Beyond Coverage — What It Will Take to Fix American Health Care

Beyond Coverage — What It Will Take to Fix American Health Care

The Affordable Care Act (ACA) fundamentally changed American health care —  expanding coverage, establishing consumer protections that are now broadly expected, and helping cement the idea that access to health care is a basic human need rather than a privilege tied to health status, gender or income. The next challenge is no longer just whether people have coverage, but whether they can afford to get it [https://80million.substack.com/p/risk-shifting-disguised-as-affordability], keep it and use it. Rising premiums, deductibles, cost-sharing and administrative barriers are straining people across Medicaid, the ACA Marketplaces, Medicare and employer-sponsored insurance. Fixing American health care will require looking across the whole system: reducing friction for patients and providers, rebuilding a durable federal floor [https://80million.substack.com/p/celebrating-the-20th-anniversary] for coverage and access, resisting efforts to retreat to a pre-ACA coverage framework, supporting state innovation [https://80million.substack.com/p/episode-5-of-the-80-million-podcast], and accepting that meaningful reform will require mutual sacrifice across the health care ecosystem. The challenge before us is creating a health care system that is affordable, usable and sustainable for patients, providers, employers and taxpayers alike — wherever they live and whatever their income, gender, race or age. We have a great deal of work to do.

Paying for Cures — Medicaid’s Next Financing Test

High-cost therapies like cell and gene therapies could transform care for Medicaid beneficiaries with serious conditions, but their upfront prices — often $500,000 to $5 million per patient — do not fit a financing system built around predictable, chronic-care spending.  The pressure will only grow as the pipeline expands, eligible populations broaden and treatments become easier to administer. Medicaid’s fixed budgets, enrollment churn and limited data infrastructure make it hard to pay for these therapies at scale or capture their long-term value.  Outcomes-based payment and Centers for Medicare & Medicaid Services (CMS) models are important near-term tools, but they are not enough. Durable access will require bolder federal financing solutions such as reinsurance, risk pooling or a dedicated funding stream for transformative therapies.  Listen to the full conversation on Spotify, Apple Podcasts, or wherever you get your podcasts to hear Patti Boozang, Terry Cothran and Ross Margulies unpack the promise of curative therapies, the limits of Medicaid’s current financing model and the policy choices needed to make access real.

America Is Getting Older. Its Long-Term Care System Is Getting Weaker.

Americans are rapidly aging, which is accelerating the demand for the long-term services and supports (LTSS) necessary to their care, as well as the care of a diverse range of children and adults with disabilities. Medicaid is the primary payer for LTSS. Since the early 1980s, that coverage has included home and community-based services (HCBS), which have proven better for health, less expensive and what most people prefer over institutional care. HCBS now make up almost two-thirds of long-term services and support spending, double the rate in 2001 [https://www.everycrsreport.com/reports/RL32132.html]. Because HCBS are an optional benefit under Medicaid [https://80million.substack.com/p/the-perfect-storm-is-here-for-medicaid-b53?utm_source=publication-search], states facing fiscal crises can limit access, including through enrollment caps and waiting lists. Today more than 600,000 people are waiting for care [https://www.kff.org/medicaid/a-look-at-waiting-lists-for-medicaid-home-and-community-based-services-from-2016-to-2025/] across 41 states. With states facing nearly $1 trillion in federal Medicaid funding cuts over the next decade from H.R. 1 and a drumbeat of recent statements from federal leaders questioning the integrity [https://80million.substack.com/p/the-medicaid-fraud-waste-and-abuse?utm_source=publication-search] and purpose of HCBS, the fragile infrastructure that keeps people out of nursing homes is at risk — bringing greater urgency to the imperative for change.

States on the Front Lines — Leading Through Federal Retrenchment

The scale of federal retrenchment is no longer theoretical. In Massachusetts alone, the state is bracing for an estimated $3.5 billion annual loss in federal Medicaid funding once H.R. 1 is fully implemented, against a total Medicaid budget of over $20 billion. Even with aggressive mitigation, the state could still see about 300,000 residents lose coverage. The idea that H.R. 1 simply “right-sizes” Medicaid while protecting the most vulnerable is already breaking down. Children, pregnant women, and people with disabilities are already feeling the effects through fear-driven disenrollment, mounting pressure on rural maternity care, and tighter scrutiny of home- and community-based services. States cannot replace lost federal dollars, but they are not standing still. This episode of The 80 Million Podcast shows how state leaders are investing in trusted, community-based outreach to keep eligible people covered, tackling affordability, shoring up providers and leading through the maelstrom.

Addressing Social Needs in Medicaid — The Evidence Is In. Now What?

The evidence that addressing social needs like food and transportation improves health outcomes and reduces Medicaid costs is no longer theoretical. We’ve seen recent data from two efforts: North Carolina’s Healthy Opportunities Pilots [https://80million.substack.com/p/addressing-social-needs-saves-money] (HOP) generated $164 in savings per member per month, according to a new, multiyear evaluation [https://www.ncdhhs.gov/hop-evaluation/download?attachment] of 31,000 Medicaid enrollees by the Sheps Center at University of North Carolina. The Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities model [https://www.cms.gov/priorities/innovation/data-and-reports/2024/ahc-3rd-eval-report-aag] showed 3%–4% reductions in total cost of care through screening and navigation alone. Payment remains a major structural barrier. Most of this work — outreach, navigation and coordination — has no billing code under fee for service. Scaling requires value-based arrangements with real teeth, not the “value veneers” that occupy value-based care real estate without changing care delivery. Waymark, a Medicaid-focused care delivery company, addresses this by pairing AI-enabled community-based care teams with value-based contracts designed to measure impact and align payment with proven intervention. States don’t need to wait for federal action. Managed Medicaid contracts allowing for accountable programs that meet social and clinical needs, using in-lieu-of services authority, and directing rural health transformation dollars [https://80million.substack.com/p/rural-health-transformation-the-smart?utm_source=publication-search] toward this infrastructure are all available now. Still, permanent scale will require Congress to move this work from waiver territory into the core Medicaid benefit. Rajaie Batniji, Patti Boozang and Mandy Cohen explore what the latest evidence on addressing social needs in Medicaid means for policy and practice in this week’s 80 Million Podcast. The discussion examines why the case for action is stronger than ever, what it takes to scale these interventions, and where states can move now.