Reflecting Forward by Elisabeth Wright Burak, MPP, MSW
The past few years have seen important Early Relational Health (ERH) progress at the national and state levels: extended postpartum coverage for pregnant women, broader reimbursement in Medicaid for key screenings and services, growing the community-based workforce of doulas and community health workers who may support ERH, and investments in high-performing medical homes that use team-based, family-driven approaches. A strong and stable Medicaid program offers states a major policy and funding tool to advance ERH, especially in ensuring families can get the right care and support at the right time.
As we celebrate this progress, it’s also important to look ahead to the new administration and Congress, which have signaled priorities and plans. While you may not hear the word “Medicaid” in the news as much as “tax cuts” or “immigration reform,” credible news reports have shown that the incoming congressional leadership will seek to cut Medicaid through proposals we’ve seen in past years, most recently 2017. My colleague Edwin Park outlines proposals here that are high on the list for 2025 budget negotiations. While specific numbers or new legislation is not yet public, we know from past experience and news outlets that any effort to save or offset big tax cuts or reduce the federal deficit will focus on Medicaid.
How Might Medicaid Be Impacted?
Among its 80 million enrollees, Medicaid provides health insurance — and the economic security that comes with it — to nearly half of all the nation’s children and covers 40 percent of all births. Medicaid also provides health insurance for children and adults with disabilities, pregnant women, and low-income parents, as well as covering long-term care for seniors. Next year’s proposals to Medicaid would cut federal funds but also change the program’s nearly 60-year financing structure, which entitles states to a federal match, or an open-ended contribution to the cost of services for Medicaid enrollees. The current federal commitment means that states continue to have federal matching support when enrollment rises during a recession as families lose private insurance. The federal financial support also provides a cushion to states when costs rise from new drugs or technologies to treat diseases like hepatitis or HIV become available. Other possible cuts to Medicaid would reduce the federal matching share for the Affordable Care Act’s Medicaid expansion, which extended health coverage to millions of uninsured adults (many of whom are parents).
Medicaid makes up more than half of all federal funding support for state budgets. By comparison, K12 education is the largest source of state general revenue funding, with Medicaid coming in third for the size share of state general revenue at 18%. All proposals under consideration in Congress will dramatically cut the federal Medicaid share, shifting costs to states. This would leave governors and state lawmakers holding the bag to decide how to make up for the loss of federal funding: raising state revenues, cutting optional Medicaid services or enrollees, or making cuts to other areas of state spending such as education or pre-K.
What Does This Mean for ERH?
These proposals to cut the federal share of Medicaid would undermine states’ abilities to maintain existing services that support ERH, affecting most directly the millions of Americans covered by Medicaid. Although the proposals suggest added state flexibility, with capped funding that grows over time, the only flexibility states will have to make up for lost federal support is where to make spending cuts, such as:
- Rolling back Medicaid income eligibility or services (i.e., fewer families receive Medicaid services)
- Cutting payments to healthcare providers (i.e., providers of primary care are under greater economic pressure for survival and may opt not to serve Medicaid families)
- Adding administrative barriers that add stress to families (e.g., more frequent eligibility checks, added paperwork, or documentation requirements)
If states opt to use other state funding to fill the gaps left by federal Medicaid cuts, it could also mean collateral damage to other state systems that rely predominantly on state revenues. Cuts to state education or pre-K funds, for example, could reduce the reach of school-based health clinics, mental health consultation, or home visiting.
As we move into a busy 2025 and the start of a new administration and legislative cycle, we’re presented with a crucial time to educate grassroots, community, state, and federal leaders about the critical role that Medicaid plays for children, families, and members of every generation.
Now is the time to remind our policymakers of Medicaid’s foundational role in healthcare, state budgets, and — most important of all — supporting the health and economic well-being of children, families, and communities.
For more information:
CCF webinar: How Medicaid Works & What’s at Stake in 2025
CBPP: Medicaid Cuts in the Upcoming Congress
New York Times: Medicaid May Face Big Cuts and Work Requirements
Elisabeth Wright Burak, MPP, MSW, is a senior fellow at Georgetown University’s McCourt School of Public Policy’s Center for Children and Families (CCF) with more than two decades of experience in federal and state policies to support low-income children and families. She currently leads CCF projects on Medicaid’s role supporting early childhood development and maternal health. Before joining CCF in 2011, Burak worked in state policy as health and legislative affairs director with Arkansas Advocates for Children and Families and policy director for the Arkansas Department of Human Services. She holds master of public policy and master of social work degrees from the University of Michigan.
At its heart, Nurture Connection is an engaged, insightful community of parents, caregivers, researchers, medical professionals, philanthropists, early childhood systems leaders, and policymakers dedicated to ensuring every child has strong, nurturing relationships during their earliest, formative years.
Our “Reflecting Forward” series features guest articles and reflections by dedicated members of our national network, from across the country—who are advancing the early relational health field through practice, research, and parent leadership. These reflections pave paths forward for transforming early childhood systems and imagining new possibilities for children, families, and communities.