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The alarming numbers at which people of color, particularly Black people, are dying from COVID-19 has and should ignite a conversation about structural racism. In addition to the health care, social and economic inequities that place some at more risk than others, structural racism fuels the injustice. There are a range of factors at play from health care access and underlying health conditions to living conditions and work opportunities that intersect and shape the narrative of COVID-19 and its ravaging effects on people of color. Blacks are less likely to trust the health system due to a legacy of abuse and bias by providers and health systems; Black people are less likely to be referred for COVID-19 testing; people of color disproportionately live in under-resourced communities that are inequitably financed; and people of color (particularly Black, Asian and Pacific Islander and Latina women) hold low-wage essential jobs that place them at higher risk of infection. Furthermore, if you are undocumented, there are simply no options for financial support or to physically distance if you are working to maintain basic needs. This is a perfect storm for so many across our country. Choosing between your livelihood and placing yourself at high risk for becoming infected with the coronavirus (due to unfair and discriminatory barriers to health and economic security) is double jeopardy. Lacking health coverage is an added injury.
For all of these reasons, Medicaid is at the core of our work – and our campaign to advance equitable access to health coverage in this moment of crisis.
Fund the Solution
Medicaid makes it possible for people and families who struggle to make ends meet to get the care they need to stay healthy. Medicaid provides health insurance and economic security to children and their families, older adults, people with disabilities and others who face unfair barriers to care; Medicaid is a primary source of coverage for low-wage workers, many of whom are working in essential jobs. More funding to support this key program to shelter people from harm during a pandemic is paramount. While the Families First Coronavirus Response Act (FFCRA) temporarily increased the federal Medicaid matching rate (FMAP) by 6.2 percentage points for all states and territories, effective January 1 through the end of the public health emergency – it is not enough.
States are facing staggering revenue shortages and need federal support to maintain their Medicaid programs. States could face budget shortfalls of upwards of $290 billion just in the upcoming fiscal year and some states are already signaling Medicaid cuts due to fiscal stress. A failure to support Medicaid puts not only coverage at risk but also the financial stability of providers and will lead to cuts in other state services. During this time of unprecedented drops in tax revenue, states are in a precarious position. There is broad support for more enhanced Medicaid funding – the National Governors Association and the National Association of Medicaid Directors highlight the urgent need for a minimum of a federal 12 percentage point increaseto weather the recession. This increase should apply to states and territories that expanded Medicaid. Further, the 14 states that have yet to expand Medicaid should have access to full federal funding that should last for several years to encourage these states to expand.
According to research from the Georgetown Center for Children and Families, “for every $1.00 in reduced state spending, federal Medicaid funding in the states would also be cut by between $1.28 and $4.95 in fiscal year 2020, depending on each state’s FMAP.” Due to the matched financing structure of Medicaid – every state cut has a compounding effect on the program. State budgets are in trouble due to this unprecedented pandemic and the role of the federal government to intervene has never been clearer. The Medicaid program has demonstrated time and again that it remains one of the best tools policymakers have to protect people in times of need and to create more equitable access to coverage and care.
Set Up Medicaid for Long-Term Success
The Medicaid program was designed to serve as a safety-net for families when the unthinkable happens. But with a nationwide health and economic crisis upon us – the program needs additional funding in order to meet the needs of millions of people who have been harmed by the COVID-19 pandemic. As succinctly stated by Ohio’s republican Governor Mike DeWine: “The cruel nature of the economic downturn is that at a time when you need a social safety net is also the time when government revenues shrink.” While enhanced matching is both necessary and can provide a rapid response to the crisis, it does not address the longer-term challenge of an economic downturn that will exist far beyond the public health emergency. In the last two recessions, Congress increased the FMAP – the federal share of Medicaid financing – as a way to support added demand for Medicaid and to get stimulus quickly to the local level. The current recession is predicted to bring unprecedented demand. Over the next several months, according to estimates 11 to 23 million more people will need Medicaid coverage. It is in tough economic times like these – when people lose jobs and need help – that Medicaid is supposed to be there to make sure people's health needs are met. Congress has the power to set Medicaid up for success. They can make an enhanced match permanent so that we skip over all of the infighting around how much financing support for how long – this structural change would advance equity by protecting people from cuts in care when they need it most. As framed up by the Brookings Institute, a ‘trigger’ coupled to the state unemployment rate is an important permanent fix so that when demand rises, so does federal funding. This is a more data-driven and reliable way to operate Medicaid, maximizing its intended use – to safeguard families’ health and economic security.
Protect Families’ Coverage Through the Downturn
Providing funding for Medicaid and instituting a trigger for enhanced funding that is tied to a state’s unemployment rate are important. However, the intended goal of increased and equitable access to needed benefits are at risk if states have to balance budgets and seek savings in their Medicaid program. Congress must hold firm on making sure federal dollars are maximizing the role of state Medicaid programs. Maintaining coverage as a requirement of enhanced funding is an important corollary to any Medicaid package. As recently reported, states confronted with balanced budget deadlines (many at the end of June) are looking to Medicaid for savings. FFCRA currently prohibits states that accept the 6.2 percentage point FMAP increase from disenrolling Medicaid consumers until the end of the public health emergency – this is saving lives. Congress must maintain a strong maintenance of effort (MOE) provision to continue to protect people from losing coverage during the crisis. The elimination of the MOE would open the door for states to erect new barriers to Medicaid enrollment – including administrative barriers, benefit cuts and more. Weakening these protections moves state programs in the opposite direction of equity and would cost thousands coverage during a pandemic.
All of these elements together help move us forward: more funding for a longer duration with key protections and structural changes – that is what is urgently needed to respond to the COVID-19 moment. Together, this agenda is also a start toward a more equitable distribution of resources and provides tools state and community leaders needed tools to tackle longstanding and historic injustice.