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Medicaid as America's Social Safety Net | Harvard Researcher and Former HHS Deputy Benjamin Sommers
18 Plays1 month ago
We're speaking with Dr. Benjamin Sommers, a primary care physician, Harvard health economist, and former Deputy Assistant Secretary for Health Policy at HHS, about Medicaid’s role as America’s health care safety net.
Drawing on more than a decade of research and firsthand experience inside government, Dr. Sommers explains what the evidence actually shows about Medicaid expansion, access to care, and lives saved. The conversation unpacks why Medicaid doesn’t reduce spending, but remains one of the most cost-effective ways to improve population health. They also explore the unintended consequences of work requirements and resulting administrative barriers. Ultimately, this episode reframes Medicaid not as a political talking point, but as a foundational pillar of the U.S. social safety net, and a test of how we decide who deserves care.
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Transcript
Introduction and Guest Background
00:00:00
Speaker
Welcome to the Healthcare Theory Podcast. I'm your host, Nikhil Reddy, and every week we interview the entrepreneurs and thought leaders behind the future of healthcare care to see what's gone wrong with our system and how we can fix it.
00:00:14
Speaker
Today's episode is with Dr. Benjamin Summers, and i think it's going to be exciting because not only is Dr. Summers a practicing primary care physician at Harvard Medical School, but he's also a professor at the Harvard Chan School of Public Health and a leading researcher on health insurance, Medicaid, and access to care.
00:00:32
Speaker
Beyond academia, Dr. Summers has also worked inside the U.S. government, most recently serving as Deputy Assistant Secretary for Health Policy at the U.S. s Department of Health and Human Services, where his research directly informed national health policy during the COVID-19 pandemic,
00:00:48
Speaker
and even
Journey to Health Policy
00:00:49
Speaker
beyond that. More so in today's episode, we're specifically talking about Medicaid, health insurance, and what the evidence actually does tell us about whether expanding access to care and low-income populations, whether that improves lives. and So hi, Dr. Summers. Thank you so much for coming on today, and welcome to The Healthcare care Theory.
00:01:09
Speaker
Thanks a lot for having me. Looking forward to our conversation. And I'd love to start quickly on your background. I know being a physician is already time consuming enough, but what drew you to eventually getting a PhD in health policy and what perspective did offer from practicing care? Why take on the responsibility of both when really one is already a successful career? When I was trying to decide what to do with my life, I was an undergraduate English major. i was also pre-med. And I set up, like a lot of pre-med students, shadowing opportunities where I was spending time with with doctors in in their offices or in hospitals to get a sense of this, what I wanted to do with my life.
00:01:46
Speaker
I really liked my experience shadowing, but I kept having this thought that I was only seeing part of the picture. And I kept wondering, what about the patients who can't get in the door of this tertiary care medical center and see these incredibly well-trained specialists who just can't even get basic health care?
00:02:02
Speaker
And that question really stuck with me and motivated me. And ultimately what I decided was that I wanted to practice medicine, but I didn't want that to be the only thing I was doing. I was really interested in the broader ah policy context of of of how people were interacting with the health care system.
Role in the Biden Administration
00:02:19
Speaker
So I decided that I would do an MD and a PhD. I ah went to the Harvard PhD in health policy program and studied health economics. And at the same and and ah concurrent with that, I was doing med school. So I was an MD, PhD student. That was not super common in the social sciences. It's become more common. I think we have a a nice a growing group of MD, PhD policy researchers. But at the time, there were you know a small number of us.
00:02:44
Speaker
when i When I finished, I decided i i I still really cared about clinical practice. I wanted to see patients. I did my residency at Brigham and Women's Hospital in primary care and internal medicine.
00:02:56
Speaker
When I finished, I wanted a job that let me do both of those things. And so I was really ah fortunate that I had a great ah clinical opportunity to stay where I had trained as a resident at a community health center in Boston. That is a wonderful place. I really love being there. it's um It really does have a community home feeling. Our patients all live in the neighborhood, they or mostly live in the neighborhood. The staff and the patients know each other. We all know everyone well, and it's a real team-based model of care.
00:03:25
Speaker
I still do that a day a week. And then the rest of my time, I'm on faculty at the Harvard School of Public Health, teaching and doing research related to issues of health insurance and affordability and access to care.
00:03:36
Speaker
Yeah, and I'm really excited to get into your work at Harvard. But of course, and a few years ago, you took a little break from teaching at Harvard and serves as a deputy deputy assistant secretary health policy at the HHS, which is, of course, a very important position, but it's a little unique insofar as you're not like really running an agency, or but you're contributing very importantly academically and intellectually to the administration's health goals. And and what was your role like working inside the HHS? And I think For most people, government's kind of like a black box. It seems like you know what's going on, but you really don't.
00:04:09
Speaker
Was there any surprises about how policy gets done and made versus how you would theorize in academia or creating your PhD or your dissertation and things like that? Yeah, this was the second time I worked in government. The first time was right after about a year after I finished residency when I was early on as a faculty member.
00:04:27
Speaker
I went to to Washington in 2011, 2012. I worked as an advisor in an office called the Assistant Secretary for Planning and Evaluation. And the abbreviation for that is ASPE. And ASPE is essentially the in-house think tank for the Secretary of Health and Human Services.
00:04:43
Speaker
ASPE's job is to provide data and evidence and analysis to help the Secretary and the White House make decisions on important issues related to to HHS's mission. HHS is a huge department. It does a lot of things. It doesn't just do health policy. it does um yeah It does issues related to the social safety net. It does things related to economic well-being, the human services component. It does a lot of the science and technology components of our government, things like the FDA, the CDC, are all ah inputs to the work that ASPE does in advising the
Medicaid's Impact and Misconceptions
00:05:15
Speaker
secretary. When I was there, the first time I was mostly working on issues related to the implementation the Affordable Care Act. that That had just been passed and it was going to be fully implemented in 2014, so we were in that kind of planning stage.
00:05:25
Speaker
When I went back in 2021, I was lucky enough to go back to the same office that I'd worked at. But in this case, I was now appointed to be the leader of it. I was asked by by President Biden's ah team to to be the Deputy Assistant Secretary. And I was sworn in on Inauguration Day, the same day as the president, and showed up with ah you know an office of about 40 health policy staffers and analysts and and ah experts on different issues ah in the government.
00:05:54
Speaker
And we had to kind of figure out what we were going to do. Day one, take you back. This is January 2021. We're still in the heart of the pandemic. Vaccination is just getting started. We don't have any effective treatments yet for for COVID in terms of of the antiviral medications, but they're they're in the pipeline. They're coming soon. yeah And we're trying to basically do outreach. We're trying to educate people about vaccination. We're trying to put out up-to-date evidence to guide people's decisions and as to you know what activities are going to do. We're working closely with the CDC and the FDA on on on different you know aspects of that effort.
00:06:31
Speaker
At the same time, we had other non-pandemic responsibilities and and issues that we were studying like you said, ASPE doesn't run an agency, doesn't run a program, but it has its hands kind of on every part of what HHS does because we're the go-to people when there are questions on, well, how is this program working? Or what do the what's the evidence tell us? What could we do differently?
00:06:53
Speaker
And early on, we spent a lot of effort also working on issues related to coverage expansion. How do we get more people into health insurance programs? How do we get more people who are eligible for Medicaid signed up? How do we get more people to sign up for Obamacare, for the Affordable Care Act marketplaces that are eligible but night might not be enrolled?
00:07:10
Speaker
What state policies in Medicaid are we going to encourage and what state policies Medicaid are we going to discourage? So we did a lot of work in that space too. And then things change over the course of those two years. There became a big focus on prescription drugs with the passage of Medicare price negotiation. um So, you know, there's a lot of topics we could talk about, but you wanted to hear a little bit about what it's like there day to day. Is that, is is that what would be helpful?
00:07:32
Speaker
I think that could be interesting. Yeah. Whatever you'd like to, I mean, i think it would be interesting hear like what it's like and what maybe surprised you there. it's I can imagine, yeah, it's it seems quite different from your work at at Harvard, of course.
00:07:45
Speaker
Absolutely. you know the The biggest difference between academic life and this policy research role um was the timeframe.
00:07:56
Speaker
you know in In academia, you might write a grant, hopefully you get it. If the funding kicks in maybe a year later, you you know you start the studies, you write the paper, you get it reviewed, you get it rejected, you revise it, you've ultimately published it. And it might be a know couple of years.
00:08:11
Speaker
I do a lot of policy relevant, timely research, at least that's my priority in in in my academic experience. And so sometimes that timeline was shorter. Like we come up with an idea, we'd hit the ground running and we might try to have a paper out in six or nine months and that's aggressive.
00:08:25
Speaker
In government, it would be, you know, we need estimates on, you know, how many doses of antivirals should we buy and please send us those numbers by next Friday or by tomorrow, depending on the question. We're about to launch our open enrollment for the marketplaces and we want to have some early predictions on how many people are going to sign up. Or this policy went into effect six months ago. Can you tell me how we're doing?
00:08:47
Speaker
and And so everything was accelerated. It's exciting. It's also challenging because sometimes you don't have good information yet ah to make those sorts of determinations. Or sometimes you're being asked a question that really does feel like you're picking a number out of thin air and your job is to pick the best number out of not quite thin air that you can. Yeah.
00:09:08
Speaker
In a way that, you know, in in academia, there are times where there's a question that might be really interesting and you want to answer it but you realize we don't have a good way to answer this or we don't have enough data. Let's come back to this in a year. That wasn't a luxury in government. If a decision had to be made, we had to provide whatever information we could. And sometimes the answer was, we don't have a great sense, but here's our best guess. And that was really exciting. Also stressful. There would be times where, you know we were being asked to to do something quickly that we just, you know, we so we were banging our heads against the wall trying to figure out like what's what's the best answer we can give ah under a lot of uncertainty.
00:09:40
Speaker
um The other part that was really different and and really exciting is that ah the impact was was so much more palpable. ah In academia doing policy relevant research, our hope, our goal is that we write a paper that influences some some policymakers, that they see it and they say, oh, well that's important. That's going to shape out some of what we decide to do. And if you're lucky in this business, maybe once or twice a year, you publish a paper that gets some traction that some policymakers actually see and use to make
00:10:12
Speaker
to inform their decision making. But at HHS, that was basically every week, right? I mean, any analysis we were doing was because the White House wanted it, or the Secretary of Health and Human Services wanted it or the head of of Centers for Medicare and Medicaid Services wanted it. So it was just this excitement of the work you were doing was really making a difference in in terms of informing policies that were impacting you know millions of Americans. And so that was really extraordinary in terms of the excitement and the opportunity to make a difference. And um and I really enjoyed it. I have zero regrets about that time in government.
00:10:46
Speaker
That's actually really, really interesting. I didn't think so. i First of all, it sounds really cool to be able to do that every single week, just contribute to the health policy for the entire country. But also I'm surprised the timelines makes a lot of sense. I guess with Harvard, for example, the research you pursue is your own and it doesn't change every four to eight years and you don't have change the direction of it. So you have a little bit more independence, but I guess you also sacrifice the ability to like kind of actualize that research quickly and then get get that into the hands of policymakers.
00:11:16
Speaker
And I think one huge issue you're working on, but not just at Harvard, but at HHS too, was on the issue of Medicaid. But I want to step back a little bit because I think when you think about health insurance, a huge reason why health insurance is expensive and efficient is because we have Medicaid, employer-based insurance, Medicare, individual insurance, and a whole bunch of other fragmented solutions. But Medicaid is the actually most people don't understand knows that it's a backbone for, I think around 80 million Americans, including so seniors, children, a lot of other people just need healthcare. But I'd love to hear from you.
00:11:51
Speaker
i mean, given that Medicaid was designed 50 years ago, love you could walk us through what is like the actual goal of the program in your eyes? What should its goal be? And how does Medicaid tangibly meet the needs of vulnerable or marginalized populations? Yeah, a lot of important questions and I'll do my best to unpack it.
00:12:09
Speaker
Medicaid was originally created 1965, as you noted, the same time that Medicare was created. Medicaid got less attention at that time, and I think that has largely continued to be the case for the decades since. It was kind of Medicare's you know forgotten sibling. um Medicaid's a joint state and federal program. so federal government sets up the ground rules and pays for the majority of the costs. And we can talk more about that later, how exactly how much it pays, depending on on the state and the population. The federal government pays the majority, sets the ground rules, and then states have a fair bit of of flexibility in terms of actually running the program under under those ground rules.
00:12:45
Speaker
When Medicaid was first created, it was very limited in terms of who was able to be enrolled in it. It really was designed for low-income people disabilities. ah And it ah gradually expanded ah to over the years to more and more low-income working families, ah you know ah kids under the poverty level, parents of young children of children with dependent children,
00:13:08
Speaker
um Pregnant women became a single you know largest source of payment for births in the country. It continues to be really important for people with disabilities and people over 65 who have low incomes. It's the single biggest payer for long-term care and nursing home care in the United States.
00:13:23
Speaker
There was a sweeping change there that happened after kind of decades of gradual progression with you know more children are enrolled and more parents enrolled and higher income cutoffs of allowing states to cover more and more people.
00:13:36
Speaker
But there was sea change 2014 under the Affordable Care Act, and that's the Medicaid expansion. The ACA's Medicaid expansion change two important aspects of Medicaid. Prior to that, um you had to be in one of those categories of eligibility that I mentioned. You had to have a disability, be over 65, you had to be a parent of
Challenges and Implications of Medicaid Work Requirements
00:13:54
Speaker
a dependent child, pregnant, or a kid. If you weren't in those groups, it didn't matter how poor you were, you couldn't qualify for Medicaid in essentially all states. Occasionally states got special permission to do something different, but that was a a small number of of states. So if you, for instance, um were a low income adult who was working and you know maybe had had ah an income that was under the federal poverty level, but your kids had grown up and moved out or you never had kids.
00:14:22
Speaker
If you weren't pregnant, didn't have a disability, doesn't matter how poor you were. In most states in the country, you couldn't get Medicaid. And those folks just were uninsured and they and they had no way of of getting health insurance. the um The alternative under the Affordable Care Act is, well, they've now created this new pathway that simply says, as long as you meet kind of immigration citizenship requirements, if your income is below 138% the federal poverty level, you're in.
00:14:48
Speaker
You can qualify for Medicaid. And, um, and, and that is an enormous change. The other big change is not just the fact that that pathway of eligibility was, uh, was broadened. It was that that amount, that dollar amount, the, the federal poverty level cutoff was much more generous than, it had been before, because in a lot of States prior to the affordable care act, even if you were in one of those groups, let's say you were a parent and you had, yeah you know, young kids living at home, uh,
00:15:16
Speaker
Some states said that you know you had to be at like 20% of the federal poverty level or else you were too rich for Medicaid. Just to give you a sense of the dollar amounts we're talking about here, for a single person, 138% little over a year.
00:15:30
Speaker
and for a family of four about forty four thousand And what that means is without the Medicaid expansion, um you might be at six, seven, $8,000 as a single person, and your state can say that you're too rich for Medicaid, even as as a parent. And so the Affordable Care Act lifted that level and and made a whole lot more people eligible, plus it got rid of that category of eligibility restriction.
00:15:51
Speaker
As probably most of the listeners know, ah the Supreme Court made Medicaid expansion an option for states. The original goal was that every state would do it under the Affordable Care Act, but the court said no, that that states couldn't be forced to do it. And right now we have 10 states that have not expanded and we have 40 states plus Washington, D.C., which have. And it's led to a really big gap in terms of the coverage rates in those states where where the Medicaid expansion has happened, just have much higher coverage rates, much better access to services. And we have now over a decade of research showing us the the impacts of Medicaid expansion.
00:16:26
Speaker
Yeah. And I'd love to hear, I mean, we've had, I guess, through this episode through this podcast, we've spoken to multiple people who've studied this idea of what happens when people get access to healthcare. Do they spend more? Do they get healthier? And and what generally is the effect on both their communities and their health.
00:16:42
Speaker
And um i mean, you've co-authored with Dr. Kathryn Baker, Dr. Gawande, and I think that paper was in many ways like aresp response to some of the skepticism around Oregon. And of course you have many other, them but you've had other research and so of other people.
00:16:57
Speaker
But now that there's been a decade of evidence settled around this topic of what happens when you expand Medicaid or give people health care, what do you think actually, what do you think actually does happen? And what's most misunderstood about this debate about Medicaid expansion and providing health care to these populations?
00:17:15
Speaker
Yeah, also another really important question. um I think let me Let me try to to to be equal opportunity here in identifying misperceptions. I think the biggest misperception among critics of Medicaid, particularly conservative critics of Medicaid, is they say it's a broken program, doesn't work, doesn't help anybody. In the extreme, this version has been, you know, it's formulated as Medicaid actually kills people. Like, you're better off having no coverage than Medicaid. red That was the the headline of a prominent Wall Street Journal editorial, you know, about a little over 10 years ago, written by ah a leading policymaker who then held positions in in the Trump administration.
00:17:56
Speaker
So that turns out to be and ah just false, completely false. the The evidence that we have over the past decade or more shows that when you give people health insurance, they are more likely to be able to access services than when they're uninsured. They feel better. They describe their health as improving. They have better mental health.
00:18:14
Speaker
And then the question well, okay, what happens to their physical health beyond how they feel? ah the Oregon Health Insurance Experiment, which it sounds like you've talked about on some previous episodes, was a really important study conducted based on coverage around 2008 and 2010 in Oregon, so before the Affordable Care Act, where they randomized people to get Medicaid or not. And what they found was these you know these big changes in affordability in people's well-being, their their self-reported health, their mental health, but they looked at three chronic conditions and they did not find improved blood pressure control, cholesterol, or sugar you know glycemic control ah for people with diabetes. and And based on that, some critics have said, so Medicaid doesn't work.
00:18:54
Speaker
It ignores all the other things I just said, like improving depression rates, self-reported health being better. Those are real outcomes. ah you know If you're a doctor and you care for patients and you don't care if they tell you they feel better, well, you'll be out of work. You should find a new line of work, right? We we care a lot about how our patients feel. That's one of the main ways we assess if we're doing a good job.
00:19:11
Speaker
But even beyond that, we have it now 15 years or so of evidence since then, A lot of it based on changes that happened under the Affordable Care Act, looking at states that expanded and those that didn't, but also some looking at different states that that have taken similar approaches before the ACA, including some of the work that our team did.
00:19:28
Speaker
and What we found in a variety of studies is ah that we we see people are better able to get the care that they need, that they are less likely to wait until surgical conditions are extreme, they're less likely to suffer amputations or ruptured aortic aneurysms and other sort of severe conditions because they get in earlier.
00:19:46
Speaker
ah They're more likely to be diagnosed with conditions that they have like, ah like high blood pressure and and find out that they have it and receive treatment. They're less likely to die of heart disease. And overall, population mortality has gone down ah for those receiving coverage through the Medicaid expansion compared to those who are similar, but in states that didn't let them gain coverage.
Future Challenges and Innovations in Medicaid
00:20:07
Speaker
And in fact, some of that evidence is from natural experiments looking at the states that expanded versus those that didn't. But the most compelling view in my the most compelling study, my view, was actually a large randomized trial that the federal government ran, where they um they were going to send out postcards under the affordable care act this was the irs was notifying people who had been subject to the mandate penalty because they didn't have health insurance send them a reminder of here the coverage options you're uh eligible for that you could sign up for to get insurance and they didn't have enough money to send that postcard to everybody so they sent it to like several million but they also had people who are in the control group the same sorts of folks but randomized to not get it
00:20:44
Speaker
and The study overall, I think, had four to five million people, very big, like many times bigger than say the Oregon experiment. and What they found was this postcard, this nudge was modestly effective at getting more people enrolled. But because it was such a big study, they could show that that modest increase in coverage actually saved lives.
00:21:02
Speaker
more people got covered in Medicaid in the marketplaces and then fewer people died. In particular, this seems to benefit people in the kind of older age range of Medicaid in the 40s and 50s and early 60s before they qualify for Medicare, but a reduction in mortality. And in some of the related studies, it's the kind the deaths that are being prevented or or delayed are those that are for the sorts of things we think are most responsive to healthcare. Like,
00:21:27
Speaker
cancers that can be diagnosed early and treated early with good screening, managing chronic conditions that like diabetes or like asthma or like pulmonary, ah chronic pulmonary disease, where having active treatment can reduce downstream complications and delay you know serious illness and death.
00:21:44
Speaker
So we have a lot of good evidence that it makes people feel better, they get better access to services, and it saves lives. So that's, I think, pretty clear evidence at this point to me that Medicaid works and that the the argument that it's broken and hurts people is clearly flawed.
00:21:56
Speaker
On the other side, though, I told you it was going to be equal opportunity. There is a misperception among liberals that if you give if you just give people health insurance, we're going to keep everyone out of the emergency room, out of the hospital, and we're going to save money in the long run.
00:22:09
Speaker
That turns out not to be the case in any of the studies that we have. Now, you know you can always critique and say, well, what if we looked at 30 years down the road? Well, we don't have that evidence yet. But over every time frame that's been studied, when you give people health insurance, they use more health care. That's why it's beneficial, right? They use more primary care. They use more prescription drugs. They also go to the hospital more. They have more elective surgeries. If you have a patient at home who's calling and saying, I have chest pain tonight, Doc, what should I do? And I say, i think you should go to hospital. I'm worried this could be a heart attack. If they say, i don't have health insurance, I can't afford it, and they stay home, that's not a better outcome, right? It's not always bad to go to the hospital. it's not always bad to do the emergency room. Sometimes we need people to do that, and that's part of of how we're probably saving lives with insurance. So, yes, we have to spend more, but we get a lot more. People feel better, people live longer, people are more you know in better health to be working. And so there's a real investment here that health insurance is providing. And and in one study we did, we ah tried to quantify it We did a cost benefit analysis around the the lives saved and concluded that giving people Medicaid was actually a cheaper way to save lives than a lot of the other things we do in government, like environmental health regulations, for instance. And so this was the argument that, yes, we spend more, but we get a lot for that money. And and this is ah an effective program for population health.
00:23:26
Speaker
Definitely. Yeah, I think it's the issue is that people look at a lot of public infrastructure as something that should save money in the long run, as you mentioned, like what it's like something like public transportation or of course, like health care.
00:23:37
Speaker
They think it should save money when really mean, I'll say your opinion on this. I think that and in a lot of other countries, where they approach health care a little differently. I think in America, looking for a more economic perspective. But and some of your work, you've looked at Medicaid as like a social safety net.
00:23:53
Speaker
which I think is like a philosophical or ethical idea that maybe diverges from the more conservative part of the country. and And for you, like what makes this, is it more of like a moral or economic thing? And what makes it so important to Medicaid for these populations or just for the United States as a whole? Because I think in some sense, it is almost the issue is not really whether it works or not. I think for many people, they just don't think it it aligns with their sense of the world almost or that people should be getting free health care.
00:24:21
Speaker
on on their dime or their taxes and things like that. it's And it's quite hard to get that across. it I think that's right. I think that the the contours of the debate have changed over the past 10, 15 years.
00:24:33
Speaker
I think there's less now ah ah argument that Medicaid does help people. And that's good. That means the evidence is having an impact. Because I do think on the eve of Medicaid expansion, colleague and I actually went through and parsed all of the comments from governors as they talked about whether not to expand. And the two main reasons that governors offered for not expanding in the non-expansion states was one is that we can't afford it. But the other was that Medicaid doesn't work, that it's a broken program. Yeah, that's crazy.
00:25:00
Speaker
And so the idea that we weren't going to help people with this, I think it's still you'll still hear it, ah but it has become less of an issue. And certainly in the most recent debate in Congress that led to the passage of the the tax law that President Trump signed in into law and in July of 2025, also called the One Big Beautiful Bill Act, we can call OB3 for short.
00:25:21
Speaker
The debate around OB3 was less around the notion of, does Medicaid help people? And in fact, some of the early proposals that Congress kicked around under President Trump in this term were shot down pretty early. Those would have been sweeping changes to the way that Medicaid was financed. For instance, just giving states a lump sum, a block grant, instead of the current system, which would have led to big cutbacks, enormous cutbacks in Medicaid, or repealing the ACA. It was essentially a non-starter this time around after they almost succeeded in doing so in the first Trump administration.
00:25:52
Speaker
So I think some of that is because, as you said, there are fewer people who are arguing or disputing the notion that Medicaid does help people. And that's progress in terms of understanding the evidence. But now the argument that really, I think, carried the day for the OB-3 debate was around this idea of who deserves assistance, who deserves help.
00:26:11
Speaker
Medicaid has become a much bigger program, as as we were talking about a few minutes ago. And the ah the scope of Medicaid has changed. It really does now provide coverage to large numbers of low-income families and working families. It's not just for people with disabilities or kids or or or pregnant women. So there has been a change.
00:26:32
Speaker
Congress intentionally did that. It passed the Affordable Care Act and said, we're going to cover more people. yeah And the public you know since since the attempt to repeal the ACA in 2017, public opinion polls show pretty clearly people like this form of Medicaid. They like expanded Medicaid.
00:26:46
Speaker
Even in red states, the ruby red states, when you poll people and say, should your state expand Medicaid, the majority of voters, Republicans and Democrats alike, say yes. um Now, there's some Republican leaders who still don't want to expand Medicaid, but the public opinion is on the side of a bigger Medicaid program is something they like, they don't want to see it cut.
00:27:03
Speaker
But there's a wrinkle there, which OB three kind of wedges itself into, which is, okay, what about people who don't work? Should they be able to get Medicaid? And when you just present the question like that, public opinion generally says, well, yeah, you should have to work to get Medicaid. That seems fair. If you can work, you should work.
00:27:20
Speaker
yeah And so that's how we end up with a new sweeping change to Medicaid under this law to implement national work requirements. and In other words, to stay in Medicaid through the expansion pathway, you have to demonstrate every six months or even more frequently, depending on the state, that you are ah working 80 hours a month or doing something else that qualifies as, quote, community engagement.
00:27:42
Speaker
Okay. Makes sense. People generally, so at least a lot of Americans support this notion. What's the challenge? is this you know What do we know about this potential policy? The first thing to know is that most people in Medicaid are either already working or have a reason not to that should qualify them for an exemption. For instance, they have a chronic health condition that's interfering with their ability to work. They're in school full time. They're caring for a young kid or for a family member with a disability. So those those numbers add up. and And according to a bunch of studies, including some that our team did,
00:28:15
Speaker
By the time you run through all of those things, people who are working, people who are in school, people who have all these exemptions, you're really only talking about 5% to 10% of the population that's left that isn't working but potentially could. One state already tried Medicaid work requirements. This was in Arkansas in 2018. They got special permission from the Trump administration under something called a a waiver from from the federal government.
00:28:36
Speaker
And they put into effect this requirement for people 30 to 49 that they would have to work in order to stay in Medicaid. What happened over the six months that the policy was in effect, or it's actually about nine months it was in effect, was that 18,000 people were disenrolled from Medicaid for not being in compliance with this requirement. And in the studies that we did of this experience, most of those people did not gain other insurance, they became uninsured.
00:29:00
Speaker
And again, more than 95% of the people in the study, when we surveyed them, were already either working or in school or had a health problem or caring for a family member. And so they all should, most ah nearly all of them should have been able to stay enrolled. So why did they lose coverage? It turns out the story is really red tape.
00:29:17
Speaker
ah Only about one in three of the folks subject to this requirement had heard zero about it. They didn't even know it existed. They had no idea that this happened. So they didn't report anything to the state. They didn't know they had to go online and submit their activities to show them that they were working.
00:29:31
Speaker
Of those the folks who knew about it, a lot of them had difficulty navigating the reporting system. It was an online portal. Not everybody had good you know access to to online technology. The website was closed every night. So if you were working all day and you came home and tried to upload information, you couldn't, it was not available. so And so some people reported once and thought they were done. You had to go back every month. And if you didn't, you got removed from the program. So there were all of these ways that people who were actually doing what we wanted, which was working or doing other community engagement, were being removed from Medicaid, becoming uninsured. And when we went back a year later and talked to folks and that basically surveyed them and said, what happened to you in that intervening year? Did the coverage loss matter? ah The majority said it had made their health care worse or had affected their health. People were skipping medications or not taking medications at all for chronic conditions. So this was a real barrier. And ah I think we are at risk of seeing large scale coverage losses under this new federal law when these requirements take effect in 2027.
00:30:35
Speaker
And I think that's why I didn't really know. i mean, that makes a lot of sense about the red tape idea. it's kind of what our
The Role of AI in Medicaid Administration
00:30:42
Speaker
government's fits built on. But it's almost like we're we have nudges, but they're nudging them in the opposite direction, making them do more, put more information, stay active on on more and more things. And really, health care should be something that you shouldn't have to worry about constantly. kind of ruins that like study do with Oregon about increasing mental health, too.
00:31:00
Speaker
um And I want to hear a little bit about like the state by state dynamics here. I think the ACA looked really great in principle, but um some other economists have talked about because to push the bill pass, it was extremely difficult.
00:31:12
Speaker
There had to be concessions. And I think part of that is the state by state dynamic and that like not all states have expanded Medicaid. And what does that actually end up resulting in for different Americans? like Is health care wildly different for marginalized populations across different countries, different parts of the country? I imagine it's so. And what does that mean for like the larger United States that we have like this weird patchwork where some people have expanded Medicaid and some don't and some are kind of still on the fence on whether they should.
00:31:39
Speaker
Yeah. Well, I mean, the the simple consequence is that we have 10 states that haven't expanded Medicaid. And if you look at the list of the highest share of the population that's uninsured, they're non-expansion states, right? That's where we have the the largest disproportionate share of people who can't buy health insurance, can't afford coverage, and are suffering you know barriers to care and premature illness and death because they can't afford their care. So, we have these big disparities across states as a result the state policy decision-making around Medicaid expansion.
00:32:10
Speaker
To to ah a lesser extent, but still notable and in in the research that we've done on this, is the difference of how states have chosen to approach the the private insurance side of the Affordable Care Act, the marketplaces. The ACA gave states the option of setting up their own state-based marketplace, or if they didn't do that, the default was that it would it would be done by the federal government on healthcare.gov.
00:32:35
Speaker
in a study we published recently, we found that states that expanded that did the the marketplace coverage through their own state-based marketplaces were essentially twice as effective at getting people enrolled for the same amount of of financial assistance, for the same subsidy. They were twice as effective at lowering their uninsured rates in the states using the federal marketplace. and There are a lot of potential reasons for this. Some of it is outreach, some of it is ah crafting ah um a ah marketplace that meets the population's needs in terms of what information and the provider networks and that sort of thing. There may be a trust issue. People may be more likely to go to the state website as opposed to the federal website. A lot of different aspects of this. But it tells us that the ACA is not the same everywhere. Even outside of the Medicaid experience, the private insurance side of of the ACA is more effective in states that have invested and really politically supported the law compared to states that dragged their feet or or actively resisted it
00:33:31
Speaker
And that has big implications again for for millions of Americans in terms of how they get health care. I don't want to ignore the question you asked earlier. I want to circle back to this question of, well, how do we decide who gets health care? There are a lot of ways to approach that question.
00:33:44
Speaker
One of them that I think a lot of people go to ah in their own heart of hearts is the ethical question. And certainly as a primary care doctor, this resonates with me, which is all of my patients deserve health care because they're they're human beings. They all deserve to be able to get their illnesses addressed, their suffering alleviated, and to to have the chance to live a long and healthy life.
Conclusion: Importance and Advocacy for Medicaid
00:34:04
Speaker
That to me is is still a guiding principle in how I do clinical work, and and I think it motivates the desire that everyone should have affordable healthcare. care From a policy perspective, I will tell you many policymakers are less persuaded by that, and they want to understand, well, what's it going to cost and what's it going to get us? right We have a lot of decisions to make, and we have to have some metric other than it would be the right thing to do. You got to tell us how we're going to be able to afford it. There are a lot of things we'd like to do in government. We can't afford them all.
00:34:33
Speaker
And so that's where I think the evidence is really helpful to say, look, this leads to people being healthier and living longer. This also supports hospitals, especially rural safety net hospitals that are high risk of closure without Medicaid expansion. These are some of the biggest employers in a lot of towns and cities in the country. And so you know creating jobs and supporting the local economy means supporting Medicaid, right? That often goes hand in hand. And also if we think about people's ability to work,
00:35:01
Speaker
I think work requirements have it backwards. Most people in Medicaid who want to work or who who can work are working and they want to work. ah It turns out that Medicaid actually helps them do that.
00:35:12
Speaker
So surveys that have been done in the Medicaid expansion, for instance, Ohio's government put out a report on this. Most of the people who gain coverage from Medicaid said, this made it easier for me to keep a job. Or if I was looking for it it made it easier for me to for look for work because I could get my my health problems dealt with. I was feeling better. I was more able to go go work and stay in in a job. So the order of events should be give people coverage, and that will help them go get jobs and be able to participate in the economy.
00:35:38
Speaker
The work requirements are backwards. They're saying, well, if you don't have a job, we're going take your coverage away. That's just going to make it even harder for them to It doesn't make sense when you actually talk to people who are in these circumstances and trying to make ends meet. Taking something away as a penalty, most of them already want to work, and now you've just made it even harder. So I think you know there are strong ethical arguments to for having people have access to coverage, but I think there are also strong policy and economic arguments, and and ah and that's often more persuasive to people on the fence than than the ethical framing.
00:36:11
Speaker
Yeah, it makes sense. And also, i'm just going to do a quick side note here. I'm just, I did this out from the podcast, but do you have time for one or two more questions? I'll edit this part out. ah Yeah, i i need I probably need to be off in like five minutes, if that's okay. Okay, I'll just do one more quick question and then we'll end off there. Sorry, i this was, it was a good episode. So it was going a lot quicker than I, it went lot quicker than i expected, but I'll just finish that. Yeah, that makes a lot of sense. I think that Um, there's a huge issue where people, this work requirements an issue because I think people, it's hard to empathize with others when you're on on a voting sheet or a ballot or a poll.
00:36:47
Speaker
It's difficult to get an idea of like what someone's exact situation is like you hear they're not working, you hear they're lazy. You don't necessarily hear that maybe they're dealing with children or they're just got off a ah a terrible job, terrible manager.
00:37:00
Speaker
And I think looking to the future, part of what we need is empathy, but there's also a huge debate about government versus market solutions. and something you've been teaching about at Harvard. And I think there's a lot of other initiatives going on. But I'd love to hear from you.
00:37:13
Speaker
i mean, in the next few years, we're still under the Trump administration. States are still a little bit hesitant about expanding Medicaid for those other 10. What are some of the initiatives you're looking towards that might improve like equity or coverage? or and what should be the top priorities for like students of health policy or health professionals to be watching in the coming years to ensure the system improves or to navigate when the system maybe doesn't?
00:37:36
Speaker
Yeah. I think with the changes that are coming in Medicaid related to to this new law, a lot of the energy for those who support kind of universal access or broad coverage expansion really has to be about minimizing the harms of this new law. Sometimes you play offense and sometimes you play defense in terms of policies that you care about. and Right now, I think for those who who ah believe in encouraging coverage expansion and improving more equitable access to healthcare, care it's really time to play defense. And the way that that's going to play out is these work requirements have the risk of disenrolling you know millions and maybe more than 10 million people who probably mostly should still qualify for Medicaid, are going to get stuck in red tape.
00:38:19
Speaker
And so there's a lot of energy going on right now and in some of the states to figure out ways within the letter of the law to keep as many of those eligible people covered as possible. Some of that is information and outreach, helping people understand their options. Again, in our study in Arkansas, one in three people didn't even know they were subject to work requirements. and If you don't know, you're probably not going to complete any of the paperwork. but Probably even more important than that is something that's a little wonkier. and it's It's what's happening behind the scenes in terms of how states are analyzing their own data.
00:38:48
Speaker
The OB-3 work requirements provision says that states have to use their own existing data as much as possible. They can't just send forms to everybody and say, hey, fill these out and tell us if you're working. If they already know that they're working, for instance, because they have state income tax data or you know unemployment filings that show who's employed, you know who who's got a job and who doesn't. If they know you're working, they have to let you keep your coverage. they have to automatically qualify you. Similarly, some of the exemptions we talked about, the state needs to be able to do automatically. For instance, what if you are you know if you have a disability or you have a complex medical condition or you're pregnant?
00:39:26
Speaker
the The issue though is it sounds like those are pretty easy things to identify. They're not. States often don't know these things. Even one part of the state knows it, the other part doesn't. and so if If the state knows in you know that you you meet one of these criteria in one program, but they don't know that in Medicaid eligibility, the Medicaid program won't know to keep you covered. and If you don't fill out that paperwork, that cumbersome red tape, you could lose coverage.
00:39:51
Speaker
What's happening right now, and I think a lot of energy appropriately is going into, is is trying to figure out how to automate as much as possible this sort of paperwork. If the state can make more of their data systems talk to each other, can they figure out who's a full-time student in in in all the state universities, for instance, and not make those people fill out paperwork to keep their coverage? Can we make sure that we know who's got ah ah um you know a chronic health condition that should qualify them for an exemption?
00:40:17
Speaker
You would think that might be automatic. It's not. States don't always know at the time of the application or in the eligibility office what's happening in terms of people's health conditions. So that's where a lot of energy I think needs to go right now to try to reduce the potential harms of this law. Other you know more proactive things that would actually but boost coverage and not just reduce coverage losses, I still would come back to Medicaid expansion in those 10 states that haven't expanded.
00:40:42
Speaker
This is the single most important tool we have to getting coverage to low-income populations, disproportionately people of color who are really struggling to afford healthcare care in states like Texas and Florida and Mississippi. um and so you know How do you get to an expansion in those states? It's happened in a bunch of of red states already. 40 states include a lot of Republican-led states.
00:41:06
Speaker
A lot of this comes from the popular support, the public opinion that says this is something we want to do. The stakeholders like hospitals and and clinician clinician groups can be really influential here in saying, look, we need this to support what we're doing and so we can care for patients.
00:41:21
Speaker
There are parts of the law change that are going to make it harder for states to move forward with expansion. We didn't talk about it yet, but the tax law cuts the ability of states to raise money for their their portion of Medicaid costs through through taxes on providers. And that that's going to make this a ah ah a more difficult decision for some states that were considering expansion. On the other hand, work requirements for the Medicaid expansion population may make it more politically palatable to some conservatives to expand coverage that haven't wanted to do it before. And I still think this is the the most important tool we have if we want to create a more equitable healthcare care system.
00:41:54
Speaker
Yeah. And I think, of course, it'll be interesting to see what happens. But part of that, part of the best things that we can do just awareness. And I think for a lot of younger individuals, yeah I think I've seen, we've seen companies and people working on AI solutions to increase interoperability and data orchestration for these companies on the private side. And then, of course, government solutions to get that data into like single silos. And I think that could be really important to make sure that People don't have to stress about whether they have healthcare care the next week or not.
00:42:21
Speaker
That shouldn't be something anyone has to do as we've talked about. But I really appreciate your time again, Dr. Summers. I think it's been really important to illustrate what are the facts behind Medicaid? Does it work? Does it not? Of course it does. And to what extent can is it going to change and can we improve it and what extent should it be retouching the people in America? But really appreciate the time today. i think I've definitely learned a lot and I'm sure the audience has too. So thank you again.
00:42:44
Speaker
My pleasure. Thanks so much. All important topics. So I hope folks will will get engaged on these issues.