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Medicaid provides health care for millions of low-income Americans, and its future depends very much on politics. Over the past four years, the Trump administration has tried to impose conservative principles on the program while shrinking it. A Biden presidency would attempt to expand the program. Blake Farmer of member station WPLN in Nashville explains how the presidential election could reshape Medicaid at a critical moment for health care.
BLAKE FARMER, BYLINE: It was either put food on the table or drop their health insurance. Oscar Anchia of Miami says his wife's coverage was costing $700 a month, and his hours had been cut back from the pandemic. Then this month, she fell ill with COVID-19.
OSCAR ANCHIA: This is the sixth day she's been in the hospital. It's about $92,000.
FARMER: Anchia is hoping his wife will be covered by another federal program for the uninsured, but that's because he lives in one of the dozen holdout states that hasn't expanded Medicaid. Obamacare intended to provide coverage for people who are working but still need help through Medicaid.
ANCHIA: For example, me, I always work - been working 36 years in the same company. And now I find myself in this position. And Medicaid will be a great help for, you know, regular people. I'm not the only one.
FARMER: In Florida alone, roughly 1.5 million people would be eligible under expansion. Those estimates have grown amid the economic trouble caused by COVID, says Miriam Harmatz of the Florida Health Justice Project.
MIRIAM HARMATZ: The pandemic, I think, has really elevated the visibility of the suffering and that it cuts across socioeconomic lines. And these are, you know, folks you wouldn't expect to have been in with the ranks of the uninsured.
FARMER: Harmatz hopes that under a Biden administration, Democrats could deliver on a proposal known as the public option. It would bring coverage to this group without having to wait for state action.
Even under the Trump administration, some Republican-led states have moved forward with Medicaid expansion after some initial resistance. Most recently, Georgia opted in. But the libertarian Cato Institute's Michael Cannon says in the last four years, Trump's health officials pushed states to look at ways to spend less on Medicaid. Work requirements have been the most popular way to do that under Republican.
MICHAEL CANNON: They wanted to find something to say about Medicaid or a way to push back against the Medicaid expansion.
FARMER: But work requirements have been stopped by the courts. The other way the Trump administration has tried to limit Medicaid spending has also stalled out. The White House has offered to pay for Medicaid in a lump sum and let states figure out how to run it more efficiently. Tennessee is the only state that's pursuing this so-called block grant. But as Mandy Pellegrin, a policy analyst at the Sycamore Institute, points out, Tennessee is asking for a block grant that would bring in more money for Medicaid, not less.
MANDY PELLEGRIN: Expansion is certainly something that could happen under this waiver.
FARMER: Even though Tennessee's proposal has the potential to cover many more people, Democrats have generally dismissed the idea of block grants as a backdoor way to cut benefits Americans are entitled to. But the push and pull over Medicaid assumes the Affordable Care Act doesn't get struck down, including the generous federal matching money to cover the working poor. And Rachel Newsom of the Commonwealth Fund says the Trump administration is still pushing for the Supreme Court to overturn the entire law.
RACHEL NEWSOM: You would not expect that to continue under a Biden administration. So there's a fair bit of uncertainty. And what we know is that states cannot operate well in a environment of uncertainty.
FARMER: Newsom says this election, from state legislative contests up to the White House, has the potential to provide a little more certainty to how millions of Americans receive their health care.
For NPR News, I'm Blake Farmer in Nashville.
CHANG: And this story was produced in partnership with Kaiser Health News and Nashville Public Radio. Transcript provided by NPR, Copyright NPR.