Nicole Huberfeld

Examines how recent action at the state level, specifically placing work requirements for people to access Medicaid coverage, differ from the historical path of Medicaid. Finds Medicaid has historically been expanded to cover more groups of people, most recently in the Obama administration, where states applied for waivers to expand coverage to people that were not previously eligible. Notes that Stewart v. Azar shows state efforts to do the opposite- impose restrictions and limit access to Medicaid.

Finds obstacles in rural areas, such as small patient populations and low levels of health insurance, have led to hospital closures and worse health outcomes. Notes that programs like Affordable Care Act attempted to address these issues, as increasing insurance rates help individuals access care and keep rural hospitals financially stable. Notes some rural states have rejected the ACA, but their replacement choices targeting these communities appear to be less effective.

Finds the Affordable Care Act has led to complex interactions between states and the federal government. Finds this set of interactions exists everywhere, no matter what actions a state took in response to the ACA. Concludes this lack of particular behavior challenges theories on federalism.

Notes that a key aspect of the Medicaid program is the rate at which a state reimburses the providers of health services. Notes a 2015 Supreme Court case found that providers could not appeal to federal courts if they believed their reimbursement rates were too low. Finds this decision opened the door to states cutting reimbursement rates, at a period where many new people were entering Medicaid.

Notes American healthcare has historically excluded people from receiving care- private providers have claimed the right to treat (or not treat) whoever they want. Finds this system is challenged by changes to Medicaid from the Affordable Care Act, which opened up healthcare to any person below a certain income level, regardless of age or health.

Notes Medicaid is based on older state welfare programs that had a “deserving poor” in mind that were supposed to be supported. Finds the Affordable Care Act expanded Medicaid beyond these traditional groups, with the federal government providing almost all new funding for the program. Finds there is no compelling reason to keep Medicaid controlled by the states, and it would benefit being administered directly by the federal government, given state resistance to the expansion.