In Their Own Words

A Bold Plan to Fix Medicaid

Democrats Must Go Beyond Reversing Trump-Era Cuts With a New Strategy to Streamline Coverage, Reduce Waste, and Expand Access to Medicaid

July 17, 2025

By:

Ezekiel J. Emanuel, MD, PhD

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While the devastating consequences of Trump’s “One Big Beautiful Bill” are clear–like lost Medicaid coverage for an estimated 12 million Americans–rolling this bad bill back is not enough for Democrats.

Medicaid is flawed and broken, and must be improved so we can bring quality health care to all Americans. How? I’ve identified seven core design elements Democrats can propose to fundamentally fix Medicaid, not just repair the damage done by Trump:

Create one national exchange combining Medicaid, CHIP, and ACA exchanges where all uninsured Americans can purchase coverage based on income, with automatic enrollment.
Require five-year plan commitments instead of annual enrollment to reduce churn, lower administrative costs, and incentivize prevention.
Limit choices to no more than six plans per region, with at least two being state or local insurers, to enhance decision-making and limit market concentration.
Standardize benefits nationwide with low deductibles and out-of-pocket expenses capped at 2% of income, ensuring sick people don’t skip care due to costs.
Increase provider payments to Medicare levels while recalibrating to incentivize prevention and value-based care through primary care bonuses and bundled payments.
Create a single claims clearinghouse for all insurers and providers to reduce administrative waste and improve coordination.
Establish a separate long-term care program for nursing homes and assisted living, allowing families to avoid impoverishment and be reimbursed for care they provide.

I elaborate on all of these in my new piece in The Bulwark.

As Americans fear what Trump’s bill means for them, Democrats must offer a plan that’s better, cheaper, and more compassionate. Now is the time for bold reform that guarantees simple, standardized coverage that puts health over profit and protects families from bankruptcy.

Ezekiel J. Emanuel, MD, PhD is a Senior Fellow at the Leonard Davis Institute of Health Economics, Vice Provost for Global Initiatives and the Diane v.S. Levy and Robert M. Levy University Professor at the University of Pennsylvania.

Author

A Bold Plan to Fix Medicaid

Democrats Must Go Beyond Reversing Trump-Era Cuts With a New Strategy to Streamline Coverage, Reduce Waste, and Expand Access to Medicaid

Author

Ezekiel J. Emanuel, MD, PhD

Diane v.S. Levy and Robert M. Levy University Professor, Perelman School of Medicine, Wharton School.

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