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Hullabaloo


Monday, October 15, 2012

 
Will this strong support for Medicaid last under ruthless Grand Bargaineering?

by digby

This is the strongest statement of support for Medicaid I've seen from the administration and it's a very effective message:



Kevin Drum posted this earlier today which shows just how high the stakes really are:


Romney wants radical changes here too, promising to "block grant" Medicaid if he's elected. This means the program would be turned over entirely to the states. The federal government would continue to provide a share of funding, but that funding would go straight into state coffers, and states could decide how to spend it. So the question is: Once released from federal regulations, what would states do with their Medicaid money?

Romney's plan represents a massive change in our commitment to providing decent medical care for those who can least afford it.

Some states would probably try some genuinely interesting experiments, though it's unlikely we'll ever discover any magic bullets for reining in health care costs on a state level. But lots of states, especially poor states in the South, don't have much interest in experimenting. They just want to slash eligibility for Medicaid. Given the freedom to do it, they'd adopt what Ed Kilgore calls the "Mississippi model," cutting off coverage for a family of three earning anything over $8,200. For all the talk of fresh thinking and new solutions, what they really want to do is simple: They want to stop providing medical care for poor people.

But that's not all. In this case, there's more than just differences in ideology at work. Unlike Medicare, which he's willing to fund at about the same rate as Obama, Romney doesn't want to spend as much on Medicaid as Obama does. In fact, he wants to take a chainsaw to it. Aaron Carroll and Austin Frakt took a look at the Romney and Obama plans in the Journal of the American Medical Association this week, and the chart above shows their conclusions. On Medicare, the two candidates want to spend roughly similar amounts of money. On Medicaid, Romney wants to spend way, way less. And not just on poor people. As Jon Cohn points out, cuts of this size will have a huge impact on "dual eligibles," elderly patients who rely on Medicaid to pay their nursing home bills. This is not a minor point of technocratic disagreement. It represents a massive change in our commitment to providing decent medical care for those who can least afford it. Medicaid, much more than Medicare, demonstrates what's really at stake in November's election.

I'm assuming that because Obama is making such a strong commitment in this campaign, he's not going to acquiesce to demands to cut Medicaid or block grant it in any deficit reduction negotiations. But I'm not entirely sanguine. Recall this from the New York Times in the summer of 2011:
Before the talks led by Vice President Joseph R. Biden Jr. broke off 12 days ago, negotiators said, they had reached substantial agreement on many cuts in the growth of Medicare, which provides care to people 65 and older, and Medicaid, which covers lower-income people. Those proposals are still on the table when Congress reconvenes this week, aides said, and are serious options that Democrats could accept in exchange for Republican concessions that raise revenues.
Up until now, Medicaid has very much been part of Grand Bargain deficit negotiations and it's hard to see how they get to their magic numbers if they take it off the table. The devil is in the details, of course, but it's something to keep an eye on.

And just as an aside, during the health care debate, one of the most painful aspects of it to watch was progressives being morally obligated to vote for a plan that expanded Medicaid so substantially to the working poor --- all while knowing without a doubt that the funding for the program itself would be constantly under assault and almost surely whittled away over time. Certainly, I didn't expect the Obama administration to offer to do it and was quite surprised when they put it on the table, but when you look at that graph above, it's quite clear that any GOP administration with enough Democratic helpmates in the congress will cut it severely one way or the other. I expect it's true that the Republicans will end up reluctantly accepting the guts of Obamacare --- the exchanges and the basic coverage requirements --- but this population is going to be at the mercy of politics for a very long time to come.


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