Medicaid is the largest public insurer in the United States, offering more than 81 million people with low incomes — including adults, children, and people with disabilities — access to health care. Medicaid covers 42 percent of all births in the U.S. and an even greater share of births in rural areas and for people of color. It’s also the primary payer for behavioral health and long-term care services.
Medicaid enrollment soared during the COVID-19 pandemic as Congress incentivized states to keep people continuously covered to ensure access to care in exchange for enhanced federal funding. Since March 2024, states have been “unwinding” the continuous enrollment provision, leading to more than 21 million people losing Medicaid coverage as of August 2024. Throughout the unwinding, policy lessons have emerged around the importance of streamlined enrollment, continuous eligibility provisions for specific populations, and enhanced coverage for pregnant people and people leaving incarceration.
Here’s a look at how the outcome of the 2024 election could affect Medicaid and its beneficiaries across the country.
How could the election affect Medicaid beneficiaries’ coverage and access to care?
By expanding or restricting enrollment and eligibility. An incoming Harris administration could continue Democratic efforts to expand Medicaid coverage and services. This could include building upon the Biden–Harris administration’s rulemaking to streamline enrollment and renewals, and remove red tape. In 2022, the administration simplified and standardized Medicaid and Children’s Health Insurance Program (CHIP) enrollment to reduce variation in policies across eligibility groups (such as parents, older adults, and people with disabilities).
A Harris administration could also encourage more adoption of continuous enrollment policies to stabilize coverage, beyond the 12-month requirement for all children enrolled in Medicaid and CHIP. Such policies would eliminate enrollees “churning” in and out of coverage, which disproportionately affects people of color. Extending continuous eligibility for 24 months could not only expand coverage but also reduce costs for adults and families with children, as well as administrative costs at the state level.
Alternatively, a second Trump administration could revisit earlier efforts to cut Medicaid enrollment by restricting eligibility. While the Biden administration used Section 1115 state waivers to expand Medicaid coverage, the Trump administration used the waivers to limit eligibility and enrollment — a strategy that Republican lawmakers could reintroduce to limit federal spending on the program.
The Trump administration was the first to tie Medicaid eligibility to employment through work and community-engagement requirements. While most proposals were challenged in court and never implemented during his first administration, Project 2025 calls for states to have the option to adopt work incentives for nondisabled people despite evidence that work requirements reduce coverage for Medicaid beneficiaries with no increase in employment.
By issuing per capita caps, or block grants. A Trump administration could again attempt to reduce Medicaid spending through per-person funding caps or aggregate caps, also known as block grants. In 2020, the Trump administration invited states to apply for the Healthy Adult Opportunity Medicaid demonstration initiative, a block grant that provided states with less Medicaid funding in exchange for less administrative burden. Through these initiatives, conservatives aim to reduce government spending and steer more people to private insurance. However, such strategies could negatively impact states and some territories. For example, block grants in Puerto Rico contributed to the commonwealth’s fiscal and debt crisis.
How could the election affect the affordability of Medicaid coverage?
While Medicaid is an essential source of coverage and financial protection for beneficiaries, some still struggle to afford care under the program. The Commonwealth Fund’s 2023 Health Care Affordability Survey found that nearly half of working-age people with Medicaid coverage said it was very or somewhat difficult to afford health care. Election results could impact affordability.
Under a Harris administration, we may see state and federal efforts to shield beneficiaries from uncovered medical costs by ensuring retroactive eligibility, a safeguard that allows people to quickly receive care, such as when their health declines suddenly, up to three months before they even apply for Medicaid. A Harris administration could also expand the scope of Medicaid coverage by requiring states to add in currently optional benefits, such as dental and vision care for adults.
Under a Trump administration, we may see more cost sharing for certain services or premiums for higher-income enrollees to increase the financial stakes for enrollees and save state and federal dollars. Such efforts could leave more people uninsured and exposed to medical costs and debt.
How could the election affect efforts to address disparities in outcomes among Medicaid beneficiaries?
The Biden–Harris administration has embraced a whole-person approach to address health disparities by meeting social needs, such as stable housing and access to healthy food, which influence health outcomes. It has also encouraged states to use their Medicaid programs to improve health care for people returning to the community after incarceration.
A Harris administration could build upon the efforts from the Center for Medicare and Medicaid Innovation (CMS Innovation Center) to meet a wider range of social needs and test models with Medicaid beneficiaries. It also could incentivize or require data collection to identify disparities and track progress in reducing inequities in access or outcomes.
A Trump administration could choose to restrict or eliminate recently approved waivers, which states use to test innovations in their Medicaid programs, and deemphasize the importance of data collection to address disparities.
What can policymakers do to improve coverage and affordability of care through Medicaid?
The next administration could consider several approaches to improve coverage.
Encourage adoption of Medicaid expansion or fill the Medicaid coverage gap at the federal level in nonexpansion states. An incentive for states newly adopting expansion was included in the American Rescue Plan Act and remains available. The next administration could promote the incentive and how it can be combined with an 1115 waiver to tailor expansion to meet specific state needs. Federal lawmakers could create a “fallback” option allowing low-income people in the 10 states that have not expanded Medicaid to get no-cost coverage through the federal health insurance marketplace.
Expand the scope of Medicaid coverage by adding dental, vision, and other currently optional services. The scope of covered benefits varies by state, and states have the option to customize their benefits packages for certain groups. A new administration could push to streamline covered benefits across states or elevate the evidence on how covering optional benefits can improve health outcomes.
Broaden Medicaid managed care networks to increase access to providers and prevent out-of-network costs. Enrollees can face high costs when they are unable to see an in-network provider. Current standards for ensuring adequate provider networks vary considerably by state. The new Medicaid managed care rule attempts to help address network adequacy by assessing wait times for specific provider types and conducting secret shopper surveys. The next administration’s prioritization of enforcement of new Medicaid rules will determine how effective they are in meeting access to care objectives.
To improve affordability of care, policymakers may also consider the following options.
Eliminate or limit cost sharing for high-value services, or cost-effective services demonstrated to improve outcomes. Medicaid beneficiaries often lack the health literacy to make informed decisions about what services are most impactful, especially when also struggling to pay for basic needs like food and rent. Even modest copayments can discourage low-income households from seeking care or adhering to treatment plans for chronic conditions, which could lead to worse health outcomes and more emergency department visits.
Shorten the medically needy “spend down” period to lower costs for people with serious health problems. Medicaid’s “medically needy program” offers coverage to people with incomes too high to qualify for coverage but who would otherwise be eligible. A person becomes eligible if their medical costs lead them to spend down their income to a certain level set by the state. Currently, 34 states offer this program, with spend-down periods ranging from one to six months. More states could offer the program with shorter spend-down periods to better financially support people with serious health conditions.
By implementing such policies to improve coverage and affordability of care through Medicaid, lawmakers could help states reduce spending. They also could help protect the health care safety net for millions of people with low incomes or disabilities in the U.S. By making their choices this fall, voters could have a major impact on the direction of Medicaid in the years to come.
