Episode 47. Michelle's Intro
Michelle Rathman: Hello and welcome back to a new year of the Rural Impact. I'm Michelle Rathman. It is the 16th day of January 2025. I turned a year older in December, but I have a feeling that I may age about 10 years of these next 12 months ahead. Maybe you all can relate, but in any event, I can think of no better company than you to muddle through these times with. So here we go.
If you're a new listener, I will just tell you real quick that we are in a nutshell, a podcast that works to connect the dots between policy and rural everything, and I do mean rural everything. Now, in the last episode, it was a very brief episode. It was just kind of a preview of what we have in the works for you for this year.
And in that time, I mentioned that we are going to keep a close eye on the incoming administration's policies and how they may or will impact rural. Now starting with this episode, we are kicking off an ongoing series we're going to call quite simply 2025 and the Impact of Policy Shifts. I do believe shifts are going to happen.
So we know there'll be no shortage of topics from which to cover to be sure. And today we're going to focus on healthcare and really what I believe promises to be one of the most contentious, probably the most challenging for rural. And that is medicaid cuts as well as policies around the expansion of Medicare Advantage, which is proving quite frankly to be putting safety net hospitals and their patients at a disadvantage on several fronts.
So again, you're going to hear about that. And joining me for this conversation, I'm no expert on either one of these topics. I know a lot about them, but I brought the experts with us, and I was grateful to have time with Larry Levitt and Larry is Executive Vice President for Health Policy. Overseeing KFS policy work on Medicare, Medicaid, the health care marketplace, the Affordable Care Act, racial equity, women's health, and global health.
Now, after hearing from Larry, it was really great to have Edwin Park join me and Edwin is a research professor. At the Center for Children and Families McCourt School of Public Policy at Georgetown University and Edwin has done extensive research and as a matter of fact, some big news came out on that front this week.
So you're going to have to go to our show notes to read about that. But what really drew me to pay closer attention to Edwin was an article that he penned in November of 2024. And the headline read, this gives you a little bit of preview of our conversation, "Congressional Republican leaders start to show their hand. Draconian Medicaid cuts on the agenda for next year."
Well, here we are. It's next year. And again, this is a very important policy discussion for us to be having. And before I shift to these conversations, I thought, let me just give you a bit more context about why Medicaid cuts matter for rural, even though you may not be, if you may not think that you are directly impacted by them.
But I think by the end of this episode, it's very likely that you will see how, directly indirectly that it impacts you on either side. So, first of all, notably, rural people are much less likely to be covered by employer provided insurance. This is not an opinion. This is well documented. And we, as we've covered in past episodes, we also know in general that the rural job market pays less than other places.
So, what does this mean? Any increases in health insurance premiums will be financially challenging for millions should, again, should Congress allow the enhanced premium tax credits. Remember those? They're called PTC. Should they allow those to expire in 2025? And to help understand where we are, let's go back just a little bit.
And that is back in March of 2021, these credits made health insurance far more accessible in three really significant ways. The first is that the increases substantially increased the subsidies available to buy insurance in the marketplace in the first place. It's important to note that the legislation also extended eligibility for PTCS to people with incomes above 400 percent of the federal poverty level.
And lastly, on this point, I'll just share with you that it ensured very important that enrollees between with incomes between 100 and 150 percent of the federal poverty level could get coverage without having to pay premiums. Very significant for those folks. Now since then marketplace plan selections have risen from 12 million to roughly 21. 4 million in 2024 .That's a big number.
And because Medicaid plays such a large role in small towns and rural areas any changes to the program are more likely to affect the children and families living in small towns and rural communities. So, I think that's really important. I believe it is important to you as well.
And that's why we're bringing this conversation to another important side note before we move on a dot to connect if you will, is that we know that states without expanded Medicaid will see the largest effects, but they won't be alone because we also know that rural areas will once again contend with skyrocketing premiums, limited choices, which is already a challenge for so many rural communities.
You may have already experienced how challenging it can be to just get into see a primary care provider, let alone any kind of specialist. And, the icing on this crud cake, as I'll call it, is that as it stands right now we do know that 50 percent of rural hospitals across the U. S. are operating at a negative margin.
This simply is not sustainable. Big picture, the more uninsured does not mean the need for healthcare just disappears or dissipates or curtails. It means that already struggling hospitals will be up already. As I said, operating on thin, thin ice will have more patients to care for without a pathway to payment.
And that is hard to operate without reimbursement. Then what happens? So, I won't speculate. I'll just leave it there and and ask you and invite you to connect those dots as you're listening to this conversation. Now, as I say, often, I know these are not light subjects. But in the end, I do hope my conversations with Larry Levitt and Edwin Park and the others that we're going to have in these series do enlighten you.
So, with that said. I'm going to keep going with this. I invite you to sit back, get yourself into your podcast frame of mind and listen to this important conversation about Medicaid cuts with Larry Levitt and Edwin Park. Are you ready? You know, I am let's go.
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Michelle Rathman: Hey, Larry Levitt, Executive Vice President for Health Policy at KFF, welcome to the Rural Impact. Thank you for being here. This is a very important conversation and I cannot think of anybody better than you to kick us off.
Larry Levitt: Oh, thanks for having me.
Michelle Rathman: All right. Well, as we were kind of talking before we went on air here, one of the things that we saw during the 2024 election was that threats to Medicare and Medicaid were not reflected in the polls, which, quite frankly, was shocking to me, but I don't know really why that is.
But there was other things they wanted to cover, and certainly the media in general did not indicate that these were concerns for voters. So here we are. We're now in going into the second week of January. This one will drop at the second week of January, and we know that should there be cuts or a repeal of federal financing for expansion of Medicaid, the impact will be felt by many and in many, many ways. We could speculate, but you know more than most.
So keeping this in mind for this conversation, Medicaid plays a significant, essential role in helping fill the gaps in coverage in rural areas, and that includes for our safety net hospitals, they rely heavily on those payments. So let's start off this not light subject conversation, Larry, by offering us some numbers.
Because even this morning, you know, you posted something. What do we know about enrollment in state by state, which is a great way for us to understand the implications, and who will be impacted by health policy shifts? Noting that the biggest growth in enrollment has been in the so-called red states.
Larry Levitt: Yeah. So let's I mean, if you think about our public health insurance system, you know, it's three big programs now. It's Medicare, Medicaid and the Affordable Care Act. And we're talking, you know, roughly 160 million people nationwide who depend on those programs. And as you said, I mean, it's true in every single state with, with some differences, which I'm sure we'll, we'll get into. You know, and, and I think for a long time Medicare has been seen as a third rail of American politics.
You know, that you, you can't touch it. And for example, even in the campaign President-elect Trump said that he would not cut Medicare or social security he was conspicuously silent on on Medicaid. Um, interestingly, you know Medicaid now covers more people than than Medicare. Medicaid covers about 79 million people, compared to 68 million in in Medicare, but I think it doesn't get the same attention. Primarily because we're talking about low-income people.
Michelle Rathman: and children.
Larry Levitt: And children, absolutely.
You know, low income adults, low income children and in fact, you know, low income seniors and people with disabilities as, as well. You know, the Affordable Care Act, you mentioned that the government just announced record enrollment in, in the ACA. This has been driven by enhanced premium aid which was passed by Democrats in Congress and signed by, by President Biden.
And that enhanced assistance has, has fueled record enrollment of 24 million people. So as Donald Trump takes office, you know, we've seen record enrollment in the ACA. In fact, record enrollment in Medicaid as well, and the lowest uninsured rates, we've ever seen. And a lot of the growth in enrollment, particularly in the Affordable Care Act has, in fact, come in, in red states.
And that's particularly red states that have not expanded Medicaid eligibility under, under the Affordable Care Act.
Michelle Rathman: I think there's a reason why they don't want to talk about it. Because obviously. So, let's talk a little bit about the implications of Congress allowing, so these subsidies, if you will, they're extended through 2025.
Larry Levitt: That's right.
Michelle Rathman: And so, you know, whether or not President-elect Trump is talking about it, members of Congress are.
So what are the implications? I really think it's important for our listeners to understand what happens should Congress allow enhanced ACA financial aid to expire, uh, state by state? Because there is no like, it's a cookie cutter approach, really. I guess it depends on where you live, where your zip code is.
Larry Levitt: Absolutely. Depends on your income, where you live, how big your family is, your age. But I think, you know, we, we talk about, and even I talk about this enhanced premium aid or subsidies in a somewhat, sterile way. It has been very, very meaningful to, to people. So to, to put some numbers on it the average amount of this extra premium assistance that people are getting is about seven hundred and five dollars per year.
If that premium assistance expired, people's out of pocket premiums would increase by upwards of 80 percent. So premiums would skyrocket for people who are who are getting this aid. And, you know, enrollment would fall. I mean, millions of people would lose coverage without this extra premium assistance.
And as I said, you know, it's particularly important in those states, all red states, that have not expanded Medicaid under the ACA, and that's because very low income people who would otherwise be eligible for Medicaid are instead eligible for these ACA subsidies.
Michelle Rathman: And we are not talking about people who are unemployed. I mean, we are talking about people who, who use this program and are still maybe working two or three jobs just to get by because this is a condition. And, Larry, I wonder if you could, you know, just opine a little bit about, it's not just about people losing their coverage, but what happens to the people who provide care?
Because the people who lose their coverage still, presumably, need health care. And so, let's talk a little bit about, if you wouldn't mind, a little domino effect. What happens then?
Larry Levitt: Absolutely. So, and as you said, I mean, the people who are receiving both the ACA premium assistance and Medicaid are overwhelmingly working people. And, as you said, often working you know, struggling with a part time job, working multiple jobs, and there very much is a domino effect.
I mean, one of the effects of expanding coverage is certainly to give people better access to health care, more financial security, peace of mind, better health ultimately. But the providers who provide care to people who are eligible for these programs see improvements in their finances and fewer nonpaying patients or, or less on uncompensated care.
And we, you know, we see that in the numbers. I mean, rural hospitals certainly struggle, we know that, and they've struggled particularly recently. But rural hospitals in states that have expanded Medicaid under the Affordable Care Act have noticeably better finances, higher margins than hospitals in states that have not expanded Medicaid.
Michelle Rathman: Yeah, this is so true. I want to shift the conversation a bit to the term, you know, the trigger laws. Because I looked at the maps, and KFF does an amazing job. I love the maps. They tell the story very simply. So, we get to a place where we have a Congress that says, nope, we're, we're moving in this direction and then what happens to the states that have those trigger laws?
Because to me, the visualization in my head is that we just push a bunch of people off a cliff and everyone has to figure out if they have a parachute or not. Maybe that's a fair analogy. I'm not sure.
Larry Levitt: Yeah, the, um, you know, so, so there are, uh, I think there's a, there's a, a lot of expectation that the, the, Republicans in Congress and, and President Trump will look to cut Medicaid in the coming year. And in some ways, you know, the math is inescapable here. Republicans are looking to uh, put in place big tax cuts, which will cost a lot of money.
Uh, President Trump has said Medicare and social security cuts are off the table. You know, House Republicans have talked about cuts in federal spending of amounts like two and a half trillion dollars over 10 years. So, if you take Medicare off the table, social security off the table, defense off the table, that leaves Medicaid as, as the biggest program in the federal budget, with a big target on its back.
Um, and there are a number of ideas being put forward. talked about. I mean, There's ideas like a block grant, you know, capping federal spending and turning the money over to states with much more flexibility, or eliminating that Medicaid expansion. And the Medicaid expansion under the ACA covers about 21 million people.
As you said, a number of states have trigger laws that if the federal government cuts back on its matching payments for the Medicaid expansion, the Medicaid expansion will go away immediately in those states. But I think the, the reality is, I mean, we're talking about so much federal money that if that extra federal money for the Medicaid expansion goes away, virtually every state is going to cut back on the, the Medicaid expansion, because states just, just can't absorb that, that kind of money.
So, we're talking about potentially, you know, over 20 million people losing coverage.
Michelle Rathman: I can't even wrap my brain around what that looks like, you know, like waking up one day and then that it's just blows up the entire thing. So let us do another shift here because it's very much related. Talk a little bit about the incoming administration's views. I mean, I've read Project 2025, although there's been some kind of hope to disassociate the two, but if we lay the concepts of a plan that we're hearing about over the top of Project 2025, they do have quite a bit of connectivity there. Let's talk about views on health policy. Those vulnerable populations who rely on this, rural underserved areas, high risk populations with caps in place, or they call the block grants or the caps in place. What do you anticipate happening at the state level? Because now we have to turn inward, I think, and state legislators and leaders need to have a plan.
Larry Levitt: Yeah, no, and I mean, this is, you know, and this is not just a blue state issue. It's an everywhere issue. That you know, Medicaid, federal matching payments for Medicaid are the biggest source of federal revenue in states. You know, as I said, most people on Medicaid are, are working people.
They're working in jobs that don't have, have health benefits. They're low income early retirees. You know, this is, this is a very vulnerable population. So, you know, if you imagine the federal government capping the amount it will spend on Medicaid that just shifts the risk downhill to states.
You know, there'd be a lot of pressure for states to make up the cuts in federal spending. And again, we're talking potentially trillions of dollars over a decade. But states have to balance their budgets. You know, and the money has to come from somewhere.
Michelle Rathman: On the backs of patients.
Larry Levitt: Yeah, the backs of patients, you know, states are going to be reluctant to raise taxes, they're certainly going to be reluctant to cut education or public safety. You know, so this just, this just shifts the risk to states, to patients to providers that are, that are serving those patients.
Michelle Rathman: Yeah. And then I, you know, down the road, I'd look at researchers, not you or I, but those who will then say, “Oh, what is the connection between poorer health outcomes and, you know, a new swath of uninsured population?” All right, let's shift the conversation a bit because overall there's an agency that will be handed over to somebody else.
And right now, the President-elect Trump's pick to head CMS is Dr. Mehmet Oz who is favorable to Medicare Advantage plans. Because I have a background in, in rural health, I understand what Medicare Advantage has done to the financial situation for rural hospitals, and it's not good. So, let's talk about the impact of, if there's a shift.
From a push for more Medicare Advantage and what that does to the highest percentage of patients with Medicaid. I don't think folks really understand how these two are going to, you know, collide. I wouldn't say that are going to get along famously. They're going to collide.
Larry Levitt: Yeah, no, that's right. And, and, you know, Medicare Advantage, I mean, you know, there, there has been a long-time effort among conservatives to, to privatize Medicare. And, and to some extent, they've won at this point. More than half of Medicare beneficiaries are now in private Medicare Advantage plans.
And there are tradeoffs in those plans. As you said, those plans are often difficult for providers, particularly rural hospitals, also difficult for patients with high healthcare needs because the plans have more limited networks and have prior authorization for services, which is not the case in, in traditional Medicare.
On the other hand, these plans are often available at no premium for beneficiaries with extra benefits and, and lower cost sharing. So they're, you know, they're, it's very appealing for, for people. For many people you know, we've seen proposals like you mentioned in project 2025 to really even accelerate the privatization of Medicare, turning it into effectively a voucher program and making private Medicare Advantage plans the default rather than, than traditional Medicare.
I think there would be a big pushback among hospitals but you know, that is a natural outgrowth of the kind of policies we we've seen from conservatives over the years.
Michelle Rathman: So really 2025 is going to be a very bumpy ride where health policy is concerned. In particular, when we're talking about Medicaid. What else should we be watching for? What's on your radar screen that that you've got that you think our listeners should be? And then I have another question about advocacy, if you don't mind, but what should we be watching for Larry?
Larry Levitt: Yeah, I mean a whole set of issues. I mean, as you know, as you said at the start healthcare was not a big topic in, in the campaign. But that doesn't mean it's not important to voters and it certainly doesn't mean that we're not gonna see potentially big, big healthcare changes. In addition to changes in in Medicaid financing, I think there's also gonna be a push for work requirements in Medicaid.
And as I said, most Medicaid beneficiaries are working, but these work requirements create an administrative burden for people to report work or report exemptions like caring or an ill family member. And, you know, where a work requirement has been put in place, we see lots of people dropping out of, out of coverage.
You know, I think in, in public health, it's going to be depending on who gets confirmed. If RFK Jr. gets confirmed as Secretary of HHS. You know, he has been an outspoken opponent of vaccines. And, you know, even if he doesn't have the ability to, pull vaccines off the market you know, speaking as the head of the largest health agency in the country what he says will carry a lot of weight.
Michelle Rathman: This is so true. Our previous episode, our last episode of the year we last year, we talked about disinformation and public health and the potential dangers there as well. Well, we welcome you to come back anytime you've got news because the list is very, very long. I know we should be looking at what's going to be happening with prescription drug costs.
We had made some gains. Let's see where we go there. Workforce loan forgiveness. I'm thinking about rural health care workforce, but healthcare workforce in general and the visa programs that are tied to those. So, I'm sure your, your newsroom is quite busy these days.
Larry Levitt: Absolutely.
Michelle Rathman: Tell our listeners where they can follow you.
Larry Levitt: Yeah, so, certainly our website KFF.org, has a wealth of healthcare information, and I, I'm trying to be continuing to be active on, on social media, on Twitter X, on Blue Sky trying to get facts out there.
Michelle Rathman: Yeah. And one last thing I want to say, you know, we talk so much. I mean, this podcast is about connecting the dots between policy and rural everything and advocacy, I think more than ever. And I think I just want to tell our listeners, if you're looking for advocacy material, data and facts matter.
And so I would say that the information that you all put out are very important for our efforts and becoming educated. And, maybe, Larry, one of the reasons why Medicaid in this conversation was not on voters radar screen is because we're just not talking about it enough in the context where people can wrap their brain around it in everyday life.
Maybe that's the problem.
Larry Levitt: Absolutely. And these, you know, these issues matter to everyone. I mean, we saw, you know, at the end of last year, after the murder of United Healthcare executive Brian Thompson,you know, and just an outpouring of, uh, angst among consumers about the problems they, they have with, with health insurance.
And, you know, it was a moment where, people were telling their stories. You know, whether that translates into policy action is a different question, but it's a, it's a really good example of, of how much this matters to people and how much it's on their minds.
Michelle Rathman: Indeed. And that's where it is, a policy. I mean that we cannot, it's not about pointing the finger, it's about getting to the root and making something different happen. Oh my gosh. Larry, I cannot thank you enough for your coming again and I say come back anytime you have news for us. We welcome that.
Larry Levitt: Oh, I'd be happy to. Thanks for having me.
Michelle Rathman: My pleasure. Okay, don't go anywhere because we are coming back right after this break to continue our Rural Impact 2025 Policy Shifts conversation.
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Michelle Rathman: Hey, we're back. And now, you know, we're going to continue this conversation. So, it's my pleasure to welcome Edwin Park, research professor at the Center for Children and Families at the McCourt School of Public Policy at Georgetown University for Health Policy to the Rural Impact. Edwin, thank you for joining us.
This is a really important and timely conversation.
Edwin Park: Yeah. Thank you, Michelle. Thank you for having me.
Michelle Rathman: All right. So, I'm going to just say, and I, full disclosure, I mean, I do follow your work. We've spoken with your colleague, Joan, in the past and, and on November 18th, you wrote a blog that really I mean, I think just the headline alone just screamed at me and I've had it pinned on my desktop ever since.
And I mean that, and the headline for those of you who didn't read it goes like this, "Congressional Republican leaders start to show their hand: draconian Medicaid cuts on the agenda for next year." Could not have set it better. So, one of the things that I said at the top of the episode was that for many reasons, Medicaid and Medicare managed somehow to drop off the radar during the 2024 election.
And frankly, as I've said, Project 2025 never made it on most of the radar screens out there, unfortunately, especially where this issue is concerned. And in the blog that you share you have a chart comparing the prominent conservative GOP plans, which includes severe Medicaid cuts. That's no secret.
And as we talked about with Larry, just before you joined us, we talked about caps or block grants as they're called. But let's start by having you tell us about some of the other proposals around cutting federal Medicaid funding that target the Medicaid expansion or in some cases, limit the ability of states to finance their Medicaid programs.
I shudder at that thought, and then from there, let's get into how states facing these cuts will have no choice but to cut eligibility, and the benefits and slash provider payment rates, and all those things, the domino effect, as they say, that will happen as a result. So, it's a mouthful. Let's see if you can enlighten us.
Edwin Park: Sure. So, you know, one of the things that congressional Republican leaders have been saying is we're not going to repeal the Affordable Care Act. Again, there's not going to be an effort like there was in 2017 in the first Trump administration. But one of the proposals that is being floated to achieve really deep Medicaid cuts, you know, they're talking about, you know, 2.5 trillion dollars in spending cuts to help pay for the, the trillions of dollars in tax cuts that are likely to be extended this year. And one of the, the targets is Medicaid. You know, there's been a lot of pledges to protect Medicare to some extent, to protect Social Security, but it's notably silent.
And, the Trump campaign and now the you know, Trump officials, congressional Republican leaders have been silent about Medicaid. And one of the proposals that has been floated in a number of areas, including among house Republican leaders, over the past year or so is reducing the federal financing of the Medicaid expansion, which currently covers about 21 million people in 40 states.
And right now the federal government picks up the vast majority of state's Medicaid costs related to the expansion, 90%. on a permanent basis. And under these proposals, that 90 percent will go down to a much lower rate 57 percent on average. So, in other words, states are going to have to kick in a lot more of their own money to pay for the expansion.
So that means it's not going to be financially sustainable over the long run. And in fact, there's some states where any reduction in that expansion support automatically turns off, the Medicaid expansion.
So nine states have these so called triggers and if there's any reduction, in Arizona, if there's any reduction below 80%, the expansion just turns off right away.
And so, you know, this would have the effect of, of taking away coverage from, uh, millions of people uh, across the country in the expansion. So, it's really about effectively repealing the expansion even if it's not explicit repeal. This other proposal is called, relates to provider taxes, very wonky, very technical.
But states have to come up with a portion of the cost of Medicaid. That's how Medicaid works. And one way they do is provide assessments on hospitals, nursing homes, health plans, other health care providers to, you know, pick up a portion of their costs. And all states but Alaska rely on these taxes, increasingly rely on these taxes, and there's proposals to make it harder for states to use these taxes or even outright eliminate that use.
And so if you have these caps that you discussed with, with Larry earlier you have these, changes to the Medicaid expansion, other cuts to federal funding, and you make it harder for states to generate their own funding you know, that's just a recipe for huge state cuts to their Medicaid programs over time.
Michelle Rathman: And a lot of suffering in a lot of ways. And I, what I want to meet, you know, because we do focus on the implications for rural and as, as you and I both know, and I hope that our listeners by now know that rural residents absolutely disproportionately rely on Medicaid for their coverage. And that also means the health service provider, those who are providing care.
So let's talk a little bit about that. I mean, you know, we talk red, blue, and at the end of the day, you know, Larry talked to us about the fact that this is not a red state or blue state issue, but reliably anywhere where there's rural, which is everywhere. This has significant implications. Talk to us a little bit about that.
Edwin Park: Sure. Residents of rural areas, small towns, they have less access to employer sponsored insurance, and so they tend to rely disproportionately on Medicaid for health coverage. And it's particularly, the case with lower income rural residents, as well as you know, because of that rural hospitals, other health care providers, rural health centers disproportionately rely on Medicaid for their patient revenue.
So, you know, if you look at research we've done in 2023, 47 percent of kids in rural areas are covered by Medicaid compared to 40 percent of those in metropolitan areas. And similarly, for non-elderlt adults, it's 18 percent in rural areas versus 15 percent in metropolitan areas. So, if you are cutting federal Medicaid funding, you are taking away coverage that will impact rural families, and you'll also be affecting the hospitals and other health care providers, you know, in these areas, which already operate under thinner margins in rural areas.
And that's why, you know, the Medicaid expansion has been such a lifeline for rural hospitals when they've been adopted by states and in states that continue to not take up the expansion, a lot of rural hospitals, unfortunately, have been closing,
Michelle Rathman: Because you cannot look at this issue in a silo because there are, it just spreads across and I take a think about, for example, what happens, you know, the importance of federal Medicaid to state budgets? And I wonder, Edwin, if you guys are talking to state leaders, are they, are they just waiting for the ball to drop?
Are they planning for it? How do you plan for it? What can you talk to us about, you know, what this is going to look like at a state level? And I recognize that not every state is created equal in this particular case because we, you know what's happening in Illinois, for example, it's going to be different about what's happening in Oklahoma or Texas.
Edwin Park: Yeah, if you look at the total amount of federal funds that come into state budgets. 56 percent nationally come from Medicaid.
And so, it's a huge portion of state's funding. And you know, it'll vary a little bit by state, but if you are withdrawing, cutting a big portion of that funding coming in the state budgets, they'll have no choice but to cut their budget.
And when we're talking about Medicaid you know, the biggest spending priority for states is K through 12 education, higher education. Medicaid is third in terms of states funding, but if you're taking away all that federal funding, or you're cutting it dramatically, states are going to have to slash their budgets and it's going to be a big effect.
So this is really, federal government acting, states left holding the bag, and, in fact, state policy makers being blamed because they're going to have to think about how we're going to cut Medicaid, how we're going to make our, you know, budget numbers work, because in general, they have to balance the budget unlike the federal government.
Michelle Rathman: And there's no sugarcoating it. You can't look, I mean right now you can't look around with a house and senate. You cannot look around and try and shift the blame if you will somewhere else. And you're right, they're going to have some significant decisions to make, and with the just the cut alone when you take the flexibility out of it.
You know, Larry and I were talking about this. Some of the ACA extensions go through the end of this year, but when we remove some of the flexibility to not make Medicaid better, but in fact, put in more provisions to make it harder. What is it going to look like now with work requirements and things of that nature?
I am just curious what the research will tell us down the road with the impacts. We don't know that yet, but we can certainly anticipate what that's going to look like.
Edwin Park: Yeah, I mean, I think states will look to be, you know, slashing enrollment reducing already low provider payments taking away benefits, restricting benefits, charging higher premiums, and co pay is to make people's health care costs go up. And, you know, people are going to lose coverage. People are going to you know, forego needed care that, you know, that they need, whether it's acute care, long term services and supports, and, you know, there's a large and growing body of research that shows that, you know, Medicaid in childhood has huge long term effects.
Better health in adulthood, less likely, less incidents of disability, higher educational attainment, finishing high school, going on to college, completing four year college with a degree, and, and higher income, and, and more economic productivity and stability as adults as well. And, you know, that means that those who are going to lose coverage or not get the services they need, we're not just going to see the impact in the immediate time frame, but, you know, over future decades.
Michelle Rathman: Oh, for sure. And I think there'll be, to your point, some immediate impacts and then those longer term that, you know, we can't turn back the clock. We're just going to see in real time. Some of these things happen. Let me just talk to you just a moment. This, this one struck me a bit doing away with federal oversight of state Medicaid programs.
Is it not the argument that one of the reasons why we need reform is because Medicaid is being abused in some cases. So, I find that interesting. And that comes from the Project 2025 plan, where they would be, you know, kind of do away with oversight of the state Medicaid programs. That that doesn't seem logical to me, but go ahead.
Edwin Park: Yeah, it, it, it often is this a feature when, the federal government, you know, caps, block grants, federal programs. If you look at the experience in the past, once the federal government does that and sort of washes its hands of you know, long term, sustained federal commitment to you know, healthcare in the case of Medicaid, but other programs in the past.
It also says, states, we're giving you this limited amount of money. We've capped how much we're gonna contribute, and you can do with it what you want. And we've seen that unfortunately with TANF program. You know, when, uh, the AFTC program was converted to a block grant, the TANF Block grant during welfare reform. And then, you know, there have been stories including most recently in Mississippi about TANF funds being diverted to, you know, building a gymnasium for a university rather than going to support struggling families.
And you know, that would be you know, one of the things that we'd be worried about is not only is Medicaid going to have to shrink dramatically, people are going to lose coverage but, you know, whatever remaining dollars are available, won't be used wisely, won't be used effectively to actually provide health care services to vulnerable individuals and families.
Michelle Rathman: And I and I have my eye on, you know. We, you and I both know, that we have so many vulnerable rural health systems, rural hospital closures. We've got these rural emergency hospitals. We've got OB deserts like you know to the to the tune of you know. It the information is out there and available and so I know that that for those families for those mothers and children, the pain is going to be felt deeply. And speaking of that so I also want to connect the dots between capping Medicaid and budget cuts to other states. As you said earlier Edwin, to programs [k through 12 and that also includes things like, WIC, SNAP benefits and so forth.
So we can imagine that cuts to one will be, it's a death by a thousand cuts.
Edwin Park: Yeah, I think it's, you can look at it in a number of ways. You know, you're going to put a lot of pressure on states shifting costs to states from Medicaid. And so, they're trying to preserve parts of their Medicaid program. That means, again, you're cutting out other parts of the budget. K-12 education, higher education, other low-income programs.
But also, it's the same families who rely on Medicaid as they do on SNAP and WIC. And so, you know, they're going to be facing you know, much greater difficulty, financial difficulty because of cuts. And of course, these other low-income programs could also be on the chopping block, particularly SNAP, as part of these budget proposals from Congressional Republican leaders.
And that would be devastating. And then the last point is, you know, Medicaid play such a vital role across a whole host of arenas and, you know, for example, we think of schools and Medicaid as separate. But Medicaid actually finances school based health services, including mental health, behavioral health services, and so if you're cutting Medicaid, you're affecting, you know, how kids are going to be able to do in school, attend school. If you're gonna be taking away, you know, Medicaid funding that, states, schools are relying on in many states to support their supportive healthcare services.
Michelle Rathman: You know and I think about community health worker programs and all the grants and things that come out of CMS right now and HHS right now to help with prevention. And so, what I want our listeners here, and we'll be watching what comes out of your space too, Edwin, is that, you know, I don't, and I hope I'm wrong, I don't see an influx of resources to help address prevention, social drivers of health, and so forth.
I see the cuts, you know, it's just slashing across the board and that concerns me perhaps more than, that's why I lose a lot of sleep at night, quite frankly.
Edwin Park: Yeah, I think, you know, there's been a lot of innovation taken up by states working with hospitals, physicians, manage care plans to try to figure out how to address you know, social determinants of health, help with housing
Michelle Rathman: Health equity.
Edwin Park: and you know, Medicaid is looked to as, you know, a key component of those efforts and, you know, if Medicaid is cut, you know, certainly many of these initiatives can't move forward and they can't expand and they can't be taken up by more states in coming years. So, I think, you know, Medicaid is certainly you know, playing so many different roles. And if it's on the chopping block and if those cuts, at least some of them get enacted, it's certainly going to have, you know, major negative effects across the board.
Michelle Rathman: Absolutely. And so many areas. And I think about workforce and what that does to work for us and public health and so forth. All right, before we head out, I mean, I know you've got a little report coming out. I mean, this, this episode is dropping on next Thursday. Today is the 8th of January. So, you are releasing when this comes out, you have already released the Georgetown CCF report on Medicaid Coverage Rates in Rural Areas and Small Towns.
Can you give us a sneak preview of that?
Edwin Park: Sure. So we have a report that we come out every so often, which looks at Medicaid coverage rates, in rural areas and small towns as compared to, the coverage rates in metropolitan areas, so this county specific. And this year we'll be showing the coverage rates by kids, non-elderly adults, and seniors, and in, you know, as one would expect, consistent with past analyses, you know, Medicaid plays a vital role for, for health coverage for all three groups, and, and disproportionately so among kids and non-elderly adults in particular.
And so we'll have interactive maps and other data available on next Wednesday on January 15th.
Michelle Rathman: Wonderful. The day before we drop in, folks, be sure to know this. We're going to put that on our resource page. So you, of course, can, we'll take you right to your page, Edwin, to make sure that people can read that and we'll be watching for it. Before we close out, final things of what we should be watching for, because I think reports like what you've just described, they are, they help us in our advocacy efforts.
You know, for people who believe that they can't do anything about it, you know, you, there is a way, pick up the phone, you call your member of Congress, you call your state legislators, and when you have data in hand it helps to, you know, to help them understand why it's so important for them to just not just go along party lines, and really take a look at these issues and how it impacts their constituents.
But what else should we be watching for this year. It's going to be a very busy policy year to be sure
Edwin Park: Yeah, I think just to end with the fact that, you know, these Medicaid cuts which are, you know, very serious, very severe, very worrisome, are not inevitable. There's been efforts to deeply cut Medicaid in the past, most recently in 2017, with the repeal and replace effort, and it failed. And, you know, for example, the caps that you discussed earlier, that's been, you know, something that's been pushed in Congress since 1981, and there's been multiple efforts and again, all of those have failed.
So data, storytelling, talking about how Medicaid plays a role in your family, with your neighbors, with your community is going to be vital to you know, translate or explain how Medicaid is so valuable, so important, what it does you know, as part of our healthcare system, as a part of people's lives will be instrumental in, you know, pushing back on some of these you know, very damaging proposals.
Michelle Rathman: Yeah, and I think if people understood what it meant for their own local economies. I mean, it is all connected and it's nice to kind of think about it. You know, this doesn't concern me, but it does whether or not you use that part of the system ultimately, it does impact your small rural community.
Oh, my gosh, Edwin, before we close out, where can people follow you besides your website? And we'll make sure we put all those links in our resources. Where can we find you?
Edwin Park: so, you know, so on our website, ccf.georgetown edu, and then you can follow me on Blue Sky at Edwin C. Park.
Michelle Rathman: Yes, it's so nice to see you where the skies are blue as we say. Edwin, thank you so much for joining us. And I'm going to say this will certainly not be the last conversation on the matter because I am heading to Washington, D. C. I will be recording from the National Rural Health Association Policy Institute where I have just learned this morning that your colleague Joan Alker will be presenting.
I'm sure talking about the paper you just mentioned.
And while I'm in our nation's capital, I'm going to bop over to the National Association of Community Health Centers meeting.
And if you don't know about them, t they represent our nation's federally qualified health clinics and they've got a lot on their policy agenda as well.
And so, we're going to just keep focusing on this special episodes on our 2025 Policy Issue Shifts. A shift is going to happen as they say, as I said in our kickoff episode. Just keep, keep on watching what we're doing here and see how we can help you connect the dots between your quality of life and policy in rural America.
A big thanks to Brea Corsaro and Sarah Staub as always to all of our listeners and subscribers. Come back and join us again on a new episode of The Rural Impact, but until then I always say, and I mean it, take good care of yourself and everyone else around you. We'll see you soon.