The Objectives of Medicaid: The Legal Definition Behind America's Most Important Health Program

Medicaid work requirements were found in 2018 to be contrary to the Medicaid statute because, according to the D.C. Circuit, "the objective of Medicaid was to furnish medical assistance." Even though the Secretary of Health and Human Services determined that the work requirements were "likely to assist in improving health outcomes," the court concluded that "better health outcomes as [an] objective of Medicaid … lacks textual support. Indeed, the statute makes no mention of that objective."With the second Trump administration making Medicaid work requirements a centerpiece of its budget, the "objectives of Medicaid" reemerge as both an important statutory constraint on the program and a foundational question for health policy. Though the upcoming debate will likely ride on the efficacy of work requirements, the broad implications of the litigation will inevitably shape broad implications for future Medicaid policy.This article delves into the Medicaid statute to reveal its core objectives, and it makes one legal and one policy claim. First, Medicaid's statutory language does support the promotion of better health outcomes as one of the program's objectives, and second, providing services that fall outside "medical assistance" is critical in improving health outcomes to beneficiaries. As an empirical matter, nonmedical services have become a staple of health care delivery in recent decades, including in some of Medicaid's signature initiatives, and a careless revisitation of the legality of work requirements undermine some of the program's most important advances.To address the legality of work requirements, courts should embrace Medicaid's broader objectives and instead apply one of the statute's mostly ignored requirements: states must evaluate the efficacy of their innovations. The Medicaid statute encourages states to experiment with new health care delivery strategies to find more affordable and cost-effective strategies to promote population health, including those that rely on nonmedical interventions, but the constraint is not whether those innovations are consistent with Medicaid's legal objectives but rather whether they are empirically shown to improve population health. And precisely because public health research has identified a wealth of social, behavioral, and nonmedical interventions that have proven to be effective in promoting population health, a proper understanding of the Medicaid statute and the program's objectives are critical in implementing effective health policy, in the second Trump administration and beyond.