Ask an Expert: The Public Health Impact of Medicaid Policy with Kathleen Adams
by Ellie Pourbohloul
With the passing of a recent domestic policy bill that outlines $880 billion in spending cuts, Medicaid is once again in the news. Medicaid is a federal and state-funded program that covers millions of Americans and helps them access essential health services.
Kathleen Adams, PhD, is a professor of health policy and management at Emory University’s Rollins School of Public Health. She has over 25 years of experience in applied economic analysis with a focus on Medicaid policies and issues. Here, she discusses the public health impact of Medicaid and the potential effects of proposed budget cuts.
Why is Medicaid so important for the health and well-being of our nation?
Medicaid provides insurance coverage to millions of American citizens, which means access to health care for otherwise vulnerable populations. This includes low-income families, pregnant women and children, and people with disabilities. We know that Medicaid usage leads to more people using primary and preventive care, accessing medications, and adhering to drug regimens. This ultimately leads to improved health outcomes and lower death rates.
Medicaid also provides access to prenatal care for lower-income and uninsured pregnant women, leading to better maternal and infant outcomes. Studies show children with access to Medicaid and the Children’s Health Insurance Program (CHIP) are more likely to be employed and paying taxes as they get older. In short, Medicaid supports a healthier and more productive population.
Congress is debating significant cuts to Medicaid. What do these potential cuts mean for people?
Medicaid insures around 79 million people and costs about $880 billion per year (as of 2023). Medicaid costs are shared between the federal government and states, ranging from a 50-77% federal cost-share. The federal share is higher for those newly enrolled in Medicaid under the Affordable Care Act (ACA) or CHIP.
Medicaid cuts may take one of several forms. Cuts could include reducing the cost-share of the federal government, per-capita caps for states, or work requirements (though most working-age Medicaid recipients without disabilities are already employed). In states that expanded Medicaid, cuts might look more like restrictions in eligibility and, as with other cuts, may lead to reductions in payments to providers. Ultimately, this will negatively affect the health of people in those states and the ability of hospitals to provide services to those on Medicaid and/or those newly uninsured because of these cuts.
What are some other potential budget cuts in store?
Other potential cuts may affect federally subsidized private insurance through the ACA marketplace, which serves households earning between 100% and 400% of the federal poverty level. President Biden increased access and subsidies for the ACA marketplace, but these are set to expire by the end of the year. If they are allowed to expire, there will be more people becoming uninsured, and premiums will likely increase.
There may also be cuts to safety-net hospital subsidies. These subsidies exist to help maintain the financial stability of safety-net hospitals which provide care to low-income, uninsured, and vulnerable populations regardless of their ability to pay. Subsidies offset hospitals’ uncompensated care costs and the lower rates paid by Medicaid, thereby maintaining access for vulnerable patients. Cuts would especially hurt rural communities and hospitals that are already working under tight financial margins.
Your recent research showed how Medicaid planning waivers can improve reproductive health care. What are Medicaid planning waivers, and what’s your current work in this area?
Medicaid waivers are granted by the federal government to allow states to modify Medicaid rules and expand access to people who might not otherwise qualify for full Medicaid benefits. They may also add additional benefits that are not available through Medicaid normally.
There are many kinds of waivers that states can use to address the needs of specific populations, such as older adults, people with disabilities, and pregnant people. Our team has served as the evaluator of the Georgia Medicaid Family Planning Waiver (called Planning for Healthy Babies or P4HB) since 2011, which offers family planning services to low-income eligible women in Georgia who would not otherwise qualify for Medicaid. We have shown how expanding access to family planning services reduces unintended pregnancies and saves money in the long term, which helps extend government support for this program.
A unique aspect of this waiver provides social support and additional medical services to women who recently delivered a very low birthweight infant. We are currently analyzing how this part of the program affects postpartum care and potentially reduces adverse outcomes in a later pregnancy.
How would Medicaid cuts impact maternal health?
The first-round effect would likely be fewer women becoming insured early in pregnancy and fewer maternal health providers participating in Medicaid. This could mean later entry into prenatal care and lack of treatment aligning with evidence-based guidelines, leading to worse outcomes as measured by factors such as gestational age and birthweight. It also could mean increased rates of severe maternal morbidities (SMM), including hemorrhage, sepsis, renal failure, shock, acute respiratory distress, eclampsia, heart failure, and, in severe cases, death. These are very costly but preventable outcomes.
There would likely be differential effects on minorities who already have higher rates of these unexpected complications of labor and delivery, resulting in significant short- or long-term consequences to a woman's health.
