Understanding Republicans’ Proposed Cuts to Medicaid
57:55 Share

Business. It's all day and into the night, and it's why all the businesses that keep the world turning choose Advanced Solutions in partnership from Comcast Business.

Powering more businesses than everyone. Powering possibilities. Support for KQED Podcasts comes from Berklee Repertory Theatre. Star of Downton Abbey and Paddington, Hugh Bonneville, performs in a vibrant new production of Chekhov's classic Uncle Vanya, from February 14th through March 23rd only. More info at berkleerep.org. From KQED.

From KQED in San Francisco, I'm Alexis Madrigal. We're talking Medicaid, a federal program administered by individual states that provides health care coverage for 72 million Americans.

It's also massively popular. A recent poll found 75% of Americans have a positive view of the program. However, right now, House Republicans are proposing massive cuts as part of a budget package that would extend and expand tax cuts for the wealthy. Today, we want to dig into Medicaid and how it's developed since it was created by legislation in 1965. How does it work and what would cuts to the program do? It's coming up next, right after this news.

Alexis Madrigal here. We've got a pledge break going right now. So you get a little bonus on the pledge free stream, the podcast, or on our replay at night. I'm going to be writing some mini essays. We're calling this series "One Good Thing" and it's a doom loop antidote. Little tributes to bits of Bay Area culture and geography. So each day during this pledge break, I'll have one for you in this slot. Today, I want to talk about community activism's history in Bayview Hunters Point.

You may know that it became one of the first places where black people settled in large numbers in the Bay Area because of an old Navy installation out there.

These folks came from all across the western reaches of the American South. So like Arkansas, Texas, Louisiana, but other places too. And what they encountered out here was not no racism, but different racism, as a young man told James Baldwin in the neighborhood in a 1960s documentary. You want me to tell you about San Francisco? I'll tell you about San Francisco. The white man, he's not taking advantage of you out in public like they're doing down in Birmingham.

But he's killing you with that pencil and paper, brother. And so residents began to organize, in many cases with help from the Office of Economic Opportunity, part of the War on Poverty. And they were fighting on so many fronts: for better housing, for Head Start programs, grocery cooperatives, environmental cleanup, jobs for their families and more. And a group of women emerged as the community members who were willing and able to do the work. They became known as the Big Five.

The Big Five I found in sources from the late 1960s were Bertha Freeman, Julia Kummer, Eloise Westbrook, Ruth Williams, and Osceola Washington. But you can find other lists of five powerful women in Baby-Woo Hunter's Point, and that list might be slightly different and also called the Big Five. At first, I tried to figure out who the real Big Five was, but then I realized something even more important.

While these individual women deserve their flowers, the Big Five was more of an idea. A sense that there was a team of people looking out for the neighborhood's interests and pushing on local authorities to do right by Hunter's Point. And of course, that Big Five, individually and as a group, mentored whole other generations of community leaders. Women who are themselves now in their 70s and who have mentored the next generations.

Some people are lucky to inherit this tradition directly at the knee of Eloise Westbrook or Osceola Washington, but others can learn from the idea of it. That neighborhoods need and should have community members who know how to fight that pencil and paper, but also know how to use it themselves. The Big Five of Hunter's Point, that's your one good thing today.

Welcome to Forum. I'm Alexis Madrigal. This Trump administration has done a lot of unconventional things from empowering Elon Musk in some hazy capacity to make huge cuts to the federal workforce to trying to massively increase the power of the presidency relative to the other branches of government.

But in one crucial way, the Trump administration is aligned with a long, long-term goal of some factions in the Republican Party, and that is to cut Medicaid, the federal program that provides health care coverage to low-income and disabled Americans. Republicans have claimed that Medicaid doesn't improve health outcomes, that states inappropriately juice their federal Medicaid dollars, and that a less well-funded Medicaid could somehow be better.

Obviously, many people in healthcare disagree, and we'll get into all that. But first, we want to learn more about the basics of Medicaid and how it works. We're joined first by Larry Levitt, Executive Vice President of KFF, which was formerly known as the Kaiser Family Foundation. Welcome, Larry. Thanks for having me. So...

let's just start at the very, very, very beginning. Like I thought I knew what Medicaid covered when, when I started researching this show, but there's a lot I didn't know. So just tell us at the start, what does Medicaid do? Yeah. So Medicaid, uh, first of all is not Medicare, right? So Medicare is the program that covers, uh, seniors and, and people with disabilities. Uh, Medicaid was actually created at the same time as Medicare six, 60 years ago. Uh,

Originally, it was connected to welfare. So it covered low-income children, single parents. It's been expanded dramatically over time to cover seniors, because seniors on Medicare actually have a lot of costs, big deductibles, things Medicare doesn't cover, like nursing homes. Medicaid fills in those gaps. Medicaid was expanded to cover people with disabilities.

And most recently, under the Affordable Care Act, was expanded to cover all low-income people, at least in those states that choose to do that.

We think of Medicare and Social Security as kind of third rails in American politics, that if you touch them, you get burned. Medicaid has generally not been thought of in that same category, but it actually covers more people now than Medicare or Social Security. And then it's actually implemented at the state level, right? So that would be Medi-Cal here? That's right. And that, you know, that's part of what's so confusing is Medicaid is...

implemented differently in every state. In some states, it's called different things. As you said, in California, it's called Medi-Cal. And the financing is shared between the federal government and states. So the federal government pays, for example, in California, about half the cost. The state pays the other half of the cost. So it's not the same thing everywhere like Medicare is.

And that's kind of a point of contention around Medicaid, right? That if a state is willing to increase its spending, then the federal government will have to increase its match, right? Right. I mean, it's...

It's known as an entitlement program. And what that means is if you are eligible based on the rules in the state, you are guaranteed coverage. The state pays for the cost of that health coverage for you. And then the federal government is required to match that. So there's no cap. It's not required to be appropriated every year in the federal budget. It's essentially automatic spending. Yeah.

So one of the ways that I've encountered Medicaid is that it's really important for people who have disabilities. Talk to me about that. Like, what does Medicaid do for kids, say, who have disabilities?

Yeah. I mean, so Medicaid offers very comprehensive services. So, you know, home care, so assistance in the home for someone who has a disability or a senior, covers nursing home care, institutional care for people who need that. And it's, you know, it's really, I mean, these are people who would otherwise not be covered in private insurance, would not have the benefits they need

to stay healthy, stay in their home, in private insurance. So it is, and we think of it as covering these low-income people, low-income kids, low-income parents, low-income adults. In fact, over half the spending in Medicaid, Medi-Cal in California, goes for people with disabilities and seniors.

So what is the relationship of Medicaid to private insurance, right? Because sometimes people have like a plan through private insurer, but it's paid by Medicaid, right? Right. So, you know, most people who get covered through Medicaid, again, Medi-Cal in California, actually get covered through a private insurance plan. So the state contracts with these private insurance plans to actually deliver the coverage. So you may have a card that says Medicaid

you know, Centene, Blue Shield, Kaiser Permanente. But you're actually covered through Medi-Cal. The state and the federal government are paying for your care. But, you know, that coverage is actually being delivered through that private insurer.

Let's talk a little bit about the expansion of Medicaid that happened through the ACA. Can you just tell, like, how did that work and how is it different from how the federal government deals with other expenses in the Medicaid program? Yeah. So, you know, when the Affordable Care Act or Obamacare passed, there was this huge gap in Medicaid. You know, if you were a kid, if you had a disability, if you were a parent, Medicaid

You could be eligible for Medicaid. If you were a low income adult with no kids, you were simply not eligible no matter how low your income is. You could have zero income and you weren't eligible. So the Affordable Care Act expanded Medicaid to all low income people with incomes to just above the poverty level. Which is what is the poverty level right now? Yeah. The poverty level is.

Current poverty level is about $26,000, $27,000 for a family of three. The Affordable Care Act expanded Medicaid to people up to 138% of the poverty level. I apologize. There was going to be math this morning. And that's about almost $37,000 for a family of three.

So originally, Obamacare said, you know, every state had to expand Medicaid in this way. The Supreme Court said differently and said it would be optional for states. But the federal government is still paying 90 percent of the cost. So much higher than it does in the rest of Medicaid. Currently, about 40 states have chosen to expand Medicaid in this way, including California, 10 states.

in the South, states like Texas, Mississippi, Florida have chosen not to expand. So how do we know that Medicaid works? Like it actually provides, you know, care

know, care for people that, that, you know, makes their lives better. I mean, I've heard about this kind of famous thing called the Oregon experiment where people were kind of randomized into Medicaid coverage. And what did we learn through experiments like that? We've done actually a review of the, of the literature, all the studies, hundreds and hundreds and hundreds of studies, including this, uh,

really interesting study in Oregon where people kind of randomly got health coverage. And, you know, there's a lot of evidence that health coverage gives you better access to care, gives you better health outcomes, prevents you from dying in some cases, and really importantly, provides financial security for people. You know, so if you did not have health coverage,

uh you still would need health care you would actually go get that health care in some cases uh and you would end up with medical debt you would end up with unpaid bills um and and medicaid uh helps prevent that so there's there's a lot of evidence you know one thing that's very hard to do is um demonstrate uh

the value of health insurance, because there are so many other factors that affect people's health. I mean, some of it's random, right? You get cancer randomly. Uh, some of it is, you know, based on your circumstances, you know, where you live, uh,

You know, your access to nutritious food, your ability to exercise and poverty is a big factor in people's health. But there is a long, long, long list of studies that demonstrates that health insurance and Medicaid in particular does help people. Yeah.

We're talking about Medicaid. It's a program that covers over 70 million Americans, now a target of House Republicans. Between Medicare, Medi-Cal, the ACA, and Social Security, healthcare in America is so complicated. So we are trying to give you some grounding and some explanation here. We've been joined first by Larry Levitt, who's executive vice president of KFF, which is formerly known as the Kaiser Family Foundation. We, of course, want to hear from you, too. I mean, we know so many people are

using Medicaid and need it. What are your concerns about Medicaid being cut or maybe just general questions about how Medicaid works? You can give us a call 866-733-6786. That's 866-733-6786.

You can email your comments and questions to forum at kqed.org. You can find us on Blue Sky. You can find us on Instagram, where we're kqedforum. And of course, there's the Discord community. I'm Alexis Madrigal. Stay tuned for more right after the break. Xfinity Mobile was designed to save you money. So you get high speeds for low prices. Better than getting low speeds for high prices. Jealous? Xfinity Internet customers. Get a free unlimited line for a year when you buy one unlimited line. Bring on the good stuff.

Welcome back to Forum. Alexis Madrigal here. Now that we've given you the primer on Medicaid, a program that covers 70 million Americans, we're going to add in the rest of our panel here. We've got Larry Levin, of course, already, Executive Vice President of KFF. I want to add Joanne Kennan, who's a journalist and resident at the Johns Hopkins School of Public Health, recently written about the budget battle for Politico. Welcome, Joanne.

Hi, thanks for having me. Great to have you. We're also joined by Christophe Stramikis, who is Director of Market Analysis and Insight with the California Healthcare Foundation, which is an independent nonprofit focused on improving healthcare for Californians. Welcome, Christophe.

Good morning, Alexis. Thanks for having me. We are also joined by Chiquita Brooks-Lashore, who's former administrator of the Centers for Medicare and Medicaid Services. Brooks-Lashore served from 2021 to 2025 during the Biden administration. Welcome, Chiquita.

Thank you. Good morning. Also, my aunt is named Chiquita and first guest we've had on named Chiquita so far. Great to have you. Chiquita, I did want to ask you, Medicaid has been a longtime target of Republicans, but it has changed a lot, particularly since Obamacare. Can you just describe some of what's changed in the way that Medicaid runs and is administered?

Absolutely. And Larry really outlined how Medicaid has been expanded over the years. And I would just add a couple of important things. I would say Medicaid

Medicaid has grown in its importance, not just for the number of people that are covered, but also as a part of our economy. And I would say that when you think about the number of births that Medicaid is responsible for, so in many states, Medicaid is responsible for covering 50% of children that are born in this country.

When you think about how many hospitals are dependent on the Medicaid program to stay in business. And as CMS administrator, I talked to hospitals across this country who were struggling, particularly in rural areas. And there was a significant difference in the health of hospitals in states that have expanded Medicaid versus those that do not.

And so I think it's really important that as we talk about making changes to the Medicaid program, which, as you said, has long been a target and has been in the past really described as a welfare program. It is now a lifeline blood of our health care as a country and, again, really linked to our economy.

And many low-income people are covered by Medicaid, but a lot of middle-class people are too. So if you have a child with high needs who's born needing an organ transplant, most of the people who are covered in children's hospitals in this country depend on Medicaid for their surgeries, for their drugs. So it's not just...

a program for the low income, which of course, people who are low income need access to health insurance. It is also vital to the middle class when most people in this country need help with long-term care. Medicaid is the primary payer because Medicare does not cover many of the services that people need when they need nursing home level of care.

So I just want to explain to folks, too, that you were in charge of the entire program for the country. I mean, your successor may be Dr. Mehmet Oz if he's confirmed. And one of the things I'm hearing you say is that Medicaid isn't only important sort of on a kind of individualized basis, but sort of as a crucial structural piece of our health care system. So like what would happen if, say, there were ultra deep cuts to Medicaid funds?

Would it impact health care outside of people who are covered under Medicaid? Absolutely. And of course, the first effect would be on the millions of people that are covered by the program. We're talking about 41 million children that are covered in this state, in this in this country. But it also certainly would affect families.

the states that are trying to do the right thing. So states like California, which have had a strong commitment to the Medicaid program, if there are changes made in payments, that will either put burdens on states to use their funds, state-only dollars, to try to supplement coverage or having to cut services.

But again, I think it's really important for us to all understand how much Medicaid supports the underlying health care system. I mentioned hospitals, community health centers. A lot of providers really depend. Medicaid is the primary payer for mental health services. And I remember when my staff sent that email.

Note to me, I said, I want you to check this again. Are you sure that that's true? And they came back and said, yes, Chiquita, most of the primary payer of mental health services in this country are through Medicaid.

And educational services are often supplemented when you need help with your child with autism, with who needs special needs. Again, just Medicaid is important to the millions of people that depend on the program, but also to the healthcare system overall.

Casey over on the Discord, just to put a little meat on these bones, says, I worked on Medicaid expansion efforts between 2014 and 2016. My dad did rounds at the local hospital and would take on no-doc patients, a term for uninsured folks. This was before Medicaid expansion. No one got paid for services rendered. Medicaid reimbursement continues to be way too low, but 50% is more than zero. Say they block grant Medicaid, what would the impact be on hospitals, rural hospitals specifically, which I think you've already covered?

Joanne, I wanted to bring you in on sort of what Republicans are saying about Medicaid and what they think they can cut and how they think they can do it. There's a big difference right now between the House and the Senate. And I'm going to sort of focus on and also Trump is all over the map, like in ways that are confusing, even when you're used to watching Trump's confusing. He said he would cherish the program. Right. And then and then supported the House Republican plan.

Yes. Remember that during all three of his presidential campaigns, he talked about protecting Medicare and Social Security, as you noted, but he never said, I'm going to protect Medicaid. He left it, you know, Medicare and Social Security are safe. Medicaid, which is a program for lower income people,

didn't make that promise. There's been a realignment in the Republican Party and more working class, sort of lower middle class people who are on Medicare, Medicaid are Trump voters. So you've changed the political dynamic here. I mean, who relies on Medicaid is different than historically as Medicaid has gotten bigger. Trump came out with this sort of offhand remark a couple, very end of January about he's gonna love and cherish Medicaid. And like we all said, huh?

It sounded like a marital vow. And then the Republicans have gone deep, deep, deep toward cuts. We don't know they can achieve them. We're at the very, very, very beginning of what is a very long budget process. The budget resolution that came out of committee called for $880 billion with a B cuts that had to be directed by the committee.

the committee that oversees Medicaid. It's confusing because it's the Committee on Energy and Commerce, which doesn't sound like Energy and Commerce should be in charge of Medicaid, but it is for historical reasons that we are going to ignore right now. Fair enough. They, yeah, it was a power struggle between chairmen. We can ignore that.

Do they have other things? Yeah, energy and commerce can pull from more than just Medicaid, but if they have to do $880 billion of cuts over 10 years, Medicaid is going to be the bulk of that. They passed it at a committee. They're having trouble getting it through the floor. It's a very, very tight majority in the House, as you know. It's just a couple of moderates or a couple of lawmakers from swing districts who

have already said, uh-uh. So meanwhile, the Senate didn't go that route. And then yesterday, Trump, who's all loving and cherishing, you know, his Medicaid, just flipped and said he's backing this, the House bill. So, you know, it's dizzy making. The, you know, I think

cutting $880 billion and really fundamentally altering. You can't just chisel away at programs. That would require a fundamental restructuring. It would not look like Medicaid looks today. It would not be an entitlement anymore. It would be what they call a per capita cap. On the other hand, they've been trying to do that since the Reagan years.

Literally, this has been a priority in certain circles on the right for 45 years now, and they haven't gotten it. And I think there's a lot of reasons, including who is the base of the Republican Party, that

to not expand. It's not going to be easy to do this. I think the odds are against them. I mean, you can't rule out anything anymore because things that you thought could never possibly happen are happening by the dozen, right? But it's really, really an uphill struggle. And sort of what they're dangling politically is a big tax cut. And even extension of the previous Trump tax cuts, we know the majority of those benefits went to wealthier Americans. And then an extension even or an expansion of those cuts too.

Right. So and how do you if Trump wants to pay for them? I mean, they could at the end of the day decide, you know, budget rule, schmudge it rule. We're not going to pay for them. We're just going to have tax cuts. You know, Trump did expand the deficit a lot in his in his prior term and he could do it again. I mean, that's not what we're hearing at the moment. I mean, they're they're going through the normal budget process at the moment. But it's it's it's both the people who will be affected. And as Chiquita mentioned, it's the providers, you know, the the the.

The rate of rural hospital closures in states that did not expand Medicaid under the ACA is much higher than states that took the expansion. It's not that no rural hospital has closed in a blue state or in a red state that did expansion. There have been closures. But the depth of that crisis is way worse in states that didn't expand. And you're going to hear from the providers, you know, if they're going to lose 880,000

billion dollars of revenue or anything close to that, they're going to lobby. They're going to be out there and it'll be their voices you hear a lot on the Hill, which I think was different than the ACA repeal. Usually it is the lobbies. Usually it is K Street. I think with the ACA, a lot of it was just the public. They wanted that protection. They wanted the protection against

pre-existing conditions and other protection of the ACA. The littlest lobbyists, those children on Medicaid, we all remember them. They helped save the ACA. This, I think, will be a lot of it will be provider driven. Christophe, I want to bring you in here. You know, I listened to a really excellent report from the health care podcast Trade Offs.

And they tried to examine sort of the three main conservative complaints about Medicaid. And I wanted to just offer them to you and then have you kind of talk about them a little bit. I mean, one was that Medicaid offers sort of low value in terms of health conditions. One was the federal government's kind of handing states this kind of ratchet mechanism and a blank check for incentives to grow their Medicaid programs. And the third was that Medicaid is covering kind of too many people who should be on private insurance programs.

If those are sort of the complaints, how would CUT sort of try to address this? Look, there's a lot of different threads there, and we probably don't have enough time to go methodically through all of them. And so when I hear things like that, I look for what do we know?

And I think what we know is reductions of the sort that Joanne and Chiquita are talking about can only really lead to three sort of outcomes and probably some combination of all three of these. Number one is fewer people will be covered by Medicaid programs, including Medi-Cal here in California. Number two, the benefits that states are offering or that are included in

Medicaid, health insurance, including Medi-Cal here in California will be reduced. So fewer things will be covered. And then to both Joanne and Chiquita's point, the payments that are going into the system to providers, to hospitals, to skilled nursing facilities, to nursing homes will be reduced. And so those are the outcomes. I don't think anyone would argue with that.

Now, does what does that satisfy in terms of longer term policy goals and objectives? I don't really know. 1 thing I do here quite frequently is this discussion around the population and needing to reduce the population.

You know, one thing we also know, sort of hard numbers, is the way in which this program supports people who are working here in the state of California. We know that's a hot topic often. It kind of bubbles up every few years.

the discussion or debate around introducing work requirements for Medicaid. There are some states that have those already. We don't have them in California. What we do know here about work in California, though, is this is a program that supports one in five California, one in five

people who are in our workforce here in California. And when you ask people on Medi-Cal here in California, two in three of the folks that are on the program are working. And the vast majority of the folks that aren't working are doing something like caring for a sick family member. They themselves are disabled and not yet eligible for or not enrolled in federal disability insurance or they're in school.

And so this really is a program that supports many, many people here and people in different circumstances. And by the way, those life circumstances, as they do for everyone, they change. This isn't one static group of people. It really is there for all sorts of Californians. It's really important to a lot of different people. Let's bring in a caller here. Let's bring in John in Oakland. Welcome.

Hi, I'm actually a history teacher. I teach U.S. history at high school level. And so as such, I tend to orient towards looking at big picture narratives and trying to kind of like understand, like getting past the minutiae like your last panelist was talking about where there's the sort of Gish Gallup style of like presenting conservative issues that are all sort of like,

easily dismantled, but they just put so many at once, it's impossible to really address them all. I mean, the real big picture thing is that this is a multi-decade sustained assault on the Great Society and New Deal that's been happening since those things started to happen. And it's not just been political, but also cultural.

So you see it all the way back to the kind of movies and things of my childhood from conservative media groups like Disney, where you'd watch a cartoon about Robin Hood, where they're not even complaining about the fact that they're serfs and they're being exploited by a king. But they're talking about taxes. Well, we've got to pay all these taxes. And of course, taxes in medieval serfdom didn't provide public services. But this is the whole idea of tax is bad.

government bad. And then what do we have? We have Elon Musk basically dismantling the government. So this is tough because politically now we have multiple generations that have been brought up in a mental rubric of just believing that the public discourse and publicly owned institutions is antithetical to a sense of values that they have around rugged individualism. And of course, when they experience it personally...

It's not going to turn out so great for them. Yeah, John, appreciate that big picture zoom out about kind of the...

The deep politics of American culture these days. On the other side of it, Lee, or sort of in the depths of it, Lee writes in to say, you know, I'm a busy program manager overseeing a Medicaid, Medi-Cal population health and quality improvement program at a Bay Area hospital. Quality outcomes in these programs are at par or better than commercial payer quality outcomes. This is despite the many structural and social challenges faced by the population who access these programs.

the CARE. Thanks to the Center for Medicaid Services and state demonstration programs like the Delivery System Reform Incentive Payment and the Quality Improvement Project, we've been innovating in this space for over a decade with exceptional outcomes. We deliver care better, cheaper, and more efficiently. The data doesn't lie. We're talking about Medicaid. Obviously, it's a program that covers a lot of people, 70 million Americans, now a target of Republican budget cuts.

Here to explain what's at stake, we've got Christoph Stramekis, director of market analysis and insight at the California Healthcare Foundation. We've got Chiquita Brooks-Lashore, former administrator of the Centers for Medicare and Medicaid Services, served from 2021 to 2025 during the Biden administration administration.

We've got Joanne Kennan, who's a journalist in residence at Johns Hopkins School of Public Health, recently written about the budget battle for Politico. And we've got Larry Levitt, executive vice president of KFF.

We'd love to hear from you. If you're someone who is touched by Medicaid, either on the provider side or maybe you have Medicaid or access those benefits, give us a call. The number is 866-733-6786. That's 866-733-6786. You can email forum at kqed.org. You can go on social media, Blue Sky, Instagram, et cetera. We're KQED Forum. I'm Alexis Madrigal. Stay tuned for more right after the break.

Support for KQED Podcasts comes from Star One Credit Union, now offering real-time money movement with instant pay. Make transfers and payments instantly between financial institutions, online or through Star One's mobile app. Star One Credit Union, in your best interest.

Welcome back to Forum. We're doing a little Medicaid explainer here this morning on the show. Joined by Larry Levitt from KFF, journalist in residence at Johns Hopkins School of Public Health, Joanne Kennan, Christoph Stromekis, who is director of market analysis and insight at the California Healthcare Foundation, and Chiquita Brooks-Lashore, former administrator of the Centers for Medicare and Medicaid Services, otherwise known as CMS.

We'd love to hear from you if you have experience with Medicaid and any part of this kind of system. You can give us a call, 866-733-6786, forum at kqed.org. Chiquita, I wanted to come to you on the kind of efficiency and like how well this program is working. You know, we had that last comment from Lee about these different programs that have been run to improve the quality of care. Like, what would you say...

has changed or improved or declined about Medicaid during this last few years? Well, I loved hearing Lee's point and really describing some of the work that he and so many others are doing. And I would say absolutely that both at CMS and at the state and local level, there has been so many efforts over the last few years

decades really, but certainly the last five years to really make sure that Medicaid is offering important healthcare that meets high quality standards. And during the Biden administration, we took many steps to add requirements to states about the quality of their programs, as well as to give them incentives through what we call demonstrations or waivers.

to think about providing delivery of care in more efficient ways.

And so many of the companies that actually participate in Medicaid are private companies, more so than in the past. Many companies operate both in Medicaid and Medicare, some in all three markets, Medicaid, marketplace, the commercial market, and Medicare. And they're bringing some of their strategies to various parts of the program.

But yeah, there are a lot of innovative things going on across the country and states often show the way in new models. Larry, I wanted to bring you in on this question from one of our listeners over on Blue Sky who writes, who pays for nursing home care when the patients have exhausted their resources? Is it Medicaid? And maybe if we expand that to just sort of like, what is the relationship between Medicaid and this kind of long-term care?

Yeah, no, it's exactly Medicaid who pays in those situations. Nursing homes are really expensive. I mean, we're talking well over $100,000 a year on average. And Medicare does not cover long-term nursing home care, nor does it cover long-term care in the community, home care, community-based services. So people pay out of pocket until they...

Until they spend down their assets and then it's Medicaid that pays. So Medicare is by far the primary payer of nursing home care. Yeah.

We also have a question. Stay with you on this one, Larry. Jay writes in to say, why has California expanded Medi-Cal by eliminating the asset test starting in 2024? I assume there is an intention. Under the current rules, I know non-elderly families who have millions in assets who are covered because they happen to have lower income for the year. This is part of a broad program to enlarge a public health option.

Yeah. So historically, there has been an asset test in Medicaid, meaning you had to have both low income and low assets.

And yes, there are a small number of people who have a lot of assets and not very much income, although that's very, very unusual. If you've got a lot of assets, then chances are you have a fair amount of investment income. And it just, it makes it so, having an asset test makes it so much more complicated to sign up for Medicaid.

And, you know, it's there really is this divide. And it goes back to, you know, the caller from Oakland that there's been this this ideological divide between conservatives and liberals over time that liberals view Medicaid as a kind of stepping stone as a part of our complex system to get as close to universal coverage as we can. Conservatives view it as welfare, you know, only for the deserving, deserving poor. Yeah.

Let's get another caller in here. Let's bring in Kevin in San Francisco. Welcome, Kevin. Yes, hi. Can you hear me? Yeah, sure can. Go ahead. Good. Medi-Cal or Medicaid is a wonderful program that is...

It covers the needs, many of which Medicare does not cover, like caring, dental, and vision, which Bernie Sanders was fighting for when he ran in 2016, 2020. But it allows you the comfort of getting sick and not having to worry about medical debt. This is the only country, the only Western wealthy country that has medical debt. And Medi-Cal is a program that everybody should have because they have a basic coverage. I mean, I lost my job last year, and unlike every other country,

When you lose your job, you lose your health care. This is a ridiculous system. And it's only this way because our corrupt politicians will not listen to their constituents, their base, their voters. And they listen to health insurance industries instead that give them big donations. Appreciate your perspective, Kevin. I mean, I think there's a lot of people probably who agree with that as well. Let's go right to Matthew in San Francisco. Welcome, Matthew. Thank you.

Hi there. Thanks for taking my call. I just want to talk a little bit about the efficiency of Medi-Cal, for example, or other Medicaid programs. What I want to say was there are still many opportunities for Medi-Cal or Medicaid programs to be more efficient. And I just want to give a couple of examples where I think Medi-Cal and Medicaid can do better. One is there's

There's a delayed adoption of coverage for generic medicines. We're seeing this a lot where sometimes when a drug becomes off patent and generics are allowed at much lower cost,

Medi-Cal, for example, will continue to only cover the brand name. And it may take sometimes years for them to be able to cover the generic at a lower cost. I've always been puzzled by this. And I just want to put that out there as an example of where it can be better. Yeah, no, I appreciate that, Matthew. Thank you very much for that. Christophe, what do you make of this sort of like the generic point?

I think the broader point here is the idea of innovation and efficiency. And I would maybe connect that in the context of our discussion to how can the federal government support innovation and efficiency in the program today.

I think there is a theory or a drive here in the context of broad reductions in federal funding that that would somehow encourage the efficiency, you know, whether in this particular area around coverage of drugs or in other areas. I think, look, Medi-Cal, like all

health insurance and delivery systems admitting that they're all connected can improve. There are opportunities for improvement and efficiency improvements. I think about top of mind for me is how do we increase the exchange of clinical data among Medi-Cal beneficiaries that are going to different settings and getting social services?

I think the bigger public policy question here for that efficiency improvement or changes around drug coverage is reducing federal funding on the order of what Joanne is talking about, $880 billion. Do those reductions encourage that type of improvement or do those things actually cost initially more money but then pay off in the longer term? I think that's the more important question to ask ourselves here.

Chiquita, I wanted to bring you on this and I'm assuming you all have looked, you know, when you were an administrator, you were looking at, oh, could we use generics more quickly? Or like, how did you try and figure out or find that balance for when you started to provide more support for generics and relative to name brand?

Yes, I and I really appreciated Christoph's comments because I think it's so true that you have to look in the context of what's going to drive innovation and broader cuts are not the way to do that.

I think when you are in the shoes that I'm in, you really have to weigh how much do you require of the states to do things and how much do you encourage states to take action.

innovative steps. And that's the, that's sort of the push and pull between the federal government and state governments about decisions that, that they need to make. And we took a number of steps, but certainly agree that more work needs to be done when it comes to generics and drug spending. This is true of Medicaid, but even broader, which as you know, Medicare drug negotiation and drug spending was a huge part of, of,

the responsibilities of CMS and a priority to President Biden. We were working very hard to look at ways to make drugs more affordable and adopting generics more quicker is absolutely something that we were looking to encourage and see whether there are federal rules that we needed to change.

And, again, I think this is one of the biggest issues facing our country when it comes to health and continuing to get a handle on the prescription drug prices that so many Americans pay. And I really hope that there continues to be action in that forward. Joanne, I wanted to bring you in on a question from listener Annette, who writes, it would be helpful to discuss the perennial threat of block grants and what that means. What does that mean?

Well, that's the, we were talking about the per capita caps for the block grants. That's the $880 billion thing. And instead of an unlimited entitlement, like, okay, you qualify for, the federal government will pay what it has to pay to cover you. You're entitled to it. It would limit it and states would get a fixed amount and that amount would not grow enough as much a year as, it would be designed to ratchet down spending over the years. Because that's such a stretch politically, right?

It doesn't mean that, you know, that's what a lot of our conversations focus on. There are lots and lots of other things that they could do that are less dramatic and less deep that would still mean fewer people are covered or affect, you know, affect the, the expansion part of the ACA, um,

There's lots of little things, work requirements. Even just making the enrollment process more cumbersome, you end up covering a few people. So by saying, I just wanted to say that we've been talking about this big 880 per capita cap, which is a variant of a block grant. It doesn't mean there's not a lot of other things on the table because there are, and none of us expect, I don't think any of us expect Medicaid to look exactly the same now

in four years from now. I also wanted to point out briefly that you had a caller who talked about the high school history teacher. Well, I taught history for only one year, but I've read books ever since. Yes, there's been the assault on government benefits, but the fact is historically all of our benefit programs have expanded. Social security only covered half the population.

It did not cover farm workers, which were a lot in the 1930s. It did not cover domestic workers. It was commerce and industry. Social Security is pretty much... Think about Medicare. It didn't cover drugs until 2006. It didn't cover dialysis until 1970-something or other. It didn't cover a hospice. It didn't cover lots and lots of things.

Medicaid covers way more people and way more services. And, you know, basically the historical pattern of our entitlements and our public services has been to grow. And election, you know, 2016 when Trump won,

I mean, that night I thought the ACA would be repealed. I think most of us did. And it was not. It was not. Joanne, I've got to cut in real quick. This is a fundraising period for KQED Public Radio. For more information about how to support KQED, go to kqed.org. I'm Alexis Madrigal.

No, and Joanne, I just want to return briefly. You're right. There have been sort of both things, which of course is one reason why we have a huge federal deficit too, right? We both sort of have cut taxes and also...

and also continued with the programs that people rely on, like a few of our listeners who've written in with these sort of stories of their own reliance. Daniel writes, my brother was diagnosed with stage four esophageal cancer and currently relies on Medi-Cal for treatment that keeps him alive.

Chris writes, as a young single mother of three raising kids, working and putting myself through school, I accessed Medi-Cal. It was a lifesaver. I became able to work for a company that provided medical insurance, but for that brief four-year period, it was essential for me and my family. Michelle writes in to say, you know, I'm a single 58-year-old woman on Medi-Cal. Without it, I may have lost my house because the cost of the COBRA insurance after I was laid off was $700 a month with a super high deductible. I have several health issues and five medications that need remediating.

Thank you.

You know, Larry, this kind of goes to your point in the very beginning that people's circumstances change, right? I mean, we've seen these different stories of folks who otherwise didn't access Medi-Cal here in the state and then something changed and then they have to and then maybe sometimes they're able to get off. How do we kind of get at those stories in a deeper way?

Yeah, I mean, and I mean, I think it does illustrate, I mean, we've done polling at KFF, ask people their connection to Medicaid, and two thirds of people say that they've been covered by Medicaid at some point, or a family member or a close friend has.

And it's really this question of what happens to people over time, right? I mean, our health insurance system is so complex. You started there at the top of the hour. And certainly if you have a job, a good job that provides health benefits, that's how you're going to get your health insurance. But people lose their job.

People get their hours cut and lose their health benefits. People have an illness and can't work anymore. And that's what this safety net is there for. And over time, the program touches a lot of people. Yeah.

Arthur writes in to say, will California be able to make up the difference if the federal government stops providing funding? What sorts of measures can voters support to help ensure that coverage continues? Why don't we start with you, Christophe, on this one?

This is tough and it's tough because we don't know exactly what is, you know, there are many different things floating around in many different numbers. Joanne alluded to a few of them. And so we don't, you know, we don't precisely know what is being considered. What we do know though, is the federal government right now pays for between 60 and 70% of the $150 billion, $150 billion that are flowing into our healthcare system from the Medi-Cal program.

I think even under some of these small changes, we are talking about billions and billions of reduced federal dollars. And look, I'm not an expert in the California budget. I do follow along as much as I can.

I don't really think there's a lot of scenarios in which California can step in and replace billions upon billions in lost federal revenue. And so that really is leading to some pretty difficult decisions about fewer people being covered, fewer covered benefits and lower payments.

And so I think the question really is now for folks to decide, is this something we want, you know, that we support and take action? Mm-hmm.

Obviously, this is going to have a fight that plays out over a long time and it's going to have a lot of repercussions if major cuts are made. Hopefully, listeners are a little better prepared. We have been talking about Medicaid, this program that covers more than 70 million Americans, now a target of at least House Republican budget cuts.

We've been joined by an all-star panel, Chiquita Brooks-Lashore, former administrator during the Biden administration for the Centers for Medicare and Medicaid Services. Thank you so much for joining us.

It was a pleasure to be here. Thank you so much for having me. Thank you. We've also been joined by Christoph Stramekis, who is director of market analysis and insight at the California Healthcare Foundation. Thanks so much for joining us. Thanks, Alexis. Thanks for doing the show. We've had Joanne Cannon, journalist in residence at Johns Hopkins School of Public Health. You can check out her writing about the budget battle at Politico. Thanks for joining us.

I always love to talk about Medicaid for an hour. Who doesn't? Who doesn't, Joanne? And we've been joined by Larry Levitt, executive vice president of KFF. Thanks so much, Larry. Thanks, Alexis, for a great conversation. Thanks to all of our listeners for their calls and comments. I'm Alexis Madrigal. Stay tuned for another hour of Forum Ahead with Mina Kim.

Funds for the production of Forum are provided by the John S. and James L. Knight Foundation, the Generosity Foundation, and the Corporation for Public Broadcasting.