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Critiquing Project 2025: Medicaid

Project 2025 lays out a sweeping reform plan for Medicaid, couched in mysterious bureaucratic jargon. We reveal the true intent: cut health care for the poor.

June 29, 2024

Project 2025 Mandate for Leadership: The Conservative Promise
April 2024
The Heritage Foundation & partner organizations
Chapter 14: Department of Health and Human Services

Medicaid Reform Proposals (pp. 466-472)
[HJM bolding of narrative]

Reform Financing
Allow states to have a more flexible, accountable, predictable, transparent, and efficient financing mechanism to deliver medical services. This system should include a more balanced or blended match rate, block grants, aggregate caps, or per capita caps. Any financial system should be designed to encourage and incentivize innovation and the efficient delivery of health care services. Federal and state financial participation in the Medicaid program should be rational, predictable, and reasonable.

Direct Dollars to Beneficiaries More Effectively and Responsibly
End state financing loopholes
. Reform payments to hospitals for uncompensated care. Replace the enhanced match rate with a fairer and more rational match rate. Restructure basic financing and put the program on a more fiscally predictable budget.

Strengthen Program Integrity
Incentivize states to decrease waste, fraud, and abuse
. Improve Medicaid eligibility standards to protect those in need. Conduct oversight and reform of managed care.

Incentivize Personal Responsibility
Ensure that Medicaid recipients have a stake in their personal health care and a say in decisions related to the Medicaid program. Implement work requirements and match Medicaid benefits to beneficiary needs.

Allow Private Health Insurance
Enable states to contribute to a private insurance benefit for all family members in a flexible account that rewards healthy behaviors.

Increase Flexible Benefit Redesign Without Waivers
Eliminate obsolete mandatory and optional benefit requirements
for able-bodied recipients. Redesign eligibility, financing, and service delivery of long-term care.

Eliminate Current Waiver and State Plan Processes
Allow providers to make payment reforms without cumbersome waivers or state plan amendment processes. Shift the balance of responsibility for Medicaid program management to states.

Prohibit Planned Parenthood from Receiving Medicaid Funds
End taxpayer funding of Planned Parenthood and all other abortion providers.
Redirect funding to health centers that provide comprehensive health care for women.

Withdraw Medicaid funds for states that require abortion insurance
Cut 10 percent of Medicaid funds


Comment by: Jim Kahn

In my previous post, I introduced Project 2025 and the threats that it presents overall. Today is the first focused post – detailing the attack on Medicaid, our primary health insurance for the poor.*

As for understanding Project 2025’s Medicaid policy agenda, let me cut to the chase. The proposed changes, despite being couched in bureaucratic buzzwords, have a straightforward and nefarious intent: Reduce health insurance coverage for the poor, by restricting both eligibility and benefits. And, equally worrisome, use Medicaid to suppress access to abortion.

Here’s the translation of Project 2025 policy jargon:

A “balanced or blended match rate” means less federal money (currently the majority of Medicaid funding), imposing a larger financial toll on states and thus lowering overall funding. “Block grants” and “caps” means fixed funding, regardless of the size of eligible populations and their medical needs, and slow or no growth over time. “End state financing loopholes”, “reform payments”, and (again) “replace enhanced match rate” all mean: lower federal contributions. All this compromises providing care, see analyses here, here, and here.

“Improve Medicaid eligibility standards to protect those in need” means: cover only the very poorest and sickest, leaving out many who currently qualify and who, in today’s fragile health insurance environment, desperately need Medicaid.

“Incentivize personal responsibility” means – impose often onerous preconditions on getting Medicaid benefits. The example, “implement work requirements” — which don’t work.

“Allow private insurance” means abandoning the Medicaid public structure in favor of private insurance, which results in widespread under-insurance – especially dangerous for the poor.

“Eliminate … benefit requirements” means, well, removing requirements for specific medical services, thereby increasing risk. “Redesign … long-term care” means – undercut the mainstay of long-term care funding for the poor and middle class.

Layered onto this broad reduction in medical benefits is a full-bore attack on abortion services. I don’t think I need to translate the language excerpted above, which is atypically clear and direct. More on this topic in an upcoming post.

What’s amazing about Project 2025 is the ability to rhetorically cast dangerous policies as being about efficiency, generosity to the sickest, and personal virtue. In contrast, we know that true efficiency and generosity are available in true universal health insurance – single payer. The security of excellent health care access will go a long way toward increasing societal virtue.

* As I’ve written previously, I very much look forward to the day when the phrase “health insurance for the poor” no longer has meaning. Meantime … we must maintain the program that provides for the medical needs of the economically vulnerable.

About the Commentator, Jim Kahn

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Jim (James G.) Kahn, MD, MPH (editor) is an Emeritus Professor of Health Policy, Epidemiology, and Global Health at the University of California, San Francisco. His work focuses on the cost and effectiveness of prevention and treatment interventions in low and middle income countries, and on single payer economics in the U.S. He has studied, advocated, and educated on single payer since the 1994 campaign for Prop 186 in California, including two years as chair of Physicians for a National Health Program California.

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