This blog was written before the 2024 election, but discusses policy proposals that are currently gaining traction. For that reason, we are including it in our Medicaid Defense series.
For fifty-five years, the National Health Law Program (NHeLP) has fought to defend and expand access to affordable, high-quality, and nondiscriminatory health care for low-income and underserved communities across the U.S. Based on our decades of experience with Medicaid and federal health care reform, we are extremely alarmed by the proposals that the Heritage Foundation and their coalition of conservative organizations outline in their 2025 Presidential Transition Project (“Project 2025”), an authoritarian playbook for a new conservative administration. This wide-ranging far-right, anti-science, and anti-democratic agenda includes numerous proposals that endanger the future of Medicaid, the Affordable Care Act (ACA), and health-related civil rights laws and policies.
Project 2025 seeks to eviscerate access to care for Medicaid beneficiaries
Since 1965, Medicaid has played a crucial role in the struggle for equitable health care coverage in the United States (U.S.). As of May 2024, it provided essential and often lifesaving health insurance coverage to more than 73.9 million people with low incomes, and particularly Black, Indigenous, and People of Color (BIPOC), people with disabilities, LGBTQI+ people, women, and young people nationwide. Project 2025’s recommendations place the future of Medicaid in peril.
1). Project 2025’s proposals would likely cut Medicaid coverage for millions of people with low incomes across the country
One of Medicaid’s defining features is that it is an entitlement program: federal financial assistance to states is tied to the actual cost of care provided to beneficiaries. After criticizing federal Medicaid expenditures, Project 2025 recommends allowing states to fundamentally restructure the program from an entitlement program into a block grant or impose per capita caps (Project 2025 at 466). Policymakers have historically sought these reforms in order to severely cut Medicaid funding to states.
Project 2025 also proposes a parade of horribles for Medicaid eligibility reform. Although nearly all Medicaid beneficiaries who can work do so, it recommends allowing states to impose Medicaid work requirements (467–468), which involve burdensome paperwork and other administrative red tape and violate the Medicaid Act. According to a 2023 Congressional Budget Office estimate, these requirements would likely kick millions of people with low-wage jobs out of the program, jeopardizing their health and ability to stay employed. Extensive research shows that state caseworkers deny exemptions to public benefit work requirements to countless people who qualify for them, such as people with disabilities and pregnant people. Further, Project 2025 would impose time-limits on how long people with low incomes can receive Medicaid coverage during their lifetimes (468). It would also allow states to “strengthen” asset tests (467), which likely would discourage savings among people concerned about losing benefits and impose burdensome paperwork verifications on people applying or renewing coverage.
Project 2025 also criticizes federal incentives for states to expand Medicaid coverage, proposing to replace enhanced federal matching funds with a “more rational match rate” (466–467). Conservatives have historically pursued cuts to federal matching rates to reduce federal funding for Medicaid. Further, it recommends adding “flexibility to eliminate obsolete mandatory and optional benefit requirements” (468). Together, these reforms would likely prompt states to backslide on covering people in optional eligibility categories, including Medicaid expansion, which covered over 23 million people with low incomes nationwide as of June 2023. As I discuss further below, these reforms could also prompt state backsliding on coverage of Medicaid’s current mandatory benefits, such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for kids, and optional benefits, such as prescription drugs.
Project 2025 recommends allowing states to make unilateral changes to their Medicaid programs without waivers or State plan amendments and thus, without federal oversight or public comment (468–469). Project 2025 would also allow states to contribute to a private insurance benefit for Medicaid eligible-individuals, which could leave families with low incomes without critical Medicaid protections (468).
The radical agenda also proposes to restore the Trump-era public charge rule (145), which was designed to make mixed-status immigrant families who are eligible for Medicaid under federal law afraid to apply or stay enrolled.
2). Project 2025 would eviscerate sexual, reproductive, and gender-affirming health care access in Medicaid
As part of its overarching strategy to end abortion access everywhere, Project 2025 recommends codifying the Hyde Amendment’s severe restrictions on abortion coverage in Medicaid and other public programs (474). It also recommends leveraging the Comstock Act (562) and “fetal personhood” (6) to criminalize abortion nationally. The playbook proposes withdrawing federal Medicaid funding from states that require abortion coverage in private insurance (472, 493). That proposal is rooted in the same overbroad interpretation of the Weldon Amendment that the Trump-Pence administration used to justify withholding $200 million quarterly in federal Medicaid funding from California despite the state’s documentation and earlier federal findings that its abortion coverage requirement complied with federal law. Project 2025 would rescind the 2021 legal analysis that restored that Medicaid funding to California (493).
As discussed above, Project 2025’s recommendations may prompt states to end or severely reduce Medicaid coverage for mandatory benefits such as family planning services and supplies (468). It would also drastically expand and exploit the CDC’s abortion surveillance program, making state participation mandatory. Despite the fact that abortion is essential and safe health care, it recommends mandating stigmatizing and pseudo-scientific state reporting on “abortion survivors,” “abortion-related maternal deaths,” abortion complications, and “children being born alive after an abortion” (455–456). Further, Project 2025 endorses a federal bill that would make state compliance with the new abortion surveillance requirements a condition of continued federal funding for Medicaid family planning services and supplies (456). Thus, states would have to make an impossible choice: submit data that the Administration could use to bolster abortion criminalization efforts, especially for BIPOC, people with disabilities, immigrants, and other underserved communities, or lose the largest source of public funding for family planning services altogether.
Finally, federal law requires Medicaid coverage of gender-affirming care, evidence-based, clinically appropriate, safe, effective, and often life-saving health care. Nevertheless, Project 2025 seeks to restrict access, referring to gender-affirming hormone treatments as “experimental” and indicates support for policies that require parental consent for gender-affirming care for youth (333).
3). Project 2025 endangers Medicaid coverage for people with disabilities
Project 2025’s attack on federal mandatory and optional benefit requirements (468) endangers the health and lives of people with disabilities. Medicaid’s mandatory services, including nursing facility services, home health services, non-emergency medical transportation, and Medication Assisted Treatment, provide essential care to disabled people with low incomes. Similarly, Medicaid’s optional benefits, such as prescription drugs, home and community based services, and mental health services for adults, provide lifesaving care to people with disabilities.
Project 2025 also recommends redesigning eligibility, financing, and service delivery for long-term care services and supports (LTSS), which encompass the wide range of medical and personal care services that assist disabled people with critical activities of daily living (e.g., eating, bathing, dressing, medication management, meal preparation) (468). The playbook recommends restructuring LTSS “to serve the most vulnerable and truly needy and eliminate middle-income to upper-income Medicaid recipients” (id.), implying that many disabled people who rely on Medicaid LTSS for care do not truly need access, and suggesting that they intend to drastically cut eligibility for these services.
Finally, Project 2025 recommends restoring prior regulations on Section 504 of the Rehabilitation Act (495). Earlier this year, the U.S. Department of Health and Human Services (HHS) finalized robust, vital, and long-overdue updates to these regulations for the first time since 1977. The 2024 final rule clarifies vital protections against disability discrimination in programs and services that receive HHS funding. Rolling back these reforms would be a devastating loss for disabled Medicaid beneficiaries.
Project 2025’s recommendations would gut the ACA’s protections
Project 2025 aims to gut HHS’s 2024 final rule clarifying protections under Section 1557 of the ACA, which bans health care discrimination on the basis of race, color, national origin, sex, disability, age, and any combination thereof (475). In particular, it recommends rolling back regulations that define prohibited sex discrimination, such as discrimination based on gender identity, sexual orientation, pregnancy or related conditions, sex stereotypes, and sex characteristics, including intersex traits (id., 495–496). Without these regulations, sex and intersectional discrimination related to sexual, reproductive, and gender-affirming care will proliferate. Project 2025 recommends that the Department of Health and Human Services withdraw the 2022 guidance (revised in 2023) it issued to pharmacies after Dobbs, which clarified Section 1557 and Section 504 of the Rehabilitation Act’s protections against discriminatory post-Dobbs denials of prescription drugs for chronic health conditions and sexual and reproductive health care (496). It also seeks to expand exemptions from the ACA’s contraceptive mandate for employer-sponsored health plans (483), which would dramatically limit contraceptive access around the country.
The Project 2025 agenda would severely decrease access to and the quality of affordable private health insurance. It would expand “junk” health plans (short-term limited duration plans) that do not comply with the ACA’s protections (470). These plans may charge women and people with pre-existing conditions more for coverage and do not have to cover the ACA’s Essential Health Benefits, such as prescription drugs; pregnancy, maternity and newborn care; and preventive services, leaving many without the coverage they need. Project 2025 also seeks to separate unsubsidized and subsidized health plans into separate marketplaces, making it more difficult for people to compare various plans’ scope and quality (469).
Project 2025 directs the administration to reissue a 2019 Final Rule (473) that essentially made ACA’s modest protections for people to access abortion coverage meaningless, with devastating effects on health and economic futures. As part of its anti-science agenda, Project 2025 also conflates abortion and emergency contraception and proposes eliminating coverage of emergency contraception from the ACA’s contraceptive mandate (485). Further, the extremist playbook aims to undermine the ACA’s women’s preventive services mandate, which requires most health plans to cover recommended preventive services without cost-sharing, by narrowing coverage of evidence-based care and restoring ideologically driven and antiscience recommendations from the past (484–485).
Conclusion
This blog post previews just some of the looming federal threats to Medicaid, the Affordable Care Act, and health-related civil rights. Through federal administrative and Congressional advocacy, NHeLP fights federal attacks, such as Medicaid work requirements, block grants, and per capita caps; efforts to repeal-and-replace the ACA, and proposals to gut health-related civil rights (e.g., Section 1557 of the ACA). In addition to our own organizational comments that provide extensive legal analysis opposing attacks, we coordinate and author coalition sign-on comments and template comments for partner organizations, and develop comment portals for the public to share their stories about what is at stake through our My Care Counts campaign. We also fight federal threats to Medicaid, including cuts, through litigation, administrative complaints, and other legal strategies. This work includes our signature Health Law Partnerships program, through which we partner with 22 highly experienced state-based advocates to build and strengthen their Medicaid and health-related civil rights advocacy, litigation, and enforcement capacity and provide funding that empowers them to dedicate significant time and resources to related efforts.
No matter what the future holds, NHeLP’s deep bench of nationally recognized health law and policy experts will be here to defend access to affordable, high-quality, and nondiscriminatory health care for low-income and underserved communities.
