It is easy to perceive government as nothing more than politics—often bad. The nation stands at a path that leads to the 2024 Presidential election with neither presumptive nominee holding more than a 43% approval rating. Further, Congress enjoys its typically abysmal public perception (18% in February, per Gallup), and even the Supreme Court is at a nadir of trust. But there is more to government than the politicking plastered on chyrons from D.C. to De Moines. Undergirding the systems of government that keep day-to-day society functioning is policy. Defined differently many, this author views policy as the programmatic shoe leather that delivers things people need and establishes rules to positively shape behavior.

The Landscape will dive into policy areas of importance to Children’s National from time to time, and today we will begin with the most foundational of government policies and programs to pediatrics: Medicaid.

Medicaid: A Quick Primer

Confused with Medicare by even the occasional candidate for public office, Medicaid is a program established by Title XIX of the Social Security Act of 1965. Unlike Medicare, which is administered entirely by the federal government, Medicaid is a jointly run program with the states. Each state may set up their program however they would like, subject to approval by the Centers for Medicare and Medicaid Services (CMS). From eligibility requirements to income thresholds to reimbursement matching formulas there is great variety across Medicaid programs. Some states are more generous, others less so.

Medicaid took center stage in the years following passage of the Affordable Care Act because the law allowed, but per the Supreme Court could not mandate, states to expand the eligibility criteria for Medicaid to approximately 138% of the Federal Poverty Level. Democratic states tended to favor expansion, which also came with generous government incentives, while conservative and moderate (the gradients of these labels is a worthy topic of debate) either declined or took a “wait and see” approach. In state legislatures across the country careers were born and died over the issue of whether to expand Medicaid. A decade hence 40 states have gotten on board, some through ballot initiative, others through executive action, and still others through legislation. While that may seem like an embrace of the benefits of the program, however, institutional support for Medicaid remains shaky.

Medicaid is the primary health insurance covering more than 35 million children in the United States (with the Children’s Health Insurance Program covering an additional 6 million who are ineligible for Medicaid). Its benefits include essential services like the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, and it the largest payer for mental health services in the country (though not at parity with physical health). Although children make up more than 50% of the population covered by Medicaid they account for less than 20% of costs. That makes sense when you figure that Medicaid also covers medical services like long term care and nursing homes, neither of which are terribly inexpensive.

So if Medicaid is so necessary, if it’s the primary insurer of children, if it’s the backstop against millions of Americans suffering solely because of their lack of income why is it shaky? Why would elected leaders ever consider threatening the program? The answer is contained in the question: voters.

Medicare is not only NOT under assault, the mere mention of reforming the program is used as a political cudgel to attack electoral opponents. That’s because Medicare covers people 65 and older, and no bloc of voters is more reliable at showing up at the polls than those aged 65 and older. The flip side of that is that children are not eligible to vote, and the likelihood of turning out on the first Tuesday after the first Monday in November decreases as income goes down. Why is Medicaid shaky? Because it’s a large government program that primarily benefits people who lack the ability to seek redress of any cuts.

This is where Children’s advocates come in. The best tool that we have to prevent cuts to Medicaid is education of institutional leaders.

Left unchecked it is too easy for legislators to look to those least likely to complain to find budget savings. Investments made in early treatment are key and pay dividends over the life of a child who has been properly cared for. Robust, sustainable coverage is a centerpiece of that philosophy, and the policy that makes it happen is Medicaid.