medicaid into block grants or per capita caps” along with reductions in federal matching dollars to states. This would lead to dramatic increases in the number of uninsured and underinsured people in this country and, as Sen. Chafee predicted back in 1995 and was witnessed in 2017, disproportionate cuts to children.
Former President Trump declared yesterday that he would impose a benefit mandate for IVF on all health plans, yet Project 2025 declares it would “eliminate benefit mandates that exceed those in the private market.”
For the millions of children with health insurance coverage through Medicaid, that calls for the elimination of the Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) benefit, which as Estrada explains, “would leave children with less access to crucial preventative medicine and early interventions that are essential to their development.”
Estrada adds:
Project 2025 would also allow states to impose annual and lifetime caps on benefits. These caps would limit the total benefits an individual can receive during a given year and/or over their lifetime, leaving children without health care coverage once they hit the arbitrary coverage ceiling. This is especially cruel policy for children with chronic health conditions or other special health care needs by limiting access to costly services such as therapies, medications, and specialized treatments….
We are talking here about children with congenital heart conditions, spina bifida, cancer, diabetes, Fragile X Syndrome, and an array of other conditions that would be capped or eliminated under Project 2025’s proposal. A child who spent weeks in a neonatal intensive care unit (NICU) could reach their lifetime cap before even leaving the hospital after they are born.
Furthermore, in an outstanding series of blogs by Edwin Park at Georgetown’s Center for Children and Families, he highlights:
The Project 2025 blueprint, the fiscal year 2025 Republican Study Committee budget plan, and the fiscal year 2025 House budget resolution all propose draconian Medicaid cuts, with a centerpiece of capping and cutting federal Medicaid funding through bloc grants and/or per capita caps. Together, they signal that radically restructuring Medicaid would likely be a high priority if there is a second term of the Trump Administration and if Congressional Republicans win House and Senate majorities next year.
It is critical that we remain vigilant in defending Medicaid, particularly for the children who depend on it. Policymakers must be reminded that any cuts to Medicaid are, at their core, cuts to children’s health care. The stakes are too high to allow these threats to go unchecked.
There is Another Pathway: One Toward Progress for Children
Rather than threatening children with cuts to their health coverage, benefits, and access to care, we should pursue an agenda that ensures and guarantees all children have coverage and access to the care they need.
In a recent Speaking of Kids podcast, Dr. Glenn Flores, Professor and Chair of Pediatrics at the University of Miami Miller School of Medicine, outlines some of the unique health care challenges facing children and ways we should consider improving their health.
Furthermore, in a post five years ago with Bryan Sperry, former president of the Children’s Hospital Association of Texas, we proposed a series of reforms that would improve child health that are still relevant today.
Furthermore, my First Focus on Children colleague Abuko Estrada adds these important points:
Instead of gutting [Medicaid and the Children’s Health Insurance Program or CHIP], the country’s leaders must make CHIP permanent, provide continuous coverage from birth to age 6, remove barriers based on immigration status, improve children’s access to mental health services, ensure that hospitals are prepared to serve kids in their emergency rooms and enact many other improvements to help children be healthy, stay healthy and become healthy adults.
Conclusion
In 1995, 2005, and 2017, we came perilously close to dismantling a cornerstone of children’s health care in this country. The Reagan, Gingrich, Bush, and Trump proposals, with their deep cuts to Medicaid, would have left millions of children without the care they need to thrive. Thanks to the House and Sen. Bob Dole (R-KS) in 1981, President Clinton in 1995, and the U.S. Senate in 2005 and 2017, that disaster was averted — barely.
But the fight is far from over. Medicaid is under renewed threat, and the consequences of further cuts would be devastating for children. We must continue to advocate for the protection, expansion, and improvement of Medicaid toward the goal of ensuring that every child has access to the health care they need.
The health of our nation’s children is not a bargaining chip. It’s time to make sure that protecting Medicaid remains a priority — and that the next generation has the chance to grow up healthy and strong.
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