The American Health Care Act And Medicaid: Changing A Half-Century Federal-State Partnership

By Sara Rosenbaum
Health Affairs Blog, March 10, 2017

Based on page length alone, it is evident that Medicaid is a focal point of the American Health Care Act, released on March 6. Although its fate is uncertain, the bill provides a clear sense of where the Affordable Care Act repeal and replace strategy is heading. Where Medicaid is concerned, what has been discussed for years has now become real: using ACA repeal/replace as the vehicle for a wholesale restructuring of the very financial foundation of the Medicaid program as it has existed over an unparalleled, half-century federal/state partnership.

As expected, the House bill essentially eliminates the enhanced funding levels that made possible states’ expansion of Medicaid to their poorest working-age adult residents, something that 31 states and the District of Columbia now have done. Expansion states could face up to a 40-point difference between the federal funding enhancements they expected to receive in 2020 for the expansion population and what they actually would receive under the bill. What is at stake is continued coverage for some 11 million of the more than 16 million people who have gained eligibility since full implementation of the ACA Medicaid expansion.

Even more fundamentally, the bill — as expected given the draft that was leaked in mid-February — radically restructures Medicaid’s federal financing system. Along with its withdrawal of the ACA’s adult eligibility funding enhancement, the bill would shift an estimated $370 billion in financial risks to the states over the coming decade, according to the Center on Budget and Policy Priorities. And aside from several targeted and harmful restrictions on federal funding for specific state activities, the bill does nothing to provide states with the additional flexibility they would need to absorb these cuts. States have built their programs and designed their complex health care delivery systems for the poor over a half century, entirely depending on this federal/state funding arrangement. Under the bill, they either would have to accept the terms of a seriously diminished financial deal or give up federal funds entirely.

Concluding Thoughts

There’s no doubt about it: Medicaid is a big program. But its size is a reflection of the number of people it covers; the extent of poverty in the U.S.; the greater survival of children and adults with profound disabilities; the greater life spans of the elderly who need decent long-term care in nursing home and community settings; advances in technology; and a program design strategy pursued over five decades by federal and state lawmakers alike that has deliberately positioned Medicaid to function as what has been described as the “workhorse” of the American health care system.

On a per capita basis, Medicaid actually operates quite efficiently, costing less than other forms of insurance. But Medicaid is big because collectively we have asked that it assume a vast range of jobs, from financing care for the highest-risk babies to being the first line of health care defense when natural disasters strike. Some day we may spread these responsibilities across public and private insurers alike, thereby reducing the burden on the program and on states as well. But in light of the decisions we collectively have made about how best to respond to pressing national health needs, the potential effects of such a seminal shift federal Medicaid funding policy point to the importance of a slower, more carefully crafted process of change.

http://healthaffairs.org…

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Watch Paul Ryan’s Adam’s Apple When He’s Asked Why His Health Plan Cuts Taxes for the Rich

By Jonathan Chait
New York, March 9, 2017

Tucker Carlson: The overview here is that all the wealth [in] basically the last ten years basically has stuck to the top end, that’s one of the reasons we’ve had all this political turmoil, as you know. Kind of a hard sell to say, ‘Yeah, we’re gonna repeal Obamacare but we’re gonna send more money to the people who’ve already gotten the richest over the last ten years.’ I mean, that’s what this does, no? … I’m not leftist, that’s just, that’s true!

Paul Ryan: I–I–I’m not concerned about it because we said we were gonna repeal all the Obamacare taxes, this is one of the Obamacare taxes. The other point I’d is, this dramatically helps tax reform,

http://nymag.com…

In the past most conservatives have agreed that the government must provide assistance to low-income individuals for them to be able to obtain the health care that they need, that you can’t simply just cut them loose in the health care marketplace to fend for themselves. Thus the Medicaid program – a low cost program that does largely meet the health care needs of this vulnerable population. But now Congress wants to begin ratcheting down this program – a move that can have only disastrous consequences for the health care and the finances of these people in need.

Why are they doing this? Is it ideology? Isn’t that just an abstraction? Is it improving access to health care, as implied by their false rhetoric? It actually does the opposite.

Paul Ryan has explained more than once what they are doing. They are cutting “Obamacare taxes” which are progressive taxes that were designed to help pay for the health care that lower-income individuals otherwise could not afford. In fact, the two main policy features of the Republican legislation are to decrease government contributions to health care for lower-income individuals while decreasing taxes on the wealthy that would be used to pay for that care.

Even Tucker Carlson recognizes that this is a transfer of wealth from the masses to the rich. Thus it seems that their ideology is more than an anti-government abstraction, it is to prioritize greed over health care justice. Wealth for the wealthy and health care for the, well… wealthy.