President Trump released his proposed fiscal year 2021 budget this week, and you can at least give the administration credit for consistency – almost $1 trillion in cuts to the ACA and Medicaid – mirroring the budget request of 2020. More or less since the day Donald Trump took office, his administration has waged an unceasing campaign to erode the health and economic security of millions of people, with low-income people, people of color, immigrants and people with serious and chronic health conditions being particular targets. Under the Trump administration, the number of uninsured has risen by 7 million. And if the current proposed budget were to be enacted, that number would go far higher. 

The release of the budget is an annual exercise that signals the administration’s priorities—and in the case of the Trump administration, their priorities are clear: to reduce funding for health care and simultaneously reduce investments in other life necessities that make it possible to be healthy, such as food and housing.   

Fortunately, these draconian proposals will hit a House wall of opposition and will not be enacted into law. That doesn’t mean they should be ignored. The budget document is a political document not grounded in any real likelihood that it will be implemented. But it does tell us what the administration is interested in: destroying health security for millions of people.  

While that comes through loud and clear, the budget is hardly the first – and far from their most dangerous attack. In the short run recent efforts to use administrative levers to dismantle the Medicaid program through changes in financing rules and erosion of beneficiary protections are likely to do more damage. It is worth threading all these actions together to fully appreciate the depth and breadth of Medicaid sabotage that has accelerated since Congress’ failed attempt to repeal and replace the Affordable Care Act (ACA) and Medicaid.  

How did we get here?  

Frustrated by their inability to deliver on an anti-ACA legislative agenda, the Trump administration directed its energy to a set of administrative and judicial strategies to seed instability. These include the Department of Justice (DOJ) joining the Republican-led plaintiff group in the Health Care Repeal Lawsuit. as well as Health and Human Services (HHS) issuing numerous rules, directives and program offerings designed to make it harder for people to get, keep and use health care by reducing program take-up. We anticipate a flurry of administrative efforts to drive states toward block grant waivers. Of course, pile on the administration’s implementation of its racist public charge policy that uses fear to deter legally residing immigrants from utilizing needed services—we can anticipate that the administration’s fear campaign will only accelerate in the short run as states struggle to address community level concerns about health access. The end results are leading us to higher rates in uninsured (most notably of children) and widening racial and ethnic disparities in coverage that deepen inequities in health outcomes.  

The new threats  

The release of dubiously legal block grant guidance is partial fulfillment of a long-held dream of conservatives to cap federal Medicaid funding and shift costs onto states, providers and beneficiaries. What remains to be seen is if any states take the bait, once they examine the option more closely. One thing that might convince them though is a proposed change in Medicaid financing rules (known as the Medicaid Fiscal Accountability Rule or MFAR) that would reduce federal funds by billions of dollars and could send some of them scrambling for new freedom to cut program costs. The details of the financing rule are complicated and the administration has failed to produce a fiscal impact analysis, but there is little doubt that it could be devastating. A Texas paper recently chronicled how the proposed rule would cost Texas hospitals billions of dollars and Florida called the proposed rule crippling for their Medicaid program. 

Center for Children and Families’ Edwin Park summed it up in his analysis, “Many low-income beneficiaries, including millions of children and their families…could see sharply reduced access to needed care if states are forced to make sizable budget cuts to their Medicaid programs because they are unable to raise other revenues and increase provider payments in other ways.” 

On top of the financing restrictions, we anticipate that the administration will also try to increase the administrative burden on states operating outside the block grant framework in an effort to drive them to accept reduced funding in exchange for reduced hassle and more freedom to cut the program by restricting eligibility and enrollment paired with work requirements and exacting premiums and lockout periods. The portfolio of restrictions gives states tools to shrink Medicaid coverage instead of extending coverage to people who need it so that they can have healthier lives.  

All of this—from administrative tools to lawsuits—are visible in the President’s budget. The budget cuts Medicaid by almost $1 trillion dollars over 10 years by pressuring states to take up work requirements, convert to block grants and chasing after states for documentation errors. The bottom line is that under this budget framework, people will lose their health care.  

What can we do?  

That is just what has already been rolled out, not what has yet come to pass. We are not helpless in light of these attacks—there are important things advocates can and should do:  

  • First, build the Medicaid narrative. In 2017 when Medicaid was attacked, advocates responded in full force and the majority of people stood with us – this poll asking people, “Do you believe funding for your state’s Medicaid program should be…increased…decreased…stay the same?” shows clear and robust support for Medicaid. People did not want block grants and restrictions on funding in 2017 and they don’t want them now.  

  • Second, we build power by diversifying your coalition membership. Telling the stories of Medicaid, reminding people across all walks of life why Medicaid matters is valuable and a way to build health care champions—and build your list. Most importantly, recognize who cuts hurt – and they are disproportionally people of color that lack full inclusion in advocacy work. Listening to communities and their access and coverage challenges is an important step to more equitable engagement and policy agendas.  

  • Third, develop new alliances. To be clear, the current stabs at Medicaid make both red and blue states stakeholders quake – they are intended to destabilize at a pace that make governors and other state stakeholders anxious. Building out alliances even with unlikely allies can be an important strategy in combatting federal efforts to reduce their obligations to states. As evidenced by 2017-18 repeal efforts, governors, in particular, play an important role in influencing national partisan policy differences.  

Together, we can protect Medicaid and the ACA. 

Last, don’t give up. While the persistent attacks on health care coverage in general, and Medicaid in particular, have taken a toll, we have won some improbable victories. Many of these proposals are or will be tied up in court and they are not etched in stone. They are written in rules that can be reversed should this or a future administration decide to do so. By amplifying our voices through comments, events and conversations with elected officials and leaders in our communities and states about the benefits of Medicaid and the ACA, we drive continued support to protect our care.