An All-Out Defense of Medicaid
Why We Must Fight to Preserve a Program That Serves So Many
Medicaid is under assault. I won’t stand for it, and neither should you. I have two related goals for this newsletter: (a) to convince you, dear reader, that Medicaid is worth saving, and (b) equip you with the tools to help save it. In this newsletter I will lay out the stakes of this fight and provide you with a letter template that you can send to your Senator, if I can convince you to join me.
For those that may not be familiar with the program, Medicaid provides health and long-term care for low-income Americans. Millions of low-income adults, children, pregnant women, elderly adults and people with disabilities receive their health care from this program. It was signed into law in 1965, and a provision of the Affordable Care Act (or Obamacare) allows states to expand Medicaid eligibility, with the federal government covering 90% of the costs for states that opt in. This is a very basic overview, but it should be enough for readers to understand the argument I’ll be making in this newsletter.
Now, let’s get to that argument, starting with taking a look at the current threat facing Medicaid.
An Imperiled Program
I’m not being an alarmist: Medicaid is indeed under attack. I wrote about this briefly in a newsletter from a few months back, but as a reminder: Congressional Republicans are engaged in an ongoing negotiation to extend the tax cuts enacted in the 2017 Tax Cuts and Jobs Act. Last month, House Republicans passed a budget resolution aimed at enacting $4.5 trillion in tax cuts and called for $2 trillion spending cuts, to partially offset the reduction in tax revenue. Of these spending cuts, nearly half — $880 billion — would be from the House Energy and Commerce Committee, which oversees Medicaid. The nonpartisan Congressional Budget Office finds that if you exclude Medicaid funding, this Committee is responsible for approximately $581 billion.
To translate that: this committee could cut all of its non-Medicaid related spending (which includes telecommunications, consumer protection, food and drug safety, public health, to name just a few areas of responsibilities) and still be required to cut $300 billion from Medicaid. Put simply, there is no way to cut this much from the Committee without cutting Medicaid.
Several House Republicans have expressed reluctance to cut so much from this program, while others — including Speaker of the House Mike Johnson — have said that they simply intend on enacting work requirements, or eliminating ‘waste, fraud, and abuse’ (there isn’t $880 billion in waste, fraud, and abuse, FYI). President Trump has said that he ‘cherishes’ programs like Social Security and Medicaid and said the following in an interview with Sean Hannity: “Medicare, Medicaid — none of that stuff will be touched.” However, the day following this interview, President Trump posted this on his social media platform:
“The House and Senate are doing a SPECTACULAR job of working together as one unified, and unbeatable, TEAM, however, unlike the Lindsey Graham version of the very important Legislation currently being discussed, the House Resolution implements my FULL America First Agenda, EVERYTHING, not just parts of it! We need both Chambers to pass the House Budget to “kickstart” the Reconciliation process.”
The House Resolution he’s referencing is the very same resolution referenced above, which included the $880 billion in cuts, so it is hard to square his support for Medicaid and his support for that House Resolution.
As of right now, the ball is in the Senate’s court, and the politics are dicey. Several Republican Senators — like their House counterparts — are hesitant to enact such draconian cuts. For example, last week, Missouri Senator Josh Hawley stated the following:
“Beyond work requirements, if it’s something that results in reductions in benefits to folks who depend on it and who are qualified and are working, I’m not going to vote for that. That’s 20 percent of my state.”
Other Republicans have echoed this sentiment. However, so long as the goal is to enact these tax cuts while cutting $2 trillion in spending, Medicaid is in danger. This is a mathematical reality: there is only so much spending that can be slashed until you run up against Medicaid. Plus, should Medicaid survive the battle, it may not survive the war: Medicaid, like Medicare and Social Security, is never fully on firm footing.
So, why do we need Medicaid? Let me make the case.
These Cuts Would Deeply Wound Poor Children
Medicaid is quite literally a lifeline for poor children: in 2023 it covered over 8 out 10 children in poverty. There were approximately 10 million children living in poverty in 2023, and Medicaid is the sole source of healthcare for 8 million of those children. Without it, these 8 million children would be unhealthier, both now and far into the future. With Medicaid, children:
Are less likely to die young.
Experience fewer hospitalizations.
Experience fewer emergency department visits.
Receive more preventative care.
Receive more immunizations.
Had less severe illnesses.
If it only did the above, the program would be worth saving. But it does a lot more. In 2020, Andrew Goodman-Bacon — an economist at the Federal Reserve Bank of Minneapolis — estimated the long-term effects of Medicaid eligibility by looking at the rollout of Medicaid in its earliest years (1966-1970). He found the following:
People who received Medicaid as children worked more hours and are less likely to be the recipient of government benefits as adults.
People who received Medicaid as children were more likely to be healthy as adults, as measured by mortality and disability.
When you combine the above — the improvement in life expectancy and the reduction in disability — the introduction of Medicaid added 10 million quality-adjusted life years (meaning the program added the equivalent of 10 million high-quality years of life).
It did all this — even while experiencing dramatic expansion over the last few decades — at a cost that is four times lower than the average per capita cost for the elderly. One study tried to further quantify the “bang for the buck” of Medicaid and found that for every one dollar spent on Medicaid expansions to children has “paid back an estimated $1.78” — meaning that this spending generated a return of $0.78 per kid. Put differently, this is an efficient government program, especially when it covers children.
I don’t think I am doing a good job at conveying the benefits of this program, so let me list a couple more before moving on:
The expansion of Medicaid has contributed to improved perinatal and maternal health, decreased incidence of child neglect (more on that later), a decreased high school dropout rate, and contributed to a nearly 50% reduction in infant mortality.
If you consider Medicaid and CHIP as essential needs — it is healthcare, just as essential as food and housing — their impact on poverty is undeniable, though Medicaid isn’t incorporated into the official poverty measure. However, researchers found that if you were to add the value of health care to a family’s total needs and then see how many families would fall below this threshold, then Medicaid and CHIP reduced poverty from 23.7% of US children to 18.4% in 2014.
One study found that Medicaid eligibility during childhood boosts college enrollment and increases four-year college attainment. Another found that for each additional year of Medicaid eligibility as a child, “adults by age 28 had higher earnings and made $533 additional cumulative tax payments due to their higher incomes.”
I could keep going but I think you get the picture. The bottom line is this: Medicaid makes kids healthier both now and in the future, helps them do well in school, and allows them to become productive tax paying citizens as adults, all while saving the government money.
Now, let’s look at the foster care system.
Medicaid and Foster Care
Medicaid intersects with the foster care system in a million different ways. For children and young people who could be involved, are involved, and have been involved in the child welfare system, Medicaid acts as a critical lifeline.
We know poverty and entry into foster care are associated — specifically, poverty has been found to be a “contributory causal factor” for neglect — and so any efforts to reduce poverty should reduce entry into foster care. That is precisely what occurs with Medicaid, as indicated in a pair of studies (which I cite quite often to friends, family, and anyone who cares to listen):
The first finds that there were 422 fewer cases of reported neglect per 100,000 children younger than 6 years in states that expanded Medicaid between 2010 and 2016, relative to states that didn’t expand.
The second finds that Medicaid expansions are associated with a “large decrease in foster care admissions, driven by neglect incidents.”
Once in the system, all children are eligible for Medicaid, and states can receive reimbursement from Medicaid to help cover the cost of foster children’s health care. The precise way in which Medicaid serves foster youth is complex — there are a variety of pathways and service delivery models — but the program helps states coordinate their care, fund therapeutic services, and more. Medicaid — along with CHIP — covers 99% of children in foster care, according to the advocacy organization First Focus on Children.
If you need a more concrete understanding of how Medicaid serves foster youth, consider the state of Arkansas: nearly all of the “approximately 3,370 children currently in the [the state’s] foster care system are covered by some category of Medicaid to ensure their health care needs are met.” Similarly, in Virginia, Medicaid (along with CHIP) cover 99+% of children in foster care.
Cuts to the program, then, could jeopardize the care that foster children receive or strain state budgets — many of which are already strained — as they race to fill the gaps left behind by the federal government (if they fill the gaps left behind). The folks who are cavalierly discussing slicing Medicaid to the bone are playing with fire.
Ok, what about kids who ‘age out’ of the system? The ACA allows young adults to remain under their parents’ healthcare plan until age 26. Given that in most cases, a former foster child doesn’t have that ‘luxury’, there’s also a provision in the ACA that allows youth aging out of the system to maintain their Medicaid eligibility until the same age.
As of 2023, there were approximately 112,000 former foster youth between the ages of 18 and 26 in 46 states enrolled in Medicaid. For these former foster youth, coverage can be difficult to maintain, according to a report by the Government Accountability Office, as this population experiences a host of barriers, including the following:
difficulties experienced during the Medicaid enrollment and renewal process,
frequent address changes due to transient and unstable housing,
difficulty coordinating between state agencies, and
mistrust of the child welfare system by individuals formerly in foster care.
As a result of the above challenges, there could be tens of thousands of additional former foster youth who are eligible for Medicaid but are not accessing it. For them — and for the youth already using it — massive reductions in Medicaid funding can disrupt lives that have already witnessed their fair share of disruptions.
We cannot jeopardize the care that current and former foster youth receive. For their sake — and their families and caregivers — we must stand up and fight back against these proposals. How do we do that?
What You Can Do:
I read somewhere that the best thing to do when you feel like there’s not much you can do is to do something, no matter how small. This is what this section is about: doing something. One of the most effective ways to push back against Medicaid cuts is to contact your senator. I know that might sound like shouting into the void, but I can tell you from experience that it’s not. I used to work in the district office of a congresswoman, where I helped screen constituent mail. Every single letter was read, logged, and responded to. Every phone call was noted. If a senator’s office starts getting a flood of messages about Medicaid, they’ll notice—especially if they’re on the fence about how to vote.
To facilitate this, I drafted a letter template that you can either send as is, or if possible, personalize. If you or a loved one relied on Medicaid, I encourage you to include that: people in general respond more to real stories than statistics. If you live in a state where Medicaid cuts would have a devastating impact — I included some state-specific data in this newsletter, but you can find more on the web — adding that can also help. I am absolutely willing to help you edit a letter if you want. If that all sounds like a lot and you just don’t have the time, don’t worry — just copy and send the letter as is.
This is especially important if you live in a state with a Republican senator, because given the current makeup of that chamber and the process in which these cuts might be enacted (budget reconciliation, for those interested), the GOP holds all the cards. Okay, here’s how you contact your Senator:
Email:
Find your senator’s contact information at www.senate.gov. Click “Senators” and selected “Contact Your Senators.” Select your state, then click “Contact” below the senators name.
Navigate to the “Email [Senator] Section.
Copy and paste the letter (linked below) into their contact form or email. Make sure to edit specific details (such as adding the Senator’s name).
Use a clear subject line, like: Please Oppose Medicaid Cuts – [Your Name & Zip Code].
Hit Send.
Letter: If you so desire, you can also send a letter to your senator. The process is similar to the above: each Senator has their address listed, and so all you must do is print out the letter, shove it into an envelope, and fire away.
Call: Calls get logged, and a flood of calls sends a strong message (trust me, they’ll notice if the phone is ringing off the hook). You can find the phone number of your senator in the link above and say something simple like:
“Hi, my name is [Your Name], and I’m a constituent from [Your City, State]. I’m calling to urge Senator [Last Name] to oppose the Medicaid cuts in ongoing legislative negotiations. These cuts would hurt poor children and foster youth, and I believe Medicaid is too important to be on the chopping block.”
Again, you can find the letter here — it is view-only, so you can copy and paste. Let me know if you have any questions, and let me know if you end up sending this letter!
Final Notes
Folks shouldn’t read this newsletter and conclude that Ricky thinks Medicaid is perfect, or that there are no ways we can make it more efficient. There is ‘waste, fraud, and abuse’ within the system. For example, a 2024 report by the Department of Justice and the Inspector General for HHS lists several criminal and civil instigations that were conducted in 2023. Most of these focused providers, such as ambulance or substance abuse treatment services, rather than beneficiaries. However, to address this, a scalpel is needed to weed out inefficiencies and fraud; the approach proposed by House Republicans is more of a sledge hammer, smashing the system for the sake of (ostensibly) eliminating waste and fraud.
Readers might note that I haven’t commented on the tax cuts or overall proposal being advanced right now. That is on purpose: this is a newsletter for child welfare, and I gotta pick my battles on this platform. I, of course, have my opinion and would gladly share it privately for those that are curious.
I hope I convinced you of the stakes. More importantly, I hope I convinced you to act. Tax cuts shouldn’t come at the expense of children’s health care—especially for low-income and foster youth who rely on programs like Medicaid to survive and thrive. If you believe this, join me in this fight!
Thank you for reading, and I will see you in a few weeks.
Current Read(s):
I am just about to finish Golden State: The Making of California by Michael Hiltzik, a new and dang good book on the history of California. Upon finishing it, I will turn my attention to a book that’s been on my list for quite some time: We Were Once a Family: A Story of Love, Death, and Child Removal in America by Roxanna Asgarian.
I read the first chapter of this book, in anticipation of this newsletter, and boy is it tragic. It tells the story of a couple who drove off a cliff with their six adopted children, killing everyone onboard. Asgarian traces the family’s story — who were the kids, who their birth families were, why they were adopted, and what their lives were like before the incident — and offers a damning critique of a foster care system that fails to protect children, despite that being its main mandate. I will report back what I learned in my next newsletter.
What’s going on in the world of child welfare?:
Medicaid Cuts Threaten NY’s Most At-Risk Children. Protect Them (The Journal News) — An article written by two non-profit leaders who make the same argument that I make in this newsletter.
“All I Did Was Sleep”: Despite Years of Damning Reports, States Across the Country Fail to Rein in Psych Meds for Foster Youth (The Imprint) — Foster kids are still being overprescribed psychotropic drugs despite evidence that this is extraordinarily harmful (I wrote about this last year).
New York City Stands Out As a Rare Local Agency Tallying Foster Youth on Psychotropics. What Do the Numbers Reveal? (The Imprint) — The opening sentence of this article speaks for itself: “Nearly one in four New York City foster youth ages 7 to 17 is placed on psychiatric medications — a powerful class of drugs including stimulants, mood stabilizers, antipsychotics and antidepressants.”
Advocacy Group Alleges Oregon Hid Details of Foster Child’s Death (Oregon Public Radio) — A foster child died in a state-paid hotel last year, and according to an advocacy group, the state of Oregon was more interested in defending itself than being honest about the systemic shortcomings that contributed to the child’s death.
Senate Approves Bill to Extend Foster Care Support to 23 Years Old (CBS2 Idaho News) — Great news! After being signed into law by the Governor last week, Idaho has extended foster care to 23
Alaska House Votes to Increase Oversight and Limit Time for Foster Youth in Psychiatric Facilities (Alaska Beacon) — New legislation in Alaska mandates that with seven days of being placed in an “acute psychiatric” facility, a court hearing needs to be held to determine whether that placement is appropriate.
Ten Years On, There’s Still No Way to Track Kids in NC’s Child Welfare System Online (North Carolina Health News) — What happens when faulty tech meets a broken system?
Oregon Lawmakers Consider Sending Kids in Foster Care Out of State, Again. Only This Time, with Less Transparency (Jefferson Public Radio) — After a tragic history with sending children out of state, Oregon is considering returning to the practice, allegedly with more safeguards.
WV House Passes Bill to Stop ‘Unnecessary Moves’ of Foster Kids; Child Welfare Experts Critical (West Virginia Watch) — WV lawmakers decided that to prevent kids from bouncing around the system, they need to terminate parental rights faster. WV already terminates parental rights at twice the rate of any other state, but they want to speed it up. This bill, frankly, is an assault on families.
Illinois’ Child Welfare Agency Failed to Produce Reports After Child Deaths (Jacksonville Journal-Courier) — When kids in care get hurt (or worse, when they die), a reckoning needs to take place, an investigation made, and a report produced, which will hopefully lead to systemic changes. This article alleges that this process is not being followed in Illinois.