Q&A: Medicaid Reforms Strengthen Safety Net

Q: Why did Congress seek fiscal integrity changes to the Medicaid program?

A: Six decades ago, Congress added Title XIX to the Social Security Act that created a health care safety net for low-income individuals and families, with primary emphasis on dependent children and their moms, individuals with disabilities and low-income seniors. Since 1965, state governments administer the public health insurance program with cost-sharing from the federal government. Over the years, eligibility expansions and loopholes accelerated expenditures that placed a greater burden on the federal budget. The federal share of Medicaid spending has increased from 60 percent in 1991 to about 74 percent in 2023. Throughout my service on the Senate Finance Committee, which has legislative and oversight jurisdiction of the Medicaid program, I’ve led bipartisan efforts to ensure the most vulnerable populations are served, particularly child and maternal care -- including families with children with complex medical conditions -- as well as foster and adopted youth. I’ve also supported efforts to strengthen fiscal accountability measures in this federal safety net, such as the passage of my bipartisan Right Rebate Act. Without robust fiscal integrity, the strings of this safety net would unravel at the seams and put an unsustainable and unfair burden on the taxpayer. Just consider, between 2015 and 2024, the amount of improper federal Medicaid payments reached $560 billion. Some estimates suggest that figure exceeds $1 trillion. Americans deserve better fiscal stewardship over their tax dollars and the program’s intended and most vulnerable recipients deserve to know this safety net is strong enough to meet their health care needs. Every dollar lost to waste and mismanagement is one less health care dollar for nursing home residents, low-income moms and foster youth.

Q: How does the Senate-passed budget bill strengthen the Medicaid program?

A: With fiscal responsibility top of mind, the Senate bill includes integrity measures to help ensure Medicaid continues to serve vulnerable Americans in our local communities. Specifically, common sense measures are designed to reduce duplicate enrollment; ensure deceased individuals and health care providers don’t remain enrolled; reduce payments for erroneous excess provider payments; and require states to check twice yearly if an individual is eligible to be on Medicaid, instead of screening once a year. In addition, stronger oversight will save billions by establishing robust verification for individuals receiving premium tax credits through the federal marketplace created by the Affordable Care Act. If a recipient gets more subsidies than allowed, that excessive subsidy must be returned. Through my oversight of taxpayer dollars, I advised the U.S. Treasury Inspector General last year that excessive payments weren’t being recouped to the federal treasury. I discovered more than 40 percent of excessive federal marketplace subsidy payments ran to the tune of more than $10 billion going back a decade. Clawing back these payments will save tens of billions of dollars.

Also, the bill establishes a $50 billion Rural Health Transformation Program to ensure hospitals, nursing homes, community health care centers and other rural providers can continue serving their communities and improve care. The Rural Health Transformation Program will improve access to care and health outcomes. It also establishes Medicaid work requirements for able-bodied adults age 64 or under, with reasonable exemptions for individuals with disabilities, seniors, pregnant women, children, caregivers and others. Able-bodied adults will have to complete a minimum of 80 hours of work a month by working, job training, going to school or volunteering. In addition, the bill allows states to offer home and community-based services (HCBS) to a broader range of individuals, such as those with developmental disabilities, while ensuring it doesn’t negatively impact those already eligible, and it enables interim HCBS coverage while newly eligible individuals develop their full care plan.

The Senate also prioritizes Medicaid for Americans, not people who broke our laws to enter the country illegally. Our bill ends federal financial support under Medicaid for those who don’t have verified citizenship, nationality or legal immigration status. These program integrity provisions for Medicaid and other health care programs will save over $500 billion, according to a non-partisan Congressional Budget Office (CBO) estimate. Despite orchestrated efforts to mischaracterize our program integrity measures with fearmongering and misinformation, the Senate took a big step to save Medicaid for people the program is intended to serve.