Marian Jarlenski researches health equity at Pitt, and sees no way to slash Medicaid spending without hurting the health care access of children, pregnant people, low-income workers and people with disabilities.
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by Venuri Siriwardane, PublicSource
Deep cuts to Medicaid are being debated on Capitol Hill right now. Lawmakers could slash federal funding for state programs, force enrollees to work to keep their coverage or kick those who qualified under expansions off the rolls, among the options on the table.
The U.S. House of Representatives, narrowly controlled by Republicans, passed a bill last month requiring the Committee on Energy and Commerce to find $880 billion in spending cuts over a decade — a necessity to extend tax cuts that mostly benefit the wealthy. The committee oversees Medicaid, which means some aspects of the program will likely be on the chopping block.
What kind of cuts are we most likely to see? And what could they mean for vulnerable — and even well-off — people in the Pittsburgh region?
We asked Marian Jarlenski, a professor at the University of Pittsburgh’s School of Public Health and associate director of CONVERGE@Pitt, a research center that studies sexual and reproductive health. She’s an expert on Medicaid whose research explores how its policies and programs could improve pregnancy and reproductive health outcomes. Her team built this dashboard that offers a snapshot of Medicaid reliance in congressional districts nationwide. It shows that about 174,000 people in Pennsylvania’s 12th congressional district — which includes the City of Pittsburgh and is represented by Democrat Rep. Summer Lee — are enrolled in Medicaid and the state’s Children’s Health Insurance Program [CHIP].
Medicaid is jointly funded by the federal government and states, with each state administering its own program. The generosity of those programs can vary, but Jarlenski said Pennsylvania’s program is fairly robust. It covers kids with disabilities regardless of household income, connects people leaving jails and prisons with care, and integrates parts of Medicare and Medicaid plans for those who qualify for both.
Those “innovative programs” could now be at risk, she said. “It’s hindering our ability in Pennsylvania to move forward … and think of new ways to address public health. Instead, [we’ll be] on the defensive and saying, ‘Where can we cut?’”
The following conversation was edited for length and clarity.
Q: Medicaid cuts can take many forms. Which ones would cause the most damage?
This is a tough question to answer because we don’t know the details of how cuts would be implemented. But the three main cuts that Congress could consider would be:
1) Imposing a work requirement, which makes each person document their work status. The evidence shows it doesn’t increase employment, but instead creates more red tape and causes people to lose their benefits.
2) The block grant option. The federal government gives a lump sum of money to states, and states decide how to allocate the money. Typically, the lump sum would grow more slowly than the cost of medical care would grow. And so over time, states could have to limit who’s on Medicaid. Waiting lists for benefits existed before the Affordable Care Act [ACA]. We had what’s known as ‘state-only programs’ and the funding for them was restricted. This happened in Oregon, which had a waiting list for the Oregon Health Plan because there just wasn’t enough money to cover everyone.
I think the brute force of this cut would cause the most damage. It would make it really infeasible for Pennsylvania and other states to provide the kind of benefits they do now. And that’s why 20% of adults were uninsured in the United States before the ACA allowed Medicaid expansion. Because it’s just so cost-prohibitive for each state to go it alone.
3) And the third potential option is cutting off the federal match for the Medicaid expansion population. (The ACA allows states to expand coverage to adults with incomes up to 138% of the federal poverty level.) In Pennsylvania, the Medicaid expansion population is low-income adults who don’t have dependent children, and many low-income parents who have dependent children. The federal government pays 90% of the cost of this group’s Medicaid insurance, and cutting that off would increase the state’s spending burden. The increased pressure on our state budget could have negative spillover effects in other areas, such as education, transportation, economic development, all those big-ticket items.
Q: A fifth of Allegheny County residents rely on Medicaid. And your lab’s dashboard shows that more than 174,000 people in the congressional district that includes the City of Pittsburgh rely on Medicaid and CHIP. How do those numbers compare to what we’re seeing on a national level?
Our county and congressional district line up pretty closely with the national average. More than 20% of Americans are enrolled in Medicaid. Who are they? Working class and poor people who need health insurance. It also includes pregnant patients, a lot of kids, and importantly, people in long-term care settings who spent all their assets paying for those services. So a lot of middle- and even upper-middle class people will rely on Medicaid for their long-term care needs in old age.
Also, about a third of births in Allegheny County are covered by Medicaid. And we have a new policy in Pennsylvania: Any baby whose birth is covered by Medicaid is now automatically enrolled in the program through age 6, which is really exciting. But these cuts would put the health insurance of pregnant women and kids up to age 6 at risk.
Q: I want to pick up the thread on older adults with different class backgrounds needing Medicaid. We know that Medicare generally won’t pay for nursing home care, but Medicaid will. Our county has a higher concentration of older adults than most other large counties in the country. Could these cuts have a disproportionate impact here because of that?
I think it depends on the type of cuts. Some of the proposals to cut Medicaid would exempt people with disabilities, including long-term care residents. For example, a work requirement would not apply to them. … If we’re going into a block grant or limiting per-person spending, it would absolutely hurt the ability of nursing homes in our area to serve all. It can cost up to $100,000 a year per person for nursing home care, not counting additional health care in the hospital and things that may be paid for by Medicare. So I definitely would be concerned if we’re talking about limiting spending per person, or an overall block grant, for the feasibility of nursing homes to continue to serve the population.
Q: You study Medicaid’s impact on pregnancy and reproductive health outcomes. We know that maternal and infant health outcomes are worse for Black people than their white counterparts in the county. Could these cuts exacerbate the disparities?
That’s an excellent question. Before I answer it, I want to emphasize that Medicaid coverage is the same regardless of your race or ethnicity. But because of social and historical factors, such as redlining, we see in the demographic data that people of color might be more likely to be working class and belong to low-income households in Allegheny County. So we do see a slightly higher rate of Medicaid coverage in populations of color.
Medicaid is the single largest program in pregnancy and reproductive health space, so I feel it could really incentivize health care systems or Medicaid health plans to focus on interventions to reduce health disparities. If it’s a big part of the population you serve, you’re going to notice and document the disparities and try to take action to intervene on those. So in that sense, Medicaid coverage is the floor on which we could build interventions to address health disparities and ensure that everybody has high quality care and good pregnancy outcomes. If that floor goes away, those systems will be scrambling for basic insurance coverage instead of trying to build a better future.
Q: We know that Medicaid can be a lifeline for people with disabilities — especially if their disabilities prevent them from working or if they need assistance with daily living. About 11% of Pittsburghers have disabilities. How could these cuts affect them?
There are people with disabilities who receive Supplemental Security Income, which automatically qualifies them for Medicaid. Typically, a work requirement [for Medicaid enrollees] would exempt those people. Then there are people who have some kind of condition that would be disabling in their daily life, but don’t have an official disability determination. And those folks, of course, would be subject to work requirements.
The other thing I want to say is that people with a disability determination have to stay under a certain income threshold to keep their benefits. So even if people want to work full time or be promoted, they can’t do that because they have to keep their income low enough to qualify. That’s a problem that disability advocates have been talking about for probably 40 years. It has not been fixed yet, and cutting benefits is certainly not going to fix it. Like those in nursing homes, people with disabilities often have complex and expensive health care needs. So any proposal to limit per-person spending or give a block grant is going to hurt the medical system’s ability to serve them.
Q: Health care facilities power a big part of Pittsburgh’s economy. I imagine these cuts would significantly impact medical billing at hospitals and in the broader health systems, which employ so many people here.
That’s right. It would have spillover effects on the economy and jobs. Health care is a large part of our economy in Pennsylvania. And health care work is the second-most common type of job among people who are enrolled in Medicaid. So people who work as home-care attendants or as medical techs or in long-term care facilities tend to have working-class incomes, and they are actually covered by Medicaid. So it’s all tied together.
Q: The Trump administration vowed not to cut Medicaid and said the budget resolution would only target “waste and fraud in entitlement spending.” Republicans in Congress have echoed that. Experts said this is misleading, and that it’s impossible to achieve $880 billion in savings without slashing Medicaid. How is waste and fraud controlled, and do we need these cuts to do it better?
What we tend to see is fraudulent billing to Medicare or Medicaid managed care plans. A common type of fraud or abuse involves [a provider] creating a fake patient profile and billing for them. I think we can all agree that fraud is bad — I can say that unequivocally. We would all support more fraud investigation funding, and you would think the federal government would be adding jobs to the Department of Health and Human Services rather than cutting them if it wanted to beef up the workload.
The [U.S. Department of Health and Human Services] put out a report last week that actually found that Pennsylvania had the highest number of Medicaid fraud and abuse claims. They had investigated around 19,000 claims. (The state also ranked third in convictions of those who abuse its Medicaid program.) So I feel like our program is doing a pretty good job at combating fraud and abuse, and so I’m not really sure what else we can be doing there. We’re No. 1 in the nation.
Q: What can state and local policymakers do to mitigate the damage?
Well, it’s really hard because you need to fund a Medicaid program at scale. Most of our income taxes go to the federal government. And a lot of it comes back through these state and federal programs.
One option would be for states to band together to get that scale. There is a mechanism called an interstate compact. It’s been done around water rights and things of that nature, but I don’t see why that type of agreement can’t be developed for medical assistance. I think we need to draw on the expertise of people in our region, in health care and education, to think of the most creative ideas. Absent that, I think everybody has a role to play in educating elected officials about the importance of these programs to our economy and, obviously, to people’s health. Because how devastating would it be if you had a health condition and weren’t able to get care for it?
Venuri Siriwardane is PublicSource’s health and mental health reporter. She can be reached at venuri@publicsource.org or on Bluesky @venuri.bsky.social.
The Jewish Healthcare Foundation has contributed funding to PublicSource’s health care reporting.
This article first appeared on PublicSource and is republished here under a Creative Commons license.
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