Legacy shrinkage

Legacy shrinkage

by digby

So, I was thinking back to the health care debates the other day and reminded about what a terrible squeeze the whole thing put on the progressive faction of the Democratic Party over the Medicaid expansion. You remember that, right? That was the big liberal kahuna, the one outright progressive policy that was going to bring necessary health care to millions of working poor Americans and their families who could not afford even the allegedly affordable health care policies that would become available in the exchanges.

That provision was always vulnerable in the long term but I think everyone assumed that the president himself would protect all aspects of his health care reforms above all --- it's his "signature issue" etc, etc. as I've written here many times. That seems to be seriously in question. Joan McCarter writes:

The Center on Budget and Policy Priorities has a review of one of the Medicaid proposals the White House has forwarded in budget negotiations, warning that the cost shift it includes would mean a cut in services...

Under current law, the federal government pays a fixed percentage of each state's Medicaid costs, from 50 to 75% of costs depending on the state with an average of 57% nationally. It pays 70%, nationally, of the children's health program, SCHIP. The Affordable Care Act would increase that commitment to 100% for the population that is made newly eligible for Medicaid under the law, and for the first three years (2014-16) with a reduced commitment until 2019, when it's down to 90%. States that expanded Medicaid to cover patients who aren't traditionally covered (childless adults) could qualify for a higher matching rate from the federal government.

That's all if the ACA is implemented as written, in addition to current law. This new, blended-rate proposal, however, "would replace this mix of matching rates with a single matching rate for each state, which would apparently apply to all of a state’s Medicaid and CHIP expenditures, outside of administrative costs." And that would mean more burden on the states and, likely, curtailed ability on the part of the states to pay providers (meaning fewer doctors taking Medicaid patients) and to cover people who would otherwise qualify...

The fact that it would undercut the expansion of Medicaid under the ACA—the most significant part of the law for actually expanding health care—should send White House negotiators back to the drawing board on what to do with Medicaid in these budget negotiations

Indeed, they should. But since they are the one's proposing it, I doubt that's what going to happen.

A lot of us have been trying to read the tea leaves about how the Democrats were going to end up handling "entitlements" during this time of irrational deficit fever and there's been a ton of speculation about Medicaid in recent days. For all the talk about them, Medicare and SS are third rails for a reason --- they have a large and distinct constituency that will vote on those issues regardless of their political ideology. It's a heavy lift to fight back the endless assaults, but if enough people put their weight behind it, they have shown that it can be done.

But Medicaid is vulnerable and always has been. It's why the progressives with conscience were torn apart at the idea of walking away from the one chance they saw to expand this program in this era of extreme selfish indifference (if not outright hostility) to the plight of those at the lowest income strata. When would this again be possible --- and under the protection of the president and party which implemented it for at least a few years to come?

I don't think anyone expected the Democratic leadership and the president to walk away from their own hard fought health care reforms before they even had a chance to be implemented. And I didn't think this because I believed the Democrats and the president were good hearted folk who just want to help the poor. I have no idea what's in their hearts. But I did think they would have wanted to give their legacy issue a chance to be implemented in full at the beginning, so they could continue to brag about bringing health care to 30 million uninsured Americans if nothing else. I suppose they'll continue to say it, but if they approve these changes it won't be true.

But as the president says, in these tough times the government has to tighten its belt just like all American families. I guess he must realize that one of the things American families have had to cut out is their health insurance. So much for that legacy.

Oh, and by the way --- the only way this gambit saves any money is if they cut people off. Medicaid is the least expensive health care in the country.