As a retired family physician who also spent 20 years working as a nursing home medical director, I am particularly troubled by the current Republican proposals to reduce Medicaid funding both at the state and federal levels.
Polling data show that 82% of those surveyed opposed cuts to Medicaid funding. Cutting back on Medicaid will reduce care for our most vulnerable citizens, those with extremely low incomes, those who live with serious disabilities, the unhoused, those with mental illness, those with substance use disorder and those in need of long-term nursing care.
Supporters of Medicaid cuts prefer to ignore the human tragedy of numerous neighbors unable to afford essential health care, in turn leading to increased health care costs for every American household.
Medicaid is a complex insurance program funded by a combination of state and federal funds that in New Hampshire covers 184,000 people, including 1 in 9 adults ages 19-64 and 1 in 4 children. Granite Staters who are eligible for traditional Medicaid include those whose household income is below the Federal Poverty Level (aka FPL); $21,150 for a two-person household, $32,150 for a four-person household.
Medicaid also covers children, pregnant women and people with chronic disabilities who live in households making specified multiples of the FPL. Under the Affordable Care Act, Medicaid has been expanded in most states including New Hampshire to cover persons making between 100% to 138% of the FPL.
Certainly, a government program as large as Medicaid should be continuously reviewed and reformed as needed. However, such a review should be done with a research-guided scalpel and not an ideology-powered chainsaw.
Of note, the majority of adults under 65 in New Hampshire covered by Medicaid are working, albeit at low-paying jobs that do not provide employer-based health insurance. Nationally, 92% of adults on Medicaid either work full or part time, attend school, are caregivers or have a chronic illness or disability that prevents them from working.
Thus, adding a work requirement to Medicaid would not save money by getting people to start working. Rather, a work requirement would only save money by kicking people off Medicaid who are already working but have trouble meeting complicated documentation standards or unrealistic requirements for monthly hours worked.
The Republican calls for drastic cuts to Medicaid just do not make sense. First, Republicans claim that there is a dramatic amount of waste, fraud and abuse in the Medicaid program, but there is good data that the amount of improper expenditures for Medicaid is relatively small — 5% — and most of these are paperwork errors. Second, Republicans claim that Medicaid should offer short-term coverage, but many people covered by Medicaid have lifelong, disabling conditions.
And third, Republicans in Washington DC and Concord claim that cutting Medicaid is a reasonable way to fund tax breaks primarily for the wealthy; including the near $1 trillion in Trump tax cuts and the hundreds of millions of dollars of lost revenue in New Hampshire caused by the GOP’s elimination of the Interest and Dividends tax and the reduction in the business profits tax and the business enterprise tax. Does taking health care from the poor and vulnerable to reduce taxes for the wealthy seem like smart economics or ethical policy?
During my medical career, I worked extensively with people needing long-term care and mental health care. I expect such people will be particularly harmed by Medicaid cuts. Most long-term care is provided in nursing homes or in home and community-based settings. Medicaid pays a nursing home less than half its regular daily rate. Two out of three nursing home residents, both nationally and in New Hampshire, are covered by Medicaid.
Many nursing homes have long waiting lists and have had to close entire nursing units due to a lack of staff. In New Hampshire, the Choices for Independence program makes Medicaid funds available to pay for home-based care for persons who qualify for a nursing home but prefer to remain at home. Home care is much less expensive than nursing home care, but is also difficult to access due to a lack of funding and available nursing and home-health staff.
Cutting Medicaid will force many people to try to survive without necessary care. Inevitably, such vulnerable neighbors will end up in the emergency room in crisis, waiting for the next available hospital bed.
Like long-term care, the system of mental health care is trying to address increasing public need with decreasing resources. Medicaid is the largest source of funding to treat mental health conditions and substance use disorders. In New Hampshire, mental illness is increasing dramatically. The ten Community Mental Health Centers in New Hampshire provide mental health care covered by Medicaid for most Granite Staters with severe mental illness.
These centers rely on relatively low Medicaid reimbursement for one-third of their patient care. Many services these patients need are not covered by any insurance. Hence, the Community Mental Health Centers have very tight budgets, and the current staffing for the state’s ten CMHCs includes 340 vacancies for clinical care providers. If people lose access to Medicaid-funded mental health services, the rate of substance abuse, drug overdose, homelessness and suicide will likely increase due to the lack of access to appropriate care.
I believe the cuts to Medicaid proposed by Republicans are likely to cause great and unnecessary harm to our most vulnerable people and bring our health care systems in New Hampshire and across the country to the brink of collapse.
If you agree, please call our governor and your state legislators and join with your family and friends to voice your opposition to these dangerous policies.
Randy Hayes, MD., is a retired family physician from Canterbury.