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, 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 for coverage and access, resisting efforts to retreat to a pre-ACA coverage framework, supporting state innovation, 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.

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.

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.

Because HCBS are an optional benefit under Medicaid, states facing fiscal crises can limit access, including through enrollment caps and waiting lists. Today more than 600,000 people are waiting for care 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 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.

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.

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 (HOP) generated $164 in savings per member per month, according to a new, multiyear evaluation 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 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 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.

State Medicaid programs are under extraordinary pressure as they navigate federal funding uncertainty, H.R. 1 implementation, and health care cost growth that consistently outpaces both inflation and state revenue growth. States have myriad technology vendors pitching solutions to help alleviate those burdens, particularly around helping drive down the costs associated with certain clinical conditions and administrative functions. These technology solutions, increasingly, are AI powered and promise to be the differentiator for patients and Medicaid budgets alike.

It can be daunting for state Medicaid leaders to evaluate which technologies deliver, where there are risks, and the types of structural changes that are needed for innovation to benefit the people Medicaid serves rather than the vendors selling to it.

In Episode 3 of The 80 Million Podcast, host and 80 Million editor Patti Boozang speaks with Caroline Pearson, executive director of the Peterson Health Technology Institute (PHTI), and Jared Augenstein, senior managing director at Manatt Health, about what Medicaid leaders should believe — and question — about the explosion of artificial intelligence (AI) and digital health solutions entering the market.

Innovate or die: That’s the conversation health systems are having as they navigate tightening finances due to new federal policy in Medicaid, including H.R. 1, a national health care affordability crisis, rising patient acuity and a workforce depleted by burnout.  Hospital at Home may signal a paradigm shift among hospital systems driven by “losing less money.” That’s good news for Medicaid. 80 Million Editor Patti Boozang sat down with UMass Memorial Health CEO Dr. Eric Dickson and Manatt Health’s Tom Robertson to explore what real innovation looks like in a hard operating environment.

Medicaid, which is jointly funded by states and the federal government, has always operated under pressure, but this moment feels different. The program is facing a unique period of change, defined by factors that are significant on their own but far more consequential together. Centrally, the 2025 health care cuts to Medicaid and beyond, to the tune of $1 trillion over the next decade, will add nearly 10 million people to the uninsured ranks. These cuts will also trigger state budget holes and new funding gaps for the nation’s health care safety net.

The funding cuts are compounded by new administrative burdens for consumers because of new Medicaid work reporting requirements and other red-tape hoops people will need to jump through to get and keep coverage. Paperwork is a tried-and-true method for reducing enrollment, undermining decades of bipartisan efforts to streamline enrollment while ensuring program integrity through data-driven verification of eligibility. State Medicaid agencies will also feel the pinch as they operate with steep new administrative costs and fewer resources, and health providers who continue to serve low-income populations will be faced with patients churning in and out of coverage and a rise in uncompensated care.

The “old Medicaid rubric” doesn’t make sense anymore. It’s one that we’ve moved beyond for good reason through the Affordable Care Act expansion. The vast majority of Americans support and value their Medicaid coverage, including their expansion coverage,  as vital to keeping their families safe, healthy and financially secure.

For those of us at The 80 Million, our name represents a vital segment of the American population — nearly one-fifth of the nation — who rely on Medicaid for their health, financial security and in some cases, survival. Today, the program stands at a critical inflection point. As Medicaid faces what many policy experts consider its most significant existential threat since its inception, we are expanding our coverage to meet the moment. Starting May 6, we are launching a special eight-episode podcast series to explore the seismic changes reshaping Medicaid and health care access more broadly in our country.

Hosted by Senior Managing Director Patti Boozang, Season 1 of The 80 Million Podcast is about what's at risk at this moment in Medicaid, fiscally, operationally and politically, and where the program needs to adapt deliberately — not just to survive, but to get stronger. This is a time that demands solutions. Over the next decade, Medicaid is expected to see nearly $1 trillion in federal funding cuts from H.R. 1, new administrative hurdles that make getting and maintaining Medicaid coverage difficult, and federal policy shifts that limit the ability of states to raise revenue through state-directed payments and provider taxes.

This new series reflects the very best of what defines our health group — deep expertise, meaningful collaboration and a commitment to shaping the future of care for the 80 million Americans who rely on Medicaid. Across the season, Patti brings together colleagues from Manatt Health and nationally recognized leaders to explore the most pressing challenges and opportunities facing the program today. Produced by Amanda Eisenberg, The 80 Million Podcast digs into technological innovations, FWA, and the operational and fiscal tradeoffs states are facing right now.

Subscribe to The 80 Million here. Episodes will be available starting May 6 where you get your podcasts and, for subscribers, in your inbox each week!