WEBVTT 00:00:00.000 --> 00:00:01.639 Okay, let's unpack this. We're going to get into 00:00:01.639 --> 00:00:04.200 a program that so many people confuse with Medicare, 00:00:04.379 --> 00:00:09.759 but it quietly functions as the largest single 00:00:09.759 --> 00:00:11.900 source of funding for low -income health care 00:00:11.900 --> 00:00:15.560 in the U .S. We are doing a deep dive into Medicaid 00:00:15.560 --> 00:00:18.100 today. It's a real cornerstone of the American 00:00:18.100 --> 00:00:21.500 safety net that is, well, it's massive, it's 00:00:21.500 --> 00:00:24.420 essential, and it is always, always being debated. 00:00:24.660 --> 00:00:27.460 It's such a crucial topic for a deep dive, you 00:00:27.460 --> 00:00:29.280 know, partly because its structure is just so 00:00:30.079 --> 00:00:33.000 That complexity, I think, often allows the program's 00:00:33.000 --> 00:00:36.500 actual scope and its real social impact to get 00:00:36.500 --> 00:00:38.759 buried under these simplified political talking 00:00:38.759 --> 00:00:40.600 points. Right. But when you actually strip all 00:00:40.600 --> 00:00:42.420 that away, we just look at the raw scale of it. 00:00:42.479 --> 00:00:46.600 The program is a true financial and demographic 00:00:46.600 --> 00:00:48.700 behemoth in the U .S. That scale is the first 00:00:48.700 --> 00:00:50.060 thing that just jumps out at you. We're not talking 00:00:50.060 --> 00:00:52.520 about some small niche program here. This is 00:00:52.520 --> 00:00:54.539 a system that's jointly run by the federal and 00:00:54.539 --> 00:00:57.200 state governments. And in 2023, it carried a 00:00:57.200 --> 00:01:00.320 total annual cost of, well. A mind -boggling 00:01:00.320 --> 00:01:03.939 $870 billion. An incredible number. To put that 00:01:03.939 --> 00:01:06.299 in perspective for you, that's larger than the 00:01:06.299 --> 00:01:08.319 GDP of most countries on Earth. And that immense 00:01:08.319 --> 00:01:10.599 spending covers a colossal number of people. 00:01:10.920 --> 00:01:14.640 We're talking 85 million low -income and disabled 00:01:14.640 --> 00:01:18.719 individuals enrolled as of 2022. Wow. But, you 00:01:18.719 --> 00:01:20.739 know, beyond just the sheer size of it, think 00:01:20.739 --> 00:01:23.260 about its social significance. If you want just 00:01:23.260 --> 00:01:25.579 one statistic that shows how deeply integrated 00:01:25.579 --> 00:01:28.500 Medicaid is into American life, just look at 00:01:28.500 --> 00:01:32.560 childbirth. In 2019 alone, the program paid for 00:01:32.560 --> 00:01:35.920 half of all U .S. births. Half. That's incredible. 00:01:36.200 --> 00:01:38.640 It is. It's just woven into the demographic and 00:01:38.640 --> 00:01:41.200 the economic fabric of the country in a way that, 00:01:41.200 --> 00:01:43.040 you know, very few other public programs really 00:01:43.040 --> 00:01:46.079 are. So our mission in this deep dive is to move 00:01:46.079 --> 00:01:48.340 beyond those headline numbers and really try 00:01:48.340 --> 00:01:50.159 to understand the inner workings. We want to 00:01:50.159 --> 00:01:53.260 look at the unique funding structure, the high 00:01:53.260 --> 00:01:55.280 stakes policy battles that have really reshaped 00:01:55.280 --> 00:01:58.000 it recently, and critically, the surprising hard 00:01:58.000 --> 00:02:00.459 evidence of its societal impacts. Things you 00:02:00.459 --> 00:02:02.760 might not expect from crime rates to financial 00:02:02.760 --> 00:02:06.060 security. And that structural tension is absolutely 00:02:06.060 --> 00:02:08.560 the key to understanding the program's whole 00:02:08.560 --> 00:02:11.620 history. Medicaid is really defined by this. 00:02:12.840 --> 00:02:14.860 This uneasy collaboration between the federal 00:02:14.860 --> 00:02:17.539 and state governments. The feds provide matching 00:02:17.539 --> 00:02:20.969 funds, often the majority of it. Right. But the 00:02:20.969 --> 00:02:23.229 states have enormous latitude. They get to decide 00:02:23.229 --> 00:02:26.990 on eligibility standards, benefit levels, and 00:02:26.990 --> 00:02:29.590 maybe most importantly, what they pay doctors 00:02:29.590 --> 00:02:31.509 and hospitals. So it's not really one program 00:02:31.509 --> 00:02:34.169 at all. Exactly. Functionally, it's like 50 or 00:02:34.169 --> 00:02:36.330 51 different versions of a national program. 00:02:36.849 --> 00:02:39.150 And that variability is just central to all the 00:02:39.150 --> 00:02:42.069 ongoing political debates and, frankly, the wildly 00:02:42.069 --> 00:02:44.349 uneven quality of care you see from one state 00:02:44.349 --> 00:02:45.969 to the next. OK, so let's start at the beginning. 00:02:46.069 --> 00:02:48.449 Let's get into the foundations of how this massive 00:02:48.449 --> 00:02:51.289 joint venture got started. back in the 1960s? 00:02:51.310 --> 00:02:54.169 Well, Medicaid was established in 1965. It was 00:02:54.169 --> 00:02:55.550 created through the Social Security amendments 00:02:55.550 --> 00:02:59.210 in 1965. And it was a real flagship component 00:02:59.210 --> 00:03:01.770 of President Lyndon B. Johnson's Great Society 00:03:01.770 --> 00:03:03.870 programs. And it was created at the same time 00:03:03.870 --> 00:03:05.550 as Medicare, which is where a lot of the confusion 00:03:05.550 --> 00:03:09.110 comes from. At the exact same time. But the objective 00:03:09.110 --> 00:03:13.189 for Medicaid was explicitly tied to poverty alleviation. 00:03:13.550 --> 00:03:16.210 The goal was to help states assist residents 00:03:16.210 --> 00:03:19.090 whose income and resources were just too low 00:03:19.090 --> 00:03:21.770 to pay for private health insurance. So that's 00:03:21.770 --> 00:03:23.729 the crucial philosophical split right there. 00:03:23.830 --> 00:03:26.009 The goal was poverty assistance delivered through 00:03:26.009 --> 00:03:28.229 medical care. That's totally different from Medicare, 00:03:28.330 --> 00:03:30.889 which is a universal social insurance program 00:03:30.889 --> 00:03:32.810 for the elderly, no matter how wealthy they are. 00:03:32.870 --> 00:03:35.550 Precisely. And that difference is most obvious 00:03:35.550 --> 00:03:37.750 when you look at how it's financed. Medicaid 00:03:37.750 --> 00:03:40.689 is a joint federal -state partnership, and it's 00:03:40.689 --> 00:03:42.530 funded through something called the Federal Medical 00:03:42.530 --> 00:03:45.639 Assistance Program. percentages or FM. FMP. Yes. 00:03:45.759 --> 00:03:47.919 And that's basically the federal matching fund 00:03:47.919 --> 00:03:50.479 system that's provided to the states. So walk 00:03:50.479 --> 00:03:52.539 us through how that matching system works. Is 00:03:52.539 --> 00:03:55.159 the financial burden just split evenly down the 00:03:55.159 --> 00:03:57.139 middle? Not at all. And that's the really clever 00:03:57.139 --> 00:03:59.719 part of the design. The FMP system is designed 00:03:59.719 --> 00:04:02.379 to be a kind of fiscal equalizer. It ensures 00:04:02.379 --> 00:04:04.599 that the responsibility for funding health care 00:04:04.599 --> 00:04:06.939 for the poor is shared. Yeah. But it disproportionately 00:04:06.939 --> 00:04:09.719 favors states that have lower economic capacity. 00:04:10.250 --> 00:04:11.969 Okay, so what does that look like in practice? 00:04:12.310 --> 00:04:15.210 Well, the wealthiest states, say a California 00:04:15.210 --> 00:04:18.089 or a New York, they receive the lowest possible 00:04:18.089 --> 00:04:22.110 match, which is a 50 % FMAP, so the 50 -50 split. 00:04:22.329 --> 00:04:25.389 But poorer states get a much larger federal match. 00:04:25.720 --> 00:04:27.639 The federal government carries a greater financial 00:04:27.639 --> 00:04:30.639 burden in those areas, sometimes up to 75 percent 00:04:30.639 --> 00:04:33.519 or for certain populations, even higher. I see. 00:04:33.600 --> 00:04:35.839 So the structure is meant to acknowledge that 00:04:35.839 --> 00:04:38.300 while health care costs are pretty much universal, 00:04:38.759 --> 00:04:41.319 a state's ability to pay for them is absolutely 00:04:41.319 --> 00:04:43.819 not. It tries to create a minimum floor of coverage 00:04:43.819 --> 00:04:46.459 across the whole country. That's the idea. The 00:04:46.459 --> 00:04:49.449 FMAP is the essential bargain. States agree to 00:04:49.449 --> 00:04:51.970 provide a baseline of care, and in return, the 00:04:51.970 --> 00:04:54.149 federal government heavily subsidizes the cost, 00:04:54.310 --> 00:04:56.250 especially for the states that can least afford 00:04:56.250 --> 00:04:58.129 it on their own. But what does this mean for 00:04:58.129 --> 00:05:00.050 state budgets? I mean, this has to create huge 00:05:00.050 --> 00:05:02.910 pressure. Enormous pressure. On average, states 00:05:02.910 --> 00:05:05.250 spend about 16 .8 percent of their own general 00:05:05.250 --> 00:05:08.199 funds directly on their share of Medicaid. But 00:05:08.199 --> 00:05:09.980 when you factor in that massive federal match 00:05:09.980 --> 00:05:12.199 and you count the total program spending, Medicaid 00:05:12.199 --> 00:05:14.759 ends up consuming about 22 percent of a state's 00:05:14.759 --> 00:05:17.339 entire budget. A fifth of the entire state budget. 00:05:17.560 --> 00:05:20.199 Yep. And that reliance means that any small change 00:05:20.199 --> 00:05:22.939 in federal rules or matching rates can have these 00:05:22.939 --> 00:05:25.579 immediate and severe ripple effects on state 00:05:25.579 --> 00:05:29.199 treasuries and on other state services like education 00:05:29.199 --> 00:05:31.680 or infrastructure. Given that kind of financial 00:05:31.680 --> 00:05:34.240 strain, it's almost unbelievable that state participation 00:05:34.240 --> 00:05:37.980 is technically voluntary. It is a historical 00:05:37.980 --> 00:05:41.220 quirk, yes. States are not legally required to 00:05:41.220 --> 00:05:43.759 participate. But because of the overwhelming 00:05:43.759 --> 00:05:46.399 financial leverage, you know, the promise of 00:05:46.399 --> 00:05:49.139 this huge pot of federal money for a politically 00:05:49.139 --> 00:05:51.519 essential program, all states have participated 00:05:51.519 --> 00:05:55.220 since 1982. Arizona was the last state to finally 00:05:55.220 --> 00:05:57.199 join. So they can't really say no. In effect, 00:05:57.279 --> 00:06:00.000 no. A state really can't abandon its low -income, 00:06:00.139 --> 00:06:03.000 disabled, and elderly residents without the financial 00:06:03.000 --> 00:06:05.879 stability that the FMAP provides. And here's 00:06:05.879 --> 00:06:07.300 where it gets really interesting and I think 00:06:07.300 --> 00:06:09.000 surprising for a lot of people, the spending 00:06:09.000 --> 00:06:11.459 disparity. There are massive, massive differences 00:06:11.459 --> 00:06:14.060 in costs, depending entirely on which group of 00:06:14.060 --> 00:06:16.519 enrollees you're talking about. This is absolutely 00:06:16.519 --> 00:06:18.879 critical. When we throw around the average annual 00:06:18.879 --> 00:06:21.079 cost per enrollee, which is somewhere around 00:06:21.079 --> 00:06:24.699 $7 ,600, that number hides this incredible variation. 00:06:25.019 --> 00:06:27.209 You have to look at the eligibility groups. Look 00:06:27.209 --> 00:06:29.589 at children, for instance. They make up the largest 00:06:29.589 --> 00:06:32.610 group of enrollees, about 37 % of the total in 00:06:32.610 --> 00:06:36.209 the 2021 data. And their cost is, what, minimal 00:06:36.209 --> 00:06:39.149 compared to the overall budget? Exactly. Children 00:06:39.149 --> 00:06:41.350 account for only 15 % of the total spending. 00:06:41.569 --> 00:06:44.269 Their average annual cost is only about $3 ,000 00:06:44.269 --> 00:06:47.290 per person. They tend to need preventive care, 00:06:47.589 --> 00:06:50.529 immunizations, standard checkups, which are all 00:06:50.529 --> 00:06:53.180 relatively low cost. OK, so now contrast that 00:06:53.180 --> 00:06:55.000 with the high cost categories. You mentioned 00:06:55.000 --> 00:06:57.620 seniors and disabled persons. Right. That population, 00:06:57.839 --> 00:06:59.959 the aged and the disabled, they are what drives 00:06:59.959 --> 00:07:02.139 the immense costs of the program. I can imagine. 00:07:02.360 --> 00:07:04.220 They absolutely do. Even though they only make 00:07:04.220 --> 00:07:06.939 up about 21 percent of the total enrollees, they 00:07:06.939 --> 00:07:09.379 account for a staggering 52 percent of all Medicaid 00:07:09.379 --> 00:07:12.000 spending. Over half the budget for just a fifth 00:07:12.000 --> 00:07:14.360 of the people. That's right. Their average cost 00:07:14.360 --> 00:07:17.279 per person is substantial over $18 ,000 back 00:07:17.279 --> 00:07:20.220 in 2021. And that's because this group relies 00:07:20.220 --> 00:07:22.079 on Medicaid for these critical high intensity 00:07:22.079 --> 00:07:24.199 services that Medicare or commercial insurance 00:07:24.199 --> 00:07:26.980 often just won't cover. Things like chronic disease 00:07:26.980 --> 00:07:29.959 management, specialized disability services and 00:07:29.959 --> 00:07:32.279 the big one, long term services and supports 00:07:32.279 --> 00:07:36.040 or LTSS, which are. incredibly expensive. So 00:07:36.040 --> 00:07:39.279 understanding that huge cost distribution is 00:07:39.279 --> 00:07:41.420 really the key to understanding why any structural 00:07:41.420 --> 00:07:44.180 changes to Medicaid usually involve these really 00:07:44.180 --> 00:07:46.639 painful policy battles that center on services 00:07:46.639 --> 00:07:48.920 for the aged and disabled. It's always where 00:07:48.920 --> 00:07:50.660 the fight is. All right. So let's transition 00:07:50.660 --> 00:07:53.639 from the sort of static structure to the dynamic 00:07:53.639 --> 00:07:56.819 and often brutal world of policy battles. The 00:07:56.819 --> 00:07:58.720 history of Medicaid in the last decade or so 00:07:58.720 --> 00:08:01.079 has really been defined by two huge legislative 00:08:01.079 --> 00:08:03.720 events. The expansion under the Affordable Care 00:08:03.720 --> 00:08:06.279 Act and then the structural changes and cuts 00:08:06.279 --> 00:08:09.180 that were proposed in the 2025 reforms. Let's 00:08:09.180 --> 00:08:11.019 start with the Affordable Care Act, the ACA, 00:08:11.060 --> 00:08:13.720 signed back in 2010. This was intended to be 00:08:13.720 --> 00:08:15.600 the primary way to achieve something close to 00:08:15.600 --> 00:08:18.100 universal health coverage in the U .S., specifically 00:08:18.100 --> 00:08:21.319 by extending Medicaid eligibility. The original 00:08:21.319 --> 00:08:24.120 ACA mandate was, I mean, it was truly sweeping. 00:08:24.220 --> 00:08:27.100 The idea was to expand coverage to anyone earning 00:08:27.100 --> 00:08:29.819 up to 138 percent of the federal poverty level. 00:08:30.089 --> 00:08:32.309 And that was regardless of their traditional 00:08:32.309 --> 00:08:34.230 category, like whether they had a disability 00:08:34.230 --> 00:08:37.230 or were a parent. What was the financial carrot 00:08:37.230 --> 00:08:39.950 they offered states to accept this enormous expansion? 00:08:40.370 --> 00:08:44.309 The initial federal funding promise was unprecedentedly 00:08:44.309 --> 00:08:46.370 generous. The federal government pledged to cover 00:08:46.370 --> 00:08:48.529 100 percent of the cost for this newly covered 00:08:48.529 --> 00:08:51.789 population. These are the low income, able bodied 00:08:51.789 --> 00:08:53.750 adults who never had a path to coverage before. 00:08:53.909 --> 00:08:56.370 That 100 percent match would run from 2014 through 00:08:56.370 --> 00:08:58.769 2016. 100 percent. So the states paid nothing 00:08:58.769 --> 00:09:01.529 for this. group initially. Nothing. And then 00:09:01.529 --> 00:09:04.169 that match rate was set to phase down, but only 00:09:04.169 --> 00:09:06.889 to a permanent rock solid 90 percent federal 00:09:06.889 --> 00:09:10.289 share by 2020 and for all the years after. So 00:09:10.289 --> 00:09:12.629 for states that were used to paying 25 percent, 00:09:12.710 --> 00:09:14.210 maybe even 50 percent of traditional Medicaid 00:09:14.210 --> 00:09:16.970 costs, only having to pay 10 percent for this 00:09:16.970 --> 00:09:19.990 huge new population was a massive financial draw. 00:09:20.460 --> 00:09:23.059 It was essentially a blank check from the federal 00:09:23.059 --> 00:09:24.919 government for states to cover their poorest 00:09:24.919 --> 00:09:27.860 residents. But that overwhelming incentive hit 00:09:27.860 --> 00:09:30.879 a legal wall in 2012. Yes, it did. The Supreme 00:09:30.879 --> 00:09:34.019 Court ruling in NFIB v. Sebelius, the court held 00:09:34.019 --> 00:09:36.399 that threatening to withdraw all of the state's 00:09:36.399 --> 00:09:38.360 pre -existing Medicaid funding if they refused 00:09:38.360 --> 00:09:41.340 the expansion was unconstitutionally coercive. 00:09:41.440 --> 00:09:44.159 A huge deal. A monumental ruling. It effectively 00:09:44.159 --> 00:09:46.059 stripped the federal government of its enforcement 00:09:46.059 --> 00:09:48.960 power and critically made the expansion optional 00:09:48.960 --> 00:09:51.519 for states. And that one decision created the 00:09:51.519 --> 00:09:53.580 fundamental political divide we still see today. 00:09:53.779 --> 00:09:56.299 Many Republican controlled states chose to refuse 00:09:56.299 --> 00:09:58.779 the expansion. And that refusal gave birth to 00:09:58.779 --> 00:10:00.559 what we call the coverage gap, which is one of 00:10:00.559 --> 00:10:03.080 the most, I think, frustrating failures of the 00:10:03.080 --> 00:10:05.980 American health system. The coverage gap is. 00:10:07.179 --> 00:10:09.679 It's a structural absurdity created entirely 00:10:09.679 --> 00:10:12.200 by that Supreme Court ruling. See, the ACA was 00:10:12.200 --> 00:10:14.120 designed with these overlapping layers of assistance. 00:10:14.480 --> 00:10:17.500 You had Medicaid for the very poorest, which 00:10:17.500 --> 00:10:19.940 was intended to go up to 138 percent of the poverty 00:10:19.940 --> 00:10:23.419 level. And then you had federal subsidies, tax 00:10:23.419 --> 00:10:25.879 credits for private insurance for people above 00:10:25.879 --> 00:10:27.679 100 percent of the poverty level. So there was 00:10:27.679 --> 00:10:30.720 supposed to be no gap. If a state refused to 00:10:30.720 --> 00:10:32.879 expand Medicaid, what happened to the people 00:10:32.879 --> 00:10:35.340 whose income fell into that dead zone? You know, 00:10:35.340 --> 00:10:37.320 between their state's old stingy eligibility 00:10:37.320 --> 00:10:40.799 limits and that 100 percent FPL threshold for 00:10:40.799 --> 00:10:43.059 help on the marketplace. They were left completely 00:10:43.059 --> 00:10:45.139 stranded. These are individuals who make too 00:10:45.139 --> 00:10:47.559 much money to qualify under the old pre -ACA 00:10:47.559 --> 00:10:50.179 Medicaid rules, which in some states were incredibly 00:10:50.179 --> 00:10:53.039 restrictive. But they made too little money below 00:10:53.039 --> 00:10:56.019 100 percent FPL to qualify for any federal subsidy 00:10:56.019 --> 00:10:58.840 to buy private insurance. they end up with absolutely 00:10:58.840 --> 00:11:01.080 no affordable options. The source material we 00:11:01.080 --> 00:11:02.940 looked at gives a really stark example of just 00:11:02.940 --> 00:11:05.299 how restrictive those pre -ACA rules were in 00:11:05.299 --> 00:11:07.000 some of these states. Can you kind of illustrate 00:11:07.000 --> 00:11:09.320 that disconnect? Certainly. Let's take a state 00:11:09.320 --> 00:11:12.120 like Kansas before expansion. A non -disabled 00:11:12.120 --> 00:11:14.460 adult with children might only qualify for Medicaid 00:11:14.460 --> 00:11:17.980 if their income was below 32 % of the federal 00:11:17.980 --> 00:11:20.539 poverty level. 32 %? That's practically nothing. 00:11:20.820 --> 00:11:23.320 It's incredibly low. And that left this massive, 00:11:23.399 --> 00:11:26.019 unaddressed gulf from 32 percent of the poverty 00:11:26.019 --> 00:11:28.419 line all the way up to 100 percent, where people 00:11:28.419 --> 00:11:31.139 had no medical assistance at all. It's estimated 00:11:31.139 --> 00:11:33.639 that over half of the entire national uninsured 00:11:33.639 --> 00:11:36.600 population ended up living in these non -expansion 00:11:36.600 --> 00:11:39.259 states. It was a genuine public health crisis 00:11:39.259 --> 00:11:42.039 created by a policy choice. But on the flip side, 00:11:42.179 --> 00:11:44.259 the states that did embrace the expansion, they 00:11:44.259 --> 00:11:47.059 saw immediate and profound benefits, right? Undeniably. 00:11:47.100 --> 00:11:50.110 The data is crystal clear. Among adults age 18 00:11:50.110 --> 00:11:53.090 to 64, expansion states had an uninsured rate 00:11:53.090 --> 00:11:56.389 of about 7 .3 percent in early 2016. That was 00:11:56.389 --> 00:11:58.990 dramatically lower than the 14 .1 percent rate 00:11:58.990 --> 00:12:01.210 found in the non -expansion states. So it cut 00:12:01.210 --> 00:12:03.110 the uninsured rate in half, basically. Pretty 00:12:03.110 --> 00:12:05.149 much. We saw places like Arkansas and Kentucky, 00:12:05.370 --> 00:12:07.450 which historically had some of the highest uninsured 00:12:07.450 --> 00:12:09.570 rates in the country, see those rates plummet. 00:12:09.610 --> 00:12:12.789 They went from 40 or 42 percent down to 9 or 00:12:12.789 --> 00:12:15.110 14 percent in just a couple of years. And there 00:12:15.110 --> 00:12:17.450 was a counterintuitive finding about the private 00:12:17.450 --> 00:12:19.549 insurance markets in those expansion states, 00:12:19.649 --> 00:12:21.990 which I found fascinating. Yes, this is a key 00:12:21.990 --> 00:12:24.809 economic insight. Studies found that states that 00:12:24.809 --> 00:12:27.309 expanded Medicaid actually ended up with lower 00:12:27.309 --> 00:12:29.429 premiums on their private insurance exchange 00:12:29.429 --> 00:12:33.129 policies. The expansion acted like a stabilizer 00:12:33.129 --> 00:12:34.950 for that private market. How does that work? 00:12:35.659 --> 00:12:38.059 Well, by shifting the lower income population, 00:12:38.340 --> 00:12:40.899 which on average has higher health risks and 00:12:40.899 --> 00:12:43.460 uses more services into Medicaid, the private 00:12:43.460 --> 00:12:46.019 insurance risk pool became healthier and more 00:12:46.019 --> 00:12:48.559 profitable. So that resulted in lower overall 00:12:48.559 --> 00:12:50.799 costs and lower premiums for everyone who was 00:12:50.799 --> 00:12:53.480 buying private insurance on their own. It really 00:12:53.480 --> 00:12:56.470 did benefit the entire insurance ecosystem. So 00:12:56.470 --> 00:12:58.830 if the ACA expansion was this big push toward 00:12:58.830 --> 00:13:01.669 more coverage, the political pendulum swung hard 00:13:01.669 --> 00:13:04.149 in the opposite direction in 2025 with the signing 00:13:04.149 --> 00:13:07.149 of the One Big Beautiful Bill Act. This legislation 00:13:07.149 --> 00:13:11.029 focused squarely on structural changes, new eligibility 00:13:11.029 --> 00:13:13.669 limits and funding cuts. This act was really 00:13:13.669 --> 00:13:15.750 the culmination of efforts by Republican leaders 00:13:15.750 --> 00:13:18.009 in Congress who had announced these big goals 00:13:18.009 --> 00:13:19.990 of cutting up to $2 trillion from the federal 00:13:19.990 --> 00:13:22.740 budget over the next decade. Now, the stated 00:13:22.740 --> 00:13:26.139 goal was always eliminating abuse or waste, but 00:13:26.139 --> 00:13:28.240 the budget resolution that passed the House proposed 00:13:28.240 --> 00:13:32.000 cutting $880 billion from the committees that 00:13:32.000 --> 00:13:34.700 oversee both Medicaid and Medicare. And this 00:13:34.700 --> 00:13:37.879 act, signed in July 2025, it implemented a lot 00:13:37.879 --> 00:13:40.549 of those proposed reductions. The centerpiece 00:13:40.549 --> 00:13:42.629 of this effort, and certainly the most contentious 00:13:42.629 --> 00:13:45.549 part of the bill, was the mandatory work requirement 00:13:45.549 --> 00:13:47.990 for able -bodied adults. What are the specifics 00:13:47.990 --> 00:13:50.870 of that mandate? The act mandates that able -bodied 00:13:50.870 --> 00:13:53.690 adult enrollees have to work or volunteer for 00:13:53.690 --> 00:13:56.029 80 hours per month. That's roughly 20 hours a 00:13:56.029 --> 00:13:57.929 week, so half -time employment. And they have 00:13:57.929 --> 00:13:59.409 to do that to maintain their Medicaid coverage. 00:13:59.590 --> 00:14:01.490 This requirement is scheduled to begin nationwide 00:14:01.490 --> 00:14:04.840 in 2027. So what's the projected cost of this 00:14:04.840 --> 00:14:07.279 new rule? Not in dollars, but in people losing 00:14:07.279 --> 00:14:09.940 their health coverage. This is where the nonpartisan 00:14:09.940 --> 00:14:12.039 analysis from the Congressional Budget Office, 00:14:12.259 --> 00:14:16.299 the CBO, is particularly significant. The CBO 00:14:16.299 --> 00:14:19.340 estimated that the work requirements alone would 00:14:19.340 --> 00:14:22.580 lead a staggering 11 million people to lose their 00:14:22.580 --> 00:14:25.019 health coverage. 11 million people, that number. 00:14:25.960 --> 00:14:28.740 It demands a detailed explanation. Why would 00:14:28.740 --> 00:14:30.600 a work requirement cause so many people to lose 00:14:30.600 --> 00:14:32.539 coverage, especially when we know a lot of them 00:14:32.539 --> 00:14:34.840 are already working? The CBO analysis gives a 00:14:34.840 --> 00:14:37.399 very clear reason for this. The primary cause 00:14:37.399 --> 00:14:40.179 of coverage loss is not mass unemployment among 00:14:40.179 --> 00:14:43.320 recipients. It's complex administrative hurdles, 00:14:43.480 --> 00:14:46.259 or what the CBO calls red tape. A lot of those 00:14:46.259 --> 00:14:48.019 11 million people either already work enough 00:14:48.019 --> 00:14:50.340 hours or they actually qualify for an exemption, 00:14:50.539 --> 00:14:52.960 you know, due to a temporary illness or caring 00:14:52.960 --> 00:14:54.519 for a family member. But they can't prove it. 00:14:54.830 --> 00:14:57.409 They can't prove it easily. Proving that status 00:14:57.409 --> 00:15:00.330 every single month, navigating a complex verification 00:15:00.330 --> 00:15:03.009 bureaucracy, providing the right documentation, 00:15:03.230 --> 00:15:06.250 or just simply misunderstanding the new rules, 00:15:06.450 --> 00:15:09.710 it becomes an insurmountable barrier to receiving 00:15:09.710 --> 00:15:12.710 care. It's what some people call paperwork poverty. 00:15:13.049 --> 00:15:15.110 They lose coverage because of administrative 00:15:15.110 --> 00:15:17.669 failure, not because they're unwilling to comply. 00:15:18.490 --> 00:15:21.389 And this requirement seems to fundamentally misunderstand 00:15:21.389 --> 00:15:24.429 the economics of the core population that Medicaid 00:15:24.429 --> 00:15:27.330 serves. It completely ignores the reality of 00:15:27.330 --> 00:15:29.809 the working poor. If you look at the Government 00:15:29.809 --> 00:15:32.830 Accountability Office data, the GAO, it shows 00:15:32.830 --> 00:15:34.889 that roughly 70 percent of Medicaid recipients 00:15:34.889 --> 00:15:38.330 already work at least 35 hours per week. They're 00:15:38.330 --> 00:15:40.740 already working full time. Yes. They're the working 00:15:40.740 --> 00:15:43.159 poor. They qualify because their wages are so 00:15:43.159 --> 00:15:45.240 low they can't afford commercial insurance, even 00:15:45.240 --> 00:15:47.120 if they work full time. So the work requirement 00:15:47.120 --> 00:15:48.980 doesn't actually encourage them to work. It just 00:15:48.980 --> 00:15:51.179 adds this substantial administrative overhead 00:15:51.179 --> 00:15:54.039 and the risk of a catastrophic loss of coverage 00:15:54.039 --> 00:15:56.460 to a population that's already struggling. Beyond 00:15:56.460 --> 00:15:59.679 the work mandates, that 2025 act included a bunch 00:15:59.679 --> 00:16:01.539 of other provisions aimed at limiting eligibility 00:16:01.539 --> 00:16:04.759 and controlling funding. Absolutely. The act 00:16:04.759 --> 00:16:07.980 instituted several immediate changes. It requires 00:16:07.980 --> 00:16:10.110 recipients who are above the federal poverty 00:16:10.110 --> 00:16:12.529 level to pay higher fees for their coverage. 00:16:12.750 --> 00:16:15.309 It mandates newer and more frequent verification 00:16:15.309 --> 00:16:18.090 requirements, and it significantly increases 00:16:18.090 --> 00:16:20.610 the frequency of eligibility checks that states 00:16:20.610 --> 00:16:23.190 have to perform on the ACA expansion population, 00:16:23.490 --> 00:16:26.250 which just adds to that red tape problem. And 00:16:26.250 --> 00:16:28.029 there were some politically charged elements 00:16:28.029 --> 00:16:30.789 as well. Yes. Politically, it also prohibits 00:16:30.789 --> 00:16:32.990 Medicaid from funding any nonprofits that provide 00:16:32.990 --> 00:16:36.009 abortion care. And it bans pharmacy benefit managers, 00:16:36.190 --> 00:16:38.549 PBMs, from using what's called spread pricing. 00:16:38.710 --> 00:16:40.830 That's a practice where the PBM charges the state 00:16:40.830 --> 00:16:43.149 more for a drug than they reimburse the pharmacy. 00:16:43.370 --> 00:16:45.750 And then they just keep the difference. What 00:16:45.750 --> 00:16:48.230 about on the funding side? I know the act targeted 00:16:48.230 --> 00:16:51.049 a specific way that states fund their share of 00:16:51.049 --> 00:16:53.009 the cost, these things called provider taxes. 00:16:53.230 --> 00:16:55.929 Why were those targeted? This is the kind of 00:16:55.929 --> 00:16:57.950 political maneuvering that a well -informed listener 00:16:57.950 --> 00:17:01.370 should really focus on. Many states use these 00:17:01.370 --> 00:17:04.390 provider taxes. their taxes levied on health 00:17:04.390 --> 00:17:06.670 care providers like hospitals or nursing homes, 00:17:06.829 --> 00:17:09.410 and then they use that revenue to cover the state's 00:17:09.410 --> 00:17:11.960 portion of the Medicaid match, the FMAP. Because 00:17:11.960 --> 00:17:14.880 it's easier to tax a hospital than to tax the 00:17:14.880 --> 00:17:17.119 general public. It's politically much easier. 00:17:17.279 --> 00:17:20.059 So by limiting how states can use these provider 00:17:20.059 --> 00:17:23.740 taxes, the 2025 Act makes it significantly harder 00:17:23.740 --> 00:17:26.000 for states to meet their required matching funds 00:17:26.000 --> 00:17:28.640 without, you know, politically unpopular tax 00:17:28.640 --> 00:17:31.059 increases. This puts pressure on them to potentially 00:17:31.059 --> 00:17:34.009 reduce services or coverage levels. And finally, 00:17:34.089 --> 00:17:36.190 the bill prompted all these claims about removing 00:17:36.190 --> 00:17:39.069 undocumented immigrants from Medicaid. What does 00:17:39.069 --> 00:17:41.670 the nonpartisan data say about that specific 00:17:41.670 --> 00:17:45.490 element? The claims were largely misleading when 00:17:45.490 --> 00:17:47.890 it comes to federal Medicaid. Undocumented immigrants 00:17:47.890 --> 00:17:50.410 are already ineligible for full federal Medicaid 00:17:50.410 --> 00:17:53.029 benefits, with very limited exceptions for things 00:17:53.029 --> 00:17:55.589 like emergency medical care. Many of them access 00:17:55.589 --> 00:17:57.809 state -funded health programs that operate separately 00:17:57.809 --> 00:17:59.869 from federal Medicaid. So what did the bill actually 00:17:59.869 --> 00:18:02.720 do? The CBO analysis found that the new federal 00:18:02.720 --> 00:18:05.599 provisions primarily risked causing an estimated 00:18:05.599 --> 00:18:08.839 1 .4 million people to lose state -level health 00:18:08.839 --> 00:18:11.660 coverage. This includes undocumented immigrants, 00:18:11.900 --> 00:18:14.720 but it's by effectively pushing states to cut 00:18:14.720 --> 00:18:18.039 those non -federal, state -funded programs. So 00:18:18.039 --> 00:18:20.319 the net effect is still a loss of coverage, just 00:18:20.319 --> 00:18:22.579 not necessarily a purge from the federal Medicaid 00:18:22.579 --> 00:18:25.700 system itself. Okay, so if the policy battles 00:18:25.700 --> 00:18:28.579 of the ACA and the 2025 Act are the big political 00:18:28.579 --> 00:18:31.140 earthquakes, then the actual application process 00:18:31.140 --> 00:18:33.759 for an individual is like navigating a bureaucratic 00:18:33.759 --> 00:18:37.279 labyrinth of technical and financial rules. Let's 00:18:37.279 --> 00:18:39.279 break down the sheer complexity of figuring out 00:18:39.279 --> 00:18:41.880 who actually qualifies because it varies so widely 00:18:41.880 --> 00:18:43.759 depending on where you live and why you need 00:18:43.759 --> 00:18:45.779 help. The complexity starts with this realization 00:18:45.779 --> 00:18:48.680 that outside of the ACA expansion, eligibility 00:18:48.680 --> 00:18:51.500 is fundamentally categorical, not just based 00:18:51.500 --> 00:18:53.779 on income. So you have to fit into a box first. 00:18:53.920 --> 00:18:56.059 You have to be a low -income child, a pregnant 00:18:56.059 --> 00:18:58.119 woman, a disabled person, a low -income senior, 00:18:58.299 --> 00:19:01.180 or a parent of an eligible child. The system 00:19:01.180 --> 00:19:03.079 has to see you in one of those categories before 00:19:03.079 --> 00:19:06.109 it even looks at your income. Precisely. If you 00:19:06.109 --> 00:19:09.250 are a non -disabled, non -pregnant adult without 00:19:09.250 --> 00:19:11.490 dependent children, no matter how poor you were, 00:19:11.630 --> 00:19:14.329 you historically did not fit a category, and 00:19:14.329 --> 00:19:17.450 therefore you were ineligible. The ACA expansion 00:19:17.450 --> 00:19:19.650 was so revolutionary because it created a brand 00:19:19.650 --> 00:19:23.869 new category, low -income adults, period. Regardless 00:19:23.869 --> 00:19:26.710 of parental or disability status, it simplified 00:19:26.710 --> 00:19:29.349 the process for millions. And even the income 00:19:29.349 --> 00:19:31.349 tests are dramatically different depending on 00:19:31.349 --> 00:19:33.670 the category. We have two fundamentally different 00:19:33.670 --> 00:19:37.589 systems at play. MAGI and the SSI rules. And 00:19:37.589 --> 00:19:39.569 these systems really reflect the philosophical 00:19:39.569 --> 00:19:41.529 divide between that new expansion population 00:19:41.529 --> 00:19:44.970 and the traditional eligibility groups. The ACA 00:19:44.970 --> 00:19:46.769 expansion uses what's called modified adjusted 00:19:46.769 --> 00:19:50.089 gross income or MBGI. And this is a crucial simplification 00:19:50.089 --> 00:19:52.170 because it standardizes how income is calculated. 00:19:52.410 --> 00:19:54.849 It aligns with tax rules. And this is the big 00:19:54.849 --> 00:19:57.329 one. It explicitly prohibits the use of asset 00:19:57.329 --> 00:19:59.650 or resource tests. So it's just about your income. 00:19:59.829 --> 00:20:01.450 It's a clean income metric. It makes the enrollment 00:20:01.450 --> 00:20:03.890 process so much smoother. But if you're applying 00:20:03.890 --> 00:20:06.049 under one of those traditional categories, if 00:20:06.049 --> 00:20:08.089 you're a low income senior or a disabled person 00:20:08.089 --> 00:20:11.109 looking for long term care, you face a different, 00:20:11.269 --> 00:20:14.910 much more invasive reality. Right. Those groups, 00:20:14.990 --> 00:20:17.069 the ones seeking help for the most expensive 00:20:17.069 --> 00:20:20.650 kinds of care, they still use eligibility criteria 00:20:20.650 --> 00:20:24.200 based on supplemental security income or. SSI 00:20:24.200 --> 00:20:27.960 rules. And these rules do include very stringent 00:20:27.960 --> 00:20:30.579 asset tests. It's the difference between just 00:20:30.579 --> 00:20:34.079 showing a paycheck, which is MAGI, and actively 00:20:34.079 --> 00:20:36.140 having to prove financial destitution, which 00:20:36.140 --> 00:20:38.720 is SSI. So for traditional seniors and people 00:20:38.720 --> 00:20:40.980 seeking long -term care, there's an asset test. 00:20:41.220 --> 00:20:43.700 How low is that limit? Typically, it limits your 00:20:43.700 --> 00:20:46.079 accountable resources to around $2 ,000 for an 00:20:46.079 --> 00:20:48.880 individual in most states. $2 ,000. So if I'm 00:20:48.880 --> 00:20:51.059 understanding this correctly, for a traditional 00:20:51.059 --> 00:20:53.720 applicant, like a senior, It's not just about 00:20:53.720 --> 00:20:55.680 their income. They have to actively impoverish 00:20:55.680 --> 00:20:57.299 themselves. They have to spend down their entire 00:20:57.299 --> 00:20:59.579 life savings before they can qualify for help. 00:20:59.759 --> 00:21:03.299 That is the grim reality of the SSI model. And 00:21:03.299 --> 00:21:05.519 the asset test is where the complexity truly 00:21:05.519 --> 00:21:07.900 spirals, especially when you're dealing with 00:21:07.900 --> 00:21:10.579 long -term care planning. This brings us to the 00:21:10.579 --> 00:21:14.259 infamous five -year look -back period. Okay, 00:21:14.299 --> 00:21:17.180 what is the purpose of this policy? It was established 00:21:17.180 --> 00:21:20.529 by the Deficit Reduction Act of 2005. It's designed 00:21:20.529 --> 00:21:24.549 to prevent more affluent individuals from transferring 00:21:24.549 --> 00:21:26.750 their assets, giving away their money or their 00:21:26.750 --> 00:21:29.250 house, just before they apply for Medicaid nursing 00:21:29.250 --> 00:21:32.210 home coverage. If you transfer assets without 00:21:32.210 --> 00:21:34.269 getting fair market value in return within the 00:21:34.269 --> 00:21:36.890 five years before you apply, you incur a penalty 00:21:36.890 --> 00:21:39.329 period of ineligibility. Can you walk us through 00:21:39.329 --> 00:21:41.930 how that penalty period is calculated? Sure. 00:21:41.950 --> 00:21:44.269 The penalty is calculated by taking the total 00:21:44.269 --> 00:21:46.329 amount of assets you gifted away and dividing 00:21:46.329 --> 00:21:48.549 it by the average monthly cost of nursing home 00:21:48.549 --> 00:21:50.960 care in your state. The number you get is the 00:21:50.960 --> 00:21:52.759 exact number of months that you are ineligible 00:21:52.759 --> 00:21:54.759 for Medicaid assistance. Okay, so let's use an 00:21:54.759 --> 00:21:57.359 example. If an individual gifted, say, $60 ,000 00:21:57.359 --> 00:21:59.619 to their kids, and the average nursing home cost 00:21:59.619 --> 00:22:02.140 in their area is $6 ,000 a month. That results 00:22:02.140 --> 00:22:05.259 in a 10 -month penalty period. $60 ,000 divided 00:22:05.259 --> 00:22:08.640 by $6 ,000 is $10 ,000. But here is the absolutely 00:22:08.640 --> 00:22:11.440 devastating catch. This is the detail that creates 00:22:11.440 --> 00:22:14.859 a severe human crisis. The penalty period doesn't 00:22:14.859 --> 00:22:17.319 begin until a person has already spent down all 00:22:17.319 --> 00:22:19.599 the remaining assets and drotched below that 00:22:19.599 --> 00:22:21.700 strict Medicaid asset limit, which is usually 00:22:21.700 --> 00:22:24.980 $2 ,000. Wait, so the senior has to first spend 00:22:24.980 --> 00:22:26.779 all their other money, the money they didn't 00:22:26.779 --> 00:22:29.660 give away, to hit that $2 ,000 threshold. And 00:22:29.660 --> 00:22:32.079 only then does the 10 -month clock start ticking, 00:22:32.180 --> 00:22:34.819 so they are simultaneously impoverished and ineligible 00:22:34.819 --> 00:22:38.079 for care. Exactly. The policy leaves elders in 00:22:38.079 --> 00:22:40.599 this profound state of destitution. They have 00:22:40.599 --> 00:22:43.240 zero savings left, yet they are still not eligible 00:22:43.240 --> 00:22:45.180 for Medicaid help for a set number of months. 00:22:45.339 --> 00:22:47.579 They're left with no way to pay the nursing home 00:22:47.579 --> 00:22:50.099 bill. It creates immense hardship for families 00:22:50.099 --> 00:22:52.480 and for the providers. It's a policy designed 00:22:52.480 --> 00:22:55.140 to discourage asset transfer. But the mechanical 00:22:55.140 --> 00:22:57.359 nature of how it works often means the sickest 00:22:57.359 --> 00:22:59.779 and most vulnerable are left uninsured and broke 00:22:59.779 --> 00:23:02.240 during the exact period they need care the most. 00:23:02.440 --> 00:23:04.660 OK, so let's move from who qualifies to who actually 00:23:04.660 --> 00:23:07.339 treats them. The second major challenge for Medicaid 00:23:07.339 --> 00:23:10.579 recipients is just getting. access to care providers. 00:23:10.779 --> 00:23:13.519 And this seems to boil down entirely to the financial 00:23:13.519 --> 00:23:16.940 model. Very low reimbursement rates. This is 00:23:16.940 --> 00:23:19.460 the operational reality of Medicaid, day in and 00:23:19.460 --> 00:23:22.599 day out. In general, Medicaid plans pay providers 00:23:22.599 --> 00:23:25.059 significantly less than either Medicare or commercial 00:23:25.059 --> 00:23:28.460 insurers pay for the exact same services. The 00:23:28.460 --> 00:23:31.390 financial gap is really stark. On average, providers 00:23:31.390 --> 00:23:34.170 only get about 67 % of Medicare rates for primary 00:23:34.170 --> 00:23:37.690 care and maybe 78 % of Medicare rates for other 00:23:37.690 --> 00:23:40.089 services. Which immediately sets up a clear financial 00:23:40.089 --> 00:23:42.849 hierarchy. It puts Medicaid patients at the bottom 00:23:42.849 --> 00:23:45.130 of the priority list compared to other insured 00:23:45.130 --> 00:23:47.630 people. It leads directly to lower provider participation 00:23:47.630 --> 00:23:50.349 rates in Medicaid. It just makes business sense. 00:23:50.589 --> 00:23:52.789 Why would a highly specialized cardiologist, 00:23:52.829 --> 00:23:55.230 for example, accept a Medicaid payment at 67 00:23:55.230 --> 00:23:57.589 % of the going rate when they could get substantially 00:23:57.589 --> 00:24:00.130 more by treating a Medicare? a private patient. 00:24:00.309 --> 00:24:02.549 They have a business to run, and Medicaid often 00:24:02.549 --> 00:24:04.690 becomes the payer of last resort, especially 00:24:04.690 --> 00:24:07.309 in specialties. The ACA actually tried to fix 00:24:07.309 --> 00:24:09.369 this for a little while, didn't it? It did. They 00:24:09.369 --> 00:24:11.809 recognized this crisis in primary care access, 00:24:12.009 --> 00:24:14.809 so a federally funded provision in the ACA temporarily 00:24:14.809 --> 00:24:17.890 increased Medicaid payments in 2013 and 2014. 00:24:18.569 --> 00:24:21.069 It brought them up to 100 % of the equivalent 00:24:21.069 --> 00:24:23.750 Medicare rates, specifically for primary care. 00:24:24.230 --> 00:24:26.609 The goal was to flood the system with accessible 00:24:26.609 --> 00:24:29.910 doctors. And what happened? Unfortunately, once 00:24:29.910 --> 00:24:31.730 the federal mandate and the funding expired, 00:24:32.049 --> 00:24:34.769 most states just chose not to continue the provision. 00:24:35.069 --> 00:24:37.609 They let the primary care rates slide right back 00:24:37.609 --> 00:24:41.170 down to the lower pre -ACA levels. And beyond 00:24:41.170 --> 00:24:43.609 the gap between Medicaid and Medicare, the payments 00:24:43.609 --> 00:24:46.049 vary dramatically, even between neighboring states. 00:24:46.529 --> 00:24:48.769 This just highlights that tension we talked about 00:24:48.769 --> 00:24:51.029 earlier, how state latitude determines the actual 00:24:51.029 --> 00:24:53.490 quality of care a person gets. The state -specific 00:24:53.490 --> 00:24:55.950 variances are huge. It really reflects that 50 00:24:55.950 --> 00:24:58.690 different programs model. The data shows that 00:24:58.690 --> 00:25:00.869 the cost and time involved in complex procedures 00:25:00.869 --> 00:25:03.480 can depend heavily on your zip code. Take surgery, 00:25:03.559 --> 00:25:06.000 for instance. In 2013, the average difference 00:25:06.000 --> 00:25:08.359 in reimbursement for 10 common orthopedic procedures 00:25:08.359 --> 00:25:11.140 between New Jersey and Delaware was over $3 ,000. 00:25:11.440 --> 00:25:14.400 A $3 ,000 difference just for crossing a state 00:25:14.400 --> 00:25:17.579 line. Exactly. And these large discrepancies 00:25:17.579 --> 00:25:20.579 in payment affect not just patient access, but 00:25:20.579 --> 00:25:23.160 they affect where doctors decide to locate their 00:25:23.160 --> 00:25:25.859 practices and whether they choose to settle in 00:25:25.859 --> 00:25:27.819 a state that has a high Medicaid population. 00:25:28.539 --> 00:25:31.339 Let's shift our focus now entirely to the services 00:25:31.339 --> 00:25:33.460 that Medicaid offers, the services that make 00:25:33.460 --> 00:25:36.099 it such a vital safety net, especially because 00:25:36.099 --> 00:25:38.339 they cover areas where Medicare and private insurance 00:25:38.339 --> 00:25:41.380 leave these gaping holes. The breadth of Medicaid 00:25:41.380 --> 00:25:44.299 coverage is why it is so unique and essential. 00:25:44.480 --> 00:25:46.799 It's especially critical for the population that 00:25:46.799 --> 00:25:51.089 we call dual eligibles or MediMedis. Who falls 00:25:51.089 --> 00:25:53.750 into that dual eligibility category, and how 00:25:53.750 --> 00:25:55.930 does Medicaid complement the coverage they already 00:25:55.930 --> 00:25:58.289 have? These are people who are eligible for both 00:25:58.289 --> 00:26:01.109 Medicare and Medicaid. It's typically low -income 00:26:01.109 --> 00:26:03.809 seniors and younger adults with significant disabilities. 00:26:03.950 --> 00:26:06.089 We're talking about roughly 9 million people 00:26:06.089 --> 00:26:09.369 as of 2013. Medicare covers most of their acute 00:26:09.369 --> 00:26:11.890 hospital and medical care, but Medicaid steps 00:26:11.890 --> 00:26:14.109 in to cover the essential services that Medicare 00:26:14.109 --> 00:26:16.430 generally refuses to pay for. Like what? Well, 00:26:16.549 --> 00:26:19.069 prescription drug costs. For one, though, that 00:26:19.069 --> 00:26:21.549 changed a bit with Medicare Part D. But most 00:26:21.549 --> 00:26:24.990 critically, long -term care. And long -term services 00:26:24.990 --> 00:26:27.869 and supports, or LTSS, that is the single biggest 00:26:27.869 --> 00:26:30.269 area where Medicaid provides essential coverage 00:26:30.269 --> 00:26:32.890 that Medicare doesn't. This is the massive, hidden 00:26:32.890 --> 00:26:35.789 social cost of aging in the U .S. That is correct. 00:26:36.440 --> 00:26:38.819 And this is why that aged and disabled group 00:26:38.819 --> 00:26:42.299 drives half the program spending. Medicaid covers 00:26:42.299 --> 00:26:44.859 nursing home care and home and community -based 00:26:44.859 --> 00:26:47.000 services for low -income individuals who have 00:26:47.000 --> 00:26:50.119 minimal assets. This benefit is explicitly not 00:26:50.119 --> 00:26:52.339 covered by Medicare or most commercial insurance, 00:26:52.640 --> 00:26:54.680 which usually only covers short -term skilled 00:26:54.680 --> 00:26:57.220 nursing care after a hospitalization. What are 00:26:57.220 --> 00:26:59.059 the numbers on that? They're massive. Of the 00:26:59.059 --> 00:27:01.960 7 .7 million Americans who used LTSS in 2020, 00:27:02.259 --> 00:27:04.799 about 5 .6 million of them were covered by Medicaid. 00:27:05.470 --> 00:27:08.049 It is the overwhelming primary payer for the 00:27:08.049 --> 00:27:10.150 vast majority of long term custodial care in 00:27:10.150 --> 00:27:12.150 the United States. The social significance of 00:27:12.150 --> 00:27:14.609 that is immense. Without Medicaid filling this 00:27:14.609 --> 00:27:16.970 gap, the burden of long term care would fall 00:27:16.970 --> 00:27:19.490 entirely on families and individuals. It would 00:27:19.490 --> 00:27:21.569 financially destroy them and create massive strains 00:27:21.569 --> 00:27:25.730 on family caregivers. Precisely. Medicaid serves 00:27:25.730 --> 00:27:27.769 as the functional solution for the long -term 00:27:27.769 --> 00:27:30.630 aging crisis in the U .S. It relieves catastrophic 00:27:30.630 --> 00:27:33.170 financial pressure from families, but the program 00:27:33.170 --> 00:27:35.109 itself then has to carry the entire financial 00:27:35.109 --> 00:27:38.329 weight of that $18 ,000 plus per person annual 00:27:38.329 --> 00:27:40.490 cost we talked about. Moving to another critical 00:27:40.490 --> 00:27:43.250 area, Medicaid is also the largest single source 00:27:43.250 --> 00:27:45.170 of funding for mental health services in the 00:27:45.170 --> 00:27:47.450 U .S. This is a lesser known but absolutely critical 00:27:47.450 --> 00:27:50.529 role. Medicaid covers about 15 million adults 00:27:50.529 --> 00:27:53.130 with mental illness. That makes it the largest 00:27:53.130 --> 00:27:55.569 single payer for behavioral health services in 00:27:55.569 --> 00:27:58.650 the entire country. And it covers a broad and 00:27:58.650 --> 00:28:01.490 essential range of services. inpatient hospitalization, 00:28:01.710 --> 00:28:04.650 intensive outpatient counseling, mobile crisis 00:28:04.650 --> 00:28:07.589 services, even peer support programs, which are 00:28:07.589 --> 00:28:09.809 so vital for recovery. And there's a federal 00:28:09.809 --> 00:28:12.230 law that actually mandates equality or parity 00:28:12.230 --> 00:28:14.930 in coverage for mental health, right? Yes. The 00:28:14.930 --> 00:28:16.990 Mental Health Parity and Addiction Equity Act. 00:28:17.109 --> 00:28:19.450 It requires that Medicaid managed care plans 00:28:19.450 --> 00:28:21.769 provide mental health benefits that are equal 00:28:21.769 --> 00:28:24.210 to their physical health benefits. And states 00:28:24.210 --> 00:28:27.369 that expanded Medicaid under the ACA also saw 00:28:27.369 --> 00:28:29.490 corresponding improvements in access to mental 00:28:29.490 --> 00:28:32.250 health care and continuity of treatment. For 00:28:32.250 --> 00:28:35.869 example, a 2024 analysis showed Medicaid covered 00:28:35.869 --> 00:28:38.869 about 41 % of all psychiatric inpatients in hospitals. 00:28:39.190 --> 00:28:41.769 That just demonstrates its central role in acute 00:28:41.769 --> 00:28:44.109 care for mental illness. Okay, finally, let's 00:28:44.109 --> 00:28:46.069 talk about dental care, which seems to perfectly 00:28:46.069 --> 00:28:48.250 illustrate the state -level variation and the 00:28:48.250 --> 00:28:50.369 access challenges we've been discussing. Dental 00:28:50.369 --> 00:28:52.509 coverage is the perfect example of the program's 00:28:52.509 --> 00:28:56.029 bifurcated nature. For children under 21, dental 00:28:56.029 --> 00:28:58.650 care is a mandatory federal benefit. It's under 00:28:58.650 --> 00:29:00.970 the Early and Periodic Screening, Diagnostic 00:29:00.970 --> 00:29:04.690 and Treatment, or EPSDT mandate. And this comprehensive 00:29:04.690 --> 00:29:07.289 coverage includes pain relief, restorative care, 00:29:07.450 --> 00:29:09.769 and maintenance for dental health. But for adults 00:29:09.769 --> 00:29:12.990 21 and older, it's a policy lottery. It is entirely 00:29:12.990 --> 00:29:16.309 optional for states. Many states simply do not 00:29:16.309 --> 00:29:18.769 offer comprehensive adult dental coverage beyond, 00:29:18.890 --> 00:29:22.289 say, an emergency extraction. And even where 00:29:22.289 --> 00:29:25.250 the coverage exists, utilization is incredibly 00:29:25.250 --> 00:29:28.740 low. Why is that? Given the great need for dental 00:29:28.740 --> 00:29:31.099 care among the low -income population, where 00:29:31.099 --> 00:29:33.099 access to preventive care has often been non 00:29:33.099 --> 00:29:35.920 -existent, why is the utilization rate so poor 00:29:35.920 --> 00:29:38.400 even in states that offer it? It circles right 00:29:38.400 --> 00:29:40.859 back to that provider participation problem we 00:29:40.859 --> 00:29:44.240 discussed. Dentists cite the low reimbursement 00:29:44.240 --> 00:29:46.500 rates and the complex administrative requirements 00:29:46.500 --> 00:29:48.740 as the primary reasons they don't participate. 00:29:49.279 --> 00:29:51.759 In some areas, less than half of active private 00:29:51.759 --> 00:29:54.519 dentists participate in Medicaid. This creates 00:29:54.519 --> 00:29:56.920 these significant geographic and time -based 00:29:56.920 --> 00:29:59.099 barriers to access, even for children who are 00:29:59.099 --> 00:30:01.660 legally entitled to comprehensive care. A benefit 00:30:01.660 --> 00:30:03.619 on paper is worthless if there's no provider 00:30:03.619 --> 00:30:06.380 to deliver it. So we've explored the scale, the 00:30:06.380 --> 00:30:09.480 politics, the labyrinthine rules. Now let's ground 00:30:09.480 --> 00:30:11.640 this whole discussion in the hard empirical evidence. 00:30:11.759 --> 00:30:13.599 What actually happens when people gain Medicaid 00:30:13.599 --> 00:30:16.220 coverage? Does the cost justify the investment? 00:30:16.650 --> 00:30:18.890 If we move past the political opinions and focus 00:30:18.890 --> 00:30:21.450 solely on the empirical studies, the findings 00:30:21.450 --> 00:30:25.470 are overwhelmingly positive, especially when 00:30:25.470 --> 00:30:27.170 you look at long term outcomes and financial 00:30:27.170 --> 00:30:29.809 security. Let's start with the most impactful 00:30:29.809 --> 00:30:33.130 result, mortality reduction. The evidence seems 00:30:33.130 --> 00:30:35.990 to show Medicaid is literally a life saving investment. 00:30:36.309 --> 00:30:39.309 The evidence is conclusive. Multiple peer reviewed 00:30:39.309 --> 00:30:41.430 studies link the Medicaid expansion under the 00:30:41.430 --> 00:30:43.910 ACA to a substantial reduction in mortality. 00:30:44.460 --> 00:30:46.940 And that's driven primarily by reductions in 00:30:46.940 --> 00:30:48.900 disease -related deaths because people are able 00:30:48.900 --> 00:30:51.740 to access necessary timely care. And this benefit 00:30:51.740 --> 00:30:54.400 isn't new. Not at all. It extends throughout 00:30:54.400 --> 00:30:56.240 the life cycle, reaching all the way back to 00:30:56.240 --> 00:30:58.960 the program's origins. Studies on the initial 00:30:58.960 --> 00:31:01.440 implementation of Medicaid back in the 60s and 00:31:01.440 --> 00:31:04.440 70s showed it dramatically reduced infant and 00:31:04.440 --> 00:31:07.220 child mortality, with a particularly steep decline 00:31:07.220 --> 00:31:09.900 for non -white children who previously had almost 00:31:09.900 --> 00:31:12.359 no access to consistent care. And the health 00:31:12.359 --> 00:31:14.400 effects seen in childhood, they continue to generate 00:31:14.400 --> 00:31:17.559 dividends for decades. Yes. This is one of the 00:31:17.559 --> 00:31:19.880 most compelling findings from an economic standpoint. 00:31:20.380 --> 00:31:23.339 Early childhood Medicaid eligibility reduces 00:31:23.339 --> 00:31:26.200 mortality and disability up to 50 years later. 00:31:26.680 --> 00:31:29.359 It's also associated with a reduced incidence 00:31:29.359 --> 00:31:32.400 of advanced stage breast cancer, which implies 00:31:32.400 --> 00:31:35.220 that the increased access leads to earlier detection 00:31:35.220 --> 00:31:38.460 and therefore higher survival rates. The investment 00:31:38.460 --> 00:31:40.380 really pays off over the course of a lifetime. 00:31:40.920 --> 00:31:43.359 This sounds more like a societal investment than 00:31:43.359 --> 00:31:45.359 just an expense. Does the government actually 00:31:45.359 --> 00:31:47.720 recoup the financial cost of covering a child 00:31:47.720 --> 00:31:50.500 in the long run? Absolutely. This is the powerful 00:31:50.500 --> 00:31:52.799 economic argument that often gets lost to the 00:31:52.799 --> 00:31:55.539 political noise. Studies show that because recipients 00:31:55.539 --> 00:31:57.839 of childhood Medicaid are significantly healthier 00:31:57.839 --> 00:32:00.500 later in life, they are more likely to be employed, 00:32:00.740 --> 00:32:02.880 they earn higher wages, and they're significantly 00:32:02.880 --> 00:32:05.299 less likely to need disability transfer programs 00:32:05.299 --> 00:32:08.279 like SSI as adults. So the government saves money 00:32:08.279 --> 00:32:10.559 later on? It saves money and it makes money. 00:32:10.890 --> 00:32:12.849 The government recoups its initial investment 00:32:12.849 --> 00:32:15.730 through savings on later benefit payments and, 00:32:15.829 --> 00:32:18.369 crucially, through greater lifetime tax revenue. 00:32:18.869 --> 00:32:21.529 It earns a discounted annual return of between 00:32:21.529 --> 00:32:24.990 2 % and 7 % on the original cost of that childhood 00:32:24.990 --> 00:32:27.809 coverage. The program literally pays for itself, 00:32:28.049 --> 00:32:30.390 not just in human lives saved, but in fiscal 00:32:30.390 --> 00:32:33.410 returns. Beyond survival and long -term tax benefits, 00:32:33.789 --> 00:32:36.569 Medicaid has a huge and immediate impact on financial 00:32:36.569 --> 00:32:38.849 stability. The evidence on financial security 00:32:38.849 --> 00:32:42.019 is robust, and it's immediate. The ACA Medicaid 00:32:42.019 --> 00:32:44.740 expansion reduced unpaid medical bills sent to 00:32:44.740 --> 00:32:47.960 collection by $3 .4 billion in just its first 00:32:47.960 --> 00:32:50.920 two years. It improved credit scores, it prevented 00:32:50.920 --> 00:32:53.240 new delinquencies, and it reduced the need for 00:32:53.240 --> 00:32:55.900 bankruptcy. And furthermore, the expansion reduced 00:32:55.900 --> 00:32:58.200 rates of poverty and severe food insecurity in 00:32:58.200 --> 00:33:00.940 certain states. It provides this critical, foundational 00:33:00.940 --> 00:33:03.359 level of financial security that allows people 00:33:03.359 --> 00:33:05.680 to focus on employment and stability rather than 00:33:05.680 --> 00:33:07.849 drowning in medical debt. Which brings us back, 00:33:07.930 --> 00:33:10.869 frustratingly, to that 2025 work requirement 00:33:10.869 --> 00:33:13.990 controversy. If Medicaid provides this proven 00:33:13.990 --> 00:33:16.869 financial stability, how can supporters possibly 00:33:16.869 --> 00:33:20.210 justify imposing a requirement that seems designed 00:33:20.210 --> 00:33:22.809 to destabilize this population? Well, if we look 00:33:22.809 --> 00:33:25.250 at the real world evidence from when work requirements 00:33:25.250 --> 00:33:27.569 were tried in states like Arkansas, the results 00:33:27.569 --> 00:33:29.890 directly contradict the policy's stated goal. 00:33:30.400 --> 00:33:32.660 Studies found the requirements led to a mass 00:33:32.660 --> 00:33:35.339 increase in uninsured individuals, soaring medical 00:33:35.339 --> 00:33:37.819 debt, and people delaying necessary care and 00:33:37.819 --> 00:33:40.480 medications. But did it get more people to work? 00:33:40.819 --> 00:33:43.440 Crucially, they found no significant impact on 00:33:43.440 --> 00:33:45.940 employment levels. The outcome was a catastrophic 00:33:45.940 --> 00:33:48.660 loss of coverage and increased financial distress 00:33:48.660 --> 00:33:51.019 for the working poor, not an increase in the 00:33:51.019 --> 00:33:53.599 workforce. The political message of personal 00:33:53.599 --> 00:33:56.400 responsibility was achieved, but the actual policy 00:33:56.400 --> 00:33:59.259 outcome was simply hardship. If we connect this 00:33:59.259 --> 00:34:01.660 to the bigger picture, Medicaid's influence extends 00:34:01.660 --> 00:34:04.140 far beyond the individual patient. It stretches 00:34:04.140 --> 00:34:07.079 into the economy and the political sphere. Let's 00:34:07.079 --> 00:34:09.039 look at the financial impact on hospitals, which 00:34:09.039 --> 00:34:11.440 so often struggle with the cost of uncompensated 00:34:11.440 --> 00:34:14.239 care. The effects on hospitals are not uniform, 00:34:14.420 --> 00:34:17.420 but they are incredibly significant. Crucially, 00:34:17.579 --> 00:34:20.300 Medicaid expansion boosted the revenue in the 00:34:20.300 --> 00:34:23.280 operating margins of rural hospitals. These are 00:34:23.280 --> 00:34:25.420 facilities that often struggle the most with 00:34:25.420 --> 00:34:29.079 high rates of uncompensated care. Gaining a reliable 00:34:29.079 --> 00:34:31.639 payer, even at the lower Medicaid rates, was 00:34:31.639 --> 00:34:33.699 a financial lifeline that prevented a lot of 00:34:33.699 --> 00:34:36.420 rural hospital closures. But the effect was different 00:34:36.420 --> 00:34:39.840 for larger urban facilities. It was mixed. The 00:34:39.840 --> 00:34:42.239 expansion had little to no financial impact on 00:34:42.239 --> 00:34:45.000 small urban hospitals. And surprisingly, it led 00:34:45.000 --> 00:34:47.380 to declines in operating margins for large urban 00:34:47.380 --> 00:34:50.510 hospitals. This outcome is likely tied to the 00:34:50.510 --> 00:34:53.570 patient mix. Large hospitals saw a shift of previously 00:34:53.570 --> 00:34:56.070 commercially insured or privately covered individuals 00:34:56.070 --> 00:34:58.710 who might have been paying high deductibles into 00:34:58.710 --> 00:35:01.110 the lower paying Medicaid pool. So while it was 00:35:01.110 --> 00:35:03.309 great for the patient, it affected the hospital's 00:35:03.309 --> 00:35:05.590 overall revenue mix. What's really fascinating 00:35:05.590 --> 00:35:07.949 to me is the data that links health insurance 00:35:07.949 --> 00:35:10.969 to reduced crime rates. That's a profound connection 00:35:10.969 --> 00:35:13.690 that few people would make intuitively. It is 00:35:13.690 --> 00:35:16.769 a profound finding, and it demonstrates the holistic 00:35:16.769 --> 00:35:19.170 societal best... benefit of stabilizing a population. 00:35:19.710 --> 00:35:22.030 Studies found that Medicaid expansion reduced 00:35:22.030 --> 00:35:25.170 crime rates, and researchers propose that the 00:35:25.170 --> 00:35:28.750 mechanism involves two main factors. First, increased 00:35:28.750 --> 00:35:31.110 economic security stabilizes individuals and 00:35:31.110 --> 00:35:33.150 families, which reduces financially motivated 00:35:33.150 --> 00:35:36.289 crime. And second, greater access to substance 00:35:36.289 --> 00:35:38.690 abuse or behavioral disorder treatment helps 00:35:38.690 --> 00:35:40.889 address the underlying causes of criminality. 00:35:41.260 --> 00:35:43.519 And this effect also starts in childhood. It 00:35:43.519 --> 00:35:46.079 does. Extending that timeline, studies found 00:35:46.079 --> 00:35:48.659 that Medicaid eligibility during childhood actually 00:35:48.659 --> 00:35:50.900 reduced the likelihood of criminality in early 00:35:50.900 --> 00:35:53.340 adulthood. It suggests that this early intervention 00:35:53.340 --> 00:35:55.800 has massive generational public safety benefits. 00:35:56.139 --> 00:35:58.340 And finally, access to basic health care seems 00:35:58.340 --> 00:36:01.079 to increase political engagement and civic participation. 00:36:01.639 --> 00:36:04.139 Absolutely. Medicaid enrollment is statistically 00:36:04.139 --> 00:36:06.280 linked to an increase in political participation, 00:36:06.639 --> 00:36:09.360 specifically measured in terms of voter registration 00:36:09.360 --> 00:36:12.630 and the turnout. When people's basic health and 00:36:12.630 --> 00:36:14.750 financial needs are met, they're more likely 00:36:14.750 --> 00:36:17.369 to have the stability, the time, and the resources 00:36:17.369 --> 00:36:20.550 to engage as active citizens. This connection 00:36:20.550 --> 00:36:22.630 suggests that providing health care can actually 00:36:22.630 --> 00:36:24.809 be a mechanism for increasing civic involvement 00:36:24.809 --> 00:36:27.750 within underserved populations. Okay, here's 00:36:27.750 --> 00:36:29.829 where it gets really interesting. The Oregon 00:36:29.829 --> 00:36:32.920 Medicaid Health Experiment. This is maybe the 00:36:32.920 --> 00:36:34.980 most famous and ironically the most frequently 00:36:34.980 --> 00:36:37.059 misused piece of research in the entire health 00:36:37.059 --> 00:36:39.460 care debate. We need to look closely at its methodology 00:36:39.460 --> 00:36:42.119 and its complex, nuanced findings. The Oregon 00:36:42.119 --> 00:36:44.639 experiment is so significant because it provides 00:36:44.639 --> 00:36:47.900 a scientific gold standard for measurement. Back 00:36:47.900 --> 00:36:50.460 in 2008, Oregon had limited Medicaid funding, 00:36:50.619 --> 00:36:53.960 so they used a randomized lottery system to select 00:36:53.960 --> 00:36:57.219 10 ,000 lower -income people for coverage. And 00:36:57.219 --> 00:36:59.780 that randomization eliminated selection bias. 00:37:00.679 --> 00:37:02.880 The researchers knew that the people who won 00:37:02.880 --> 00:37:05.019 the lottery were statistically identical to those 00:37:05.019 --> 00:37:07.579 who lost it. This allowed them to accurately 00:37:07.579 --> 00:37:10.039 compare the effects of having insurance versus 00:37:10.039 --> 00:37:12.809 being uninsured. And the controversial finding, 00:37:12.909 --> 00:37:14.710 the one that initially dominated all the headlines, 00:37:14.929 --> 00:37:17.289 was the negative data point that opponents of 00:37:17.289 --> 00:37:19.809 expansion love to cite. That's right. In the 00:37:19.809 --> 00:37:21.550 first two years of the study, researchers found 00:37:21.550 --> 00:37:23.849 no significant improvements in measured physical 00:37:23.849 --> 00:37:26.769 health outcomes. They looked at key biomarkers, 00:37:26.829 --> 00:37:28.809 things like blood pressure, cholesterol levels, 00:37:28.989 --> 00:37:31.409 blood sugar control, and they found no measurable 00:37:31.409 --> 00:37:33.449 statistical difference between the insured group 00:37:33.449 --> 00:37:36.570 and the uninsured group. And that finding was 00:37:36.570 --> 00:37:38.809 seized upon by fiscal conservatives as proof 00:37:38.809 --> 00:37:40.949 that these expensive government programs weren't 00:37:40.949 --> 00:37:43.500 worth it. But that was focusing solely on short 00:37:43.500 --> 00:37:47.380 -term physical biomarkers. The study's true value, 00:37:47.559 --> 00:37:49.980 the part that proponents cite, came from the 00:37:49.980 --> 00:37:52.639 crucial positive findings that proved the program's 00:37:52.639 --> 00:37:55.679 immediate value in other fundamental ways. Exactly. 00:37:55.980 --> 00:37:58.659 While acute physical health markers might take 00:37:58.659 --> 00:38:01.579 much longer than two years to change, the program 00:38:01.579 --> 00:38:04.480 was immediately valuable in three key areas that 00:38:04.480 --> 00:38:06.980 fundamentally improved people's lives. First, 00:38:07.199 --> 00:38:10.179 utilization. The insured group used health care 00:38:10.179 --> 00:38:13.280 services far more often. Hospital use increased 00:38:13.280 --> 00:38:15.840 by 30 percent, and the number of medical procedures 00:38:15.840 --> 00:38:18.699 increased by 45 percent. People were getting 00:38:18.699 --> 00:38:21.099 needed, planned care, instead of just waiting 00:38:21.099 --> 00:38:23.739 for emergencies. And they were also using preventative 00:38:23.739 --> 00:38:26.059 services, which points to huge long -term health 00:38:26.059 --> 00:38:28.699 benefits down the road. Yes. The insured population 00:38:28.699 --> 00:38:30.739 was much more likely to see preventive care. 00:38:31.039 --> 00:38:33.739 Women were 60 percent more likely to get mammograms, 00:38:33.739 --> 00:38:36.179 and recipients overall were 20 percent more likely 00:38:36.179 --> 00:38:38.099 to have their cholesterol checked. This means 00:38:38.099 --> 00:38:40.619 the system shifted from expensive crisis management 00:38:40.619 --> 00:38:43.239 to much cheaper, more effective prevention, which 00:38:43.239 --> 00:38:45.119 ensures that long -term physical health benefits 00:38:45.119 --> 00:38:47.820 are highly likely to show up later. And the mental 00:38:47.820 --> 00:38:50.260 health and financial outcomes were starkly and 00:38:50.260 --> 00:38:52.739 immediately positive. Those with insurance were 00:38:52.739 --> 00:38:55.300 about 10 % less likely to report a diagnosis 00:38:55.300 --> 00:38:57.920 of depression. That demonstrates the immediate 00:38:57.920 --> 00:39:00.940 psychological relief of having coverage. And 00:39:00.940 --> 00:39:03.500 most importantly for quality of life, the study 00:39:03.500 --> 00:39:05.820 showed a significantly reduced financial strain. 00:39:06.219 --> 00:39:08.440 Insured patients cut in half the probability 00:39:08.440 --> 00:39:10.739 of needing loans or having to forego paying other 00:39:10.739 --> 00:39:13.840 bills just to cover their medical costs. The 00:39:13.840 --> 00:39:16.099 Oregon experiment fundamentally confirmed that 00:39:16.099 --> 00:39:18.480 Medicaid provides instant, tangible benefits 00:39:18.480 --> 00:39:21.280 in terms of financial security, access to care, 00:39:21.440 --> 00:39:24.460 and mental well -being, even if changing longstanding 00:39:24.460 --> 00:39:26.739 chronic physical health conditions takes longer 00:39:26.739 --> 00:39:28.719 than a two -year snapshot. So what does this 00:39:28.719 --> 00:39:31.130 all mean? We've explored Medicaid from its great 00:39:31.130 --> 00:39:33.630 society origins, the complexities of the FMAP 00:39:33.630 --> 00:39:36.469 system through the ACA expansion battles, right 00:39:36.469 --> 00:39:39.389 up to the dramatic 2025 policy shifts. And we've 00:39:39.389 --> 00:39:42.130 grounded everything in concrete data. At its 00:39:42.130 --> 00:39:44.889 heart, Medicaid is a reflection of the U .S. 00:39:44.889 --> 00:39:47.309 approach to poverty and health care access. It 00:39:47.309 --> 00:39:49.349 operates under this constant political pressure. 00:39:49.530 --> 00:39:51.849 You have one side generally supporting expansion 00:39:51.849 --> 00:39:54.489 and comprehensive benefits, while the other side, 00:39:54.510 --> 00:39:57.289 as we saw with the 2025 legislation, is focused 00:39:57.289 --> 00:40:00.389 on structural cuts, eligibility limits, and cost 00:40:00.389 --> 00:40:02.980 control. And the evidence is just overwhelming. 00:40:03.360 --> 00:40:06.760 The program has demonstrated its ability to fundamentally 00:40:06.760 --> 00:40:09.900 transform lives, increasing employment, reducing 00:40:09.900 --> 00:40:13.300 financial strain, decreasing mortality. And yet 00:40:13.300 --> 00:40:16.619 the policy focus continually returns to erecting 00:40:16.619 --> 00:40:19.099 these barriers to access, as we saw with the 00:40:19.099 --> 00:40:21.579 work requirements that threatened to kick 11 00:40:21.579 --> 00:40:24.460 million people off their coverage. Despite decades 00:40:24.460 --> 00:40:26.940 of research linking Medicaid coverage to profound 00:40:26.940 --> 00:40:29.599 long -term positive effects, including the fact 00:40:29.599 --> 00:40:43.079 that the government For a program that's been 00:40:43.079 --> 00:40:45.719 proven to save lives and improve financial stability, 00:40:46.139 --> 00:40:48.800 why does the legislative focus repeatedly shift 00:40:48.800 --> 00:40:51.559 to erecting those barriers? And that raises an 00:40:51.559 --> 00:40:53.400 important question for you, the listener, to 00:40:53.400 --> 00:40:56.260 consider. What does the extreme complexity of 00:40:56.260 --> 00:40:59.250 eligibility from... Asset tests for the elderly 00:40:59.250 --> 00:41:01.289 that force them to spend down their entire lives, 00:41:01.449 --> 00:41:04.090 to the punitive look -back periods for long -term 00:41:04.090 --> 00:41:06.750 care, to the burdensome work requirements imposed 00:41:06.750 --> 00:41:09.550 on the working poor, what does all that reveal 00:41:09.550 --> 00:41:12.010 about the underlying, unspoken philosophy of 00:41:12.010 --> 00:41:14.789 public assistance in the United States? It suggests 00:41:14.789 --> 00:41:17.070 a system that is constantly justifying its own 00:41:17.070 --> 00:41:19.449 existence, forcing the poorest members of society 00:41:19.449 --> 00:41:21.590 to prove their need and their moral worthiness 00:41:21.590 --> 00:41:23.969 over and over again, regardless of the clear 00:41:23.969 --> 00:41:26.909 long -term economic and societal advantages of 00:41:26.909 --> 00:41:28.480 simply providing the necessary care.