Mandates and medicaid: who could have predicted?

Mandates and Medicaid

by digby

Paul Ryan on the individual mandate in his Medicare "reform" plan:

Q: If Medicare becomes a voucher program, would you require seniors to purchase private insurance and if so isn’t that an individual mandate? If you will not require them to purchase insurance how do you propose to prevent a situation where the costs of uninsured seniors is very expensive and gets passed on to me as a private policy holder? [...]

RYAN: Its mandate works no different than how the current Medicare law works today, which is you just select from a wide range of different plans. It literally would be like Medicare Advantage…

It's also an albatross around the necks of every House Republican. The Chairman of the House Ways and Means Committee pretty much declared Ryan's plan dead in the water and clearly wants to move on. but they went so all-in that it's hard to see how they can.

He also acknowledged that their plan to repeal health care reform wasn't going anywhere (and that the sun will come up tomorrow.) But he isn't giving up on it altogether, oh no:

Rep. Dave Camp (R-Mich.), chairman of the powerful House Ways and Means Committee, acknowledged Thursday that Republican plans to repeal President Barack Obama’s signature health care law were “dead.” Instead, Camp predicted, the GOP would turn its focus to overturning the most controversial portion of that legislation: the mandate requiring individuals to buy insurance.

Oopsie. Looks like Paul Ryan's plan to turn Medicare into an individual mandate could cause a bit of a problem with this one too. The Ryan plan is the gift that keeps on giving for Democrats if they choose to run with it. Every last one of them voted for it and they can't run from it.

On the other hand, as predicted, there is one program they are probably all going to be able to agree upon slashing to the bone: Medicaid. Ezra Klein writes today:

There are two reasons Medicaid is more vulnerable than Medicare. The first is who it serves. Medicaid goes to two groups of people: the poor and the disabled. Most of the program’s enrollees are kids from poor families, though most of the program’s money is spent on the small fraction of beneficiaries who are disabled and/or elderly. These groups have one thing in common, however: They’re politically powerless.

The second is who pays. Medicare is a federal program. Medicaid is a state-federal match, and it kills states during recessions, as unlike the federal government, states can’t run deficits, and so they find themselves with increased costs because they have more people in need but decreased revenues. So there are a lot of governors — particularly GOP governors — straining under overstretched state budgets who’d like a way out of their fiscal crisis that doesn’t include raising taxes, and there are a lot of federal legislators who’d like to save money without having seniors mounting protest marches outside their office, and Medicaid begins to look like an answer to everyone’s problem. “You can shift costs to states so they can be the bad guys while the federal policymakers pretend they didn’t hurt anybody,” says Bob Greenstein, president of the Center on Budget and Policy Priorities.

I don't know how this affects the mechanism to expand Medicaid under Health Care Reform but even under the best case scenario (that the dollars are already mandated under the bill and the president refuses to sign anything that changes that), if these cuts go through, it's robbing Peter to pay Paul. Certainly, any cuts that are happening in 2012 will create a worse starting point for the level of expansion envisioned for 2014 and beyond.

This was always my gut feeling about the health care reform bill and I wrote about it incessantly during the endless debate. I believed it could improve the private insurance market for some members of the middle class who are self-employed and that there was some potential for cost savings down the road. But the only truly liberal vision contained within it --- bringing more poor people under Medicaid --- would fall apart once the deficit hawks who were already circling swooped in. (Remember Ben Nelson's Medicaid "opt-in" proposal?) This was the bait they used to trap progressives and I understood exactly why they couldn't get out of it. It's very hard to walk away from something that might benefit millions and millions of poor people. But it was always the weakest link and it's just sad to see it all playing out so predictably.

I had hoped that the administration would not let anyone mess with his plan, but I'm beginning to think that this may be the one area they are willing to compromise. Ezra quotes former Clinton health care adviser Chris Jennings:

It’s relatively invisible. It’ll give states the flexibility they say they want. And it’ll hurt a population that doesn’t vote.”

Looks like we might just be finding some "common ground" on health care after all.