People who are desperately poor and disabled file claims with Social Security for Supplemental Security Income. If that claim is approved, they are categorically eligible for Medicaid, but that approval is unlikely to come until at least several months have passed and the wait can easily be far longer than that. How do they get health care in the meantime? Since the Affordable Care Act was passed, in most states, they’ve been able to get Medicaid because of their poverty. The Kaiser Family Foundation has a piece out about what’s in the process of changing on that front. The 2025 reconciliation act requires that as of January 1, 2027 those on Medicaid must meet work requirements. One exception to this work requirement is if the person seeking to get on or stay on Medicaid is “medically frail.” Those familiar with Social Security’s definition of disability know that the term “medically frail” isn’t part of that definition. To the best of my knowledge “medically frail” isn’t part of any definition previously used in any government program in the U.S. The reconciliation act defines “medically frail” to include “five categories of individuals who: are blind or disabled; have a physical, intellectual, or developmental disability that limits their ability to perform one or more activities of daily living (ADL); have a substance use disorder; have a “disabling” mental disorder; or have a “serious or complex” medical condition.” Again, for the most part, this is not Social Security terminology. Other guidance being given the states helps little.
Who in state government will be handling the workload of determining “medical fragility?” Probably the state disability determination services but they’re already overwhelmed with Social Security work. How long will it take them? It could easily be many months especially since the guidance they’ll receive probably won’t be great, especially at the beginning. The Trump Administration doesn’t have an abundance of Medicaid expertise. Many of the career employees who might have this sort of expertise are no longer working for the government. In the Trump Administration the political appointees who are supposed to be managing this may harbor considerable hostility towards poor people. They may be the sorts of people who naively believe that almost anyone can work and that mental illness is “all in your head.”
I don’t like how this may all sort out. There may be a lot of disabled people getting all their treatment at hospital emergency rooms? That’s bad for both patient and hospital. At least the hospitals will want a loose definition of “medical fragility.” They want to get reimbursement for the treatment they render and want to keep people who just need outpatient treatment out of their ERs.
