Outgoing Medicaid director Dan Tsai on the program under Biden and Trump : Shots

President-elect Donald Trump’s inauguration is scheduled for Monday, but there is still much uncertainty about what changes his administration and the new Republican Congress will bring.

Republicans in Congress have begun to debate Possible changes Medicaid — A public health insurance program for low-income and disabled Americans that covers 80 million people. These changes could reduce federal spending on programs by more than $2 trillion over the next decade. Millions could lose insurance coverage.

These proposals will have a long road to passage, but would represent a significant departure from the Biden administration’s approach to the plan.

Mr. Biden’s team at the Center for Medicaid and Chip Services, led by Dan Tsai, worked to keep people enrolled as states redetermined eligibility for Americans for the first time since before the coronavirus pandemic. The Biden administration also encouraged states to expand coverage of the program.

“Medicaid saves lives,” Tsai said. healthcare podcast trade off This week, he reflected on his time at the helm of Medicaid.

Before coming to Washington in 2021, Tsai ran Massachusetts’ Medicaid program in the Obama and Trump administrations.

Tsai said he has seen firsthand how people in Massachusetts struggle to enroll in Medicaid. That experience served as a driving force for her work in the Biden administration.

He remembers one family in particular showing up to help fill out registration forms.

“I’m the head of Medicaid, so I couldn’t help them cringe,” Tsai said. trade off. “This shines a very clear light on why it’s so difficult for people to enroll and renew Medicaid.”

In a wide-ranging discussion, Tsai shared what she learned about Medicaid during her time in Washington and her hopes and concerns for the program’s future.

The following excerpt has been edited for length and clarity.

Interview highlights:

On why he thinks Medicaid is so important.

We know clearly that the introduction of Medicaid leads to a significant reduction in child deaths. In one study, 5% reduction in child mortality For children who have access to Medicaid. With Medicaid expansion, Reduce adult mortality rate by 9% The first four years of Medicaid expansion after the Affordable Care Act. That’s 15,000 deaths that could have been avoided if all states had adopted Medicaid expansion in 2014. wealth of the study that show When people have Medicaid coverage, they use primary care, they use preventive services, they use mental health services. And don’t forget to get your prescription medications.

I just want to emphasize that broader economic and social benefits; From Medicaid. When I was director of Medicaid in Massachusetts, the most urgent call I received was something like this: Viability of local hospitals — Being able to continue Medicaid reimbursement for that hospital and having an available anchor institution means hundreds, possibly thousands, of jobs will be created locally in the area. [It might determine] Whether there is a place for doctors or others in the community to receive oncology treatment, or whether there is a hospital where people in the community can give birth locally.

He talked about why he focused on making it easier for people to enroll in Medicaid and renew their coverage.

If you and I have enrolled in Medicaid for a family member, my best answer for when to file for Medicaid renewal is, “I don’t know. Check your email every day for the next year. That paper. Don’t miss out. And if you don’t comply within 10 days or whatever the state gives you, you will lose your medical coverage and your child who is dependent on important medications. Maybe not. We’ll get them.’ We’ll be very angry and very frustrated. we don’t accept it. And that’s something that one in four people in this country has had to go through for far too long.

How the Biden administration is making it easier for people to stay on Medicaid

We’ve doubled the speed of automatic updates. The percentage of people who renew is because the state…calls them up and says, “That person made $13,000 last year, and they still have $13,000 in income.We should auto-renew them.” ” can be said. . ”

doubled it 25 to 53 percentage points Over 18 months. Rarely have we seen progress at this scale and speed. I think this is a result of a tremendous amount of work by both CMS and the states working together and such an absolutely dedicated focus by the entire country. I cannot stress how difficult it is for dedicated public servants, whether in blue states or red states, to do incredible things.

The experience is still too complex, but we’ve improved it significantly. This is not insurmountable. It’s a very deep rocket science of how do you improve the health of an entire population… This question is much simpler. It requires a very collaborative and detailed effort, but it can happen, and it can happen in a relatively short time frame.

Concerning the continued criticism of the Biden administration millions of people Who is on Medicaid? it didn’t have to be that way

I don’t think that’s a fair criticism. Many of the policies we introduce focus on how to keep eligible people registered. And we’ve seen many people who lost their insurance during the mitigation period come right back. That means they were still eligible.

I’ll give you an example. Let’s say you were low-income, or below the federal poverty limit, last year (i.e. $15,000 for an individual and $31,200 for a family of four). And this year, the state will ping every known electronic data source and not return any revenue. In that case, 92% of the timeYou are likely still low-income and eligible for Medicaid.

We know from the data that many people were frustrated. There are many eligible people who are inappropriately losing health insurance. …This is a very surgical method that reduces red tape. And I think these are smart, data-driven policies that will actually make a difference.

On what he learned about what happens when Medicaid covers non-traditional health services like housing and food.

you always find it small percentage people account for a very large portion of health care costs. These people are almost certainly suffering from physical health, often mental health, behavioral health, and a variety of psychosocial issues such as housing instability and sometimes nutritional insecurity. I have an incredibly complex condition. And with a Medicaid program that costs $900 billion nationally, we have to find better ways to ensure that care is delivered without putting people through this tremendous expense just to get in and out of acute care settings. It doesn’t have to be.

There are a lot of really important questions, but one of the most important is: What should I pay with Medicaid? Because we are a health insurance program. And after a year and a half of intense policy debate at the federal level, we’ve come to the conclusion that, yes, Medicaid does have a role (with guardrails) to actually pay for things like housing and nutritional support in certain circumstances. Reached.

One of the things that’s really important to me for people who are interested in this is don’t underestimate how difficult it is to actually make this work in the field. I’ve been in rooms where there were literally shouting matches between healthcare providers and community-based people. [housing and nutrition] All organizations accuse others of malice or incompetence. So I think that’s a big area where we need to make progress to prevent people from biking into and out of the system.

The future of Medicaid under Republican control of the White House and Congress

Although I am optimistic, I believe we are in a period of great risk for this program. What I’m optimistic about is that a lot of the progress that we just talked about will come from a ton of systems and work that’s been done between our team and the states to actually fix the problems at the state level. This is due to operational work.

And the reason I say progress is at risk is that the kinds of policies that might be considered, i.e., deep cuts to programs, would result in more eligible people becoming uninsured. Because it connects. And I think that would have a very negative impact on the health of the American people, and I don’t think that’s an exaggeration. Health conditions will further deteriorate and people will die as a result.

Dan Gorenstein is editor-in-chief of Tradeoffs, a nonprofit health policy news organization. Produced by reporter Ryan Levi this story On the Tradeoffs podcast, he and editor Deborah Franklin adapted it for the web. Tradeoffs’ reporting for this article was supported in part by West Health.

Listen to the interview here: