Cutting Medicaid Means Cutting Care For The Poor, Sick And Elderly
The part of Paul Ryan’s budget that’s going to get the most attention is his proposal to privatize and voucherize Medicare. But the part that worries me the most is his effort to slash Medicaid, with no real theory as to how to make up the cuts.
Ryan’s op-ed introducing his budget lists Medicaid under “welfare reform,” reflecting the widespread belief that Medicaid is a program for the poor. That belief is wrong, or at least incomplete. A full two-thirds of Medicaid’s spending goes to seniors and people with disabilities — even though seniors and the disabled are only a quarter of Medicaid’s members. Sharply cutting Medicaid means sharply cutting their benefits, as that’s where the bulk of Medicaid’s money goes. This is not just about the free health care given to some hypothetical class of undeserving and unemployed Medicaid queens.
But perhaps cutting it wouldn’t be so bad if there were a lot of waste in Medicaid. But there isn’t. Medicaid is cheap. Arguably too cheap. Its reimbursements are so low many doctors won’t accept Medicaid patients. Its costs grew less quickly than those of private insurance over the past decade, and at this point, a Medicaid plan is about 20 percent cheaper than an equivalent private-insurance plan. As it happens, I don’t think Medicaid is a great program, and I’d be perfectly happy to see it moved onto the exchanges once health-care reform is up and running. But the reason that’s unlikely to happen isn’t ideology. It’s money. Giving Medicaid members private insurance would cost many billions of dollars.
That’s why it’s well understood that converting Medicaid into block grants means cutting people off from using it, or limiting what they can use it for. You can see CBO director Doug Elmendorf say exactly the same thing here. There’s just not another way to cut costs in the program. You can, of course, work to cut costs outside of the program, either by helping people avoid becoming disabled or making it cheaper to treat patients once they become disabled or sick, but those sorts of health-system reforms are beyond the ambitions of Ryan’s budget.
To get around some of this, Ryan’s op-ed talks about state flexibility, with the implication being that states have some secret Medicaid policies they’ve been dying to try but that the federal government simply hasn’t let them attempt. But the truth is there’s been a tremendous amount of experimentation in Medicaid over recent decades. Indiana converted its Medicaid program into health savings accounts. Tennessee based its program around managed care. Massachusetts folded its Medicaid money into Mitt Romney’s health-care reforms. Oregon tried to rank treatments by value. Some of these reforms have worked well and some haven’t worked at all, but none have solved the basic problem that covering the sick and disabled costs money, and you can’t get around that by trying to redesign their insurance packages. For that reason, block-granting Medicaid ultimately means cutting health-care coverage to the poor, the elderly and the disabled, even as it doesn’t actually address the factors driving costs throughout the health-care system.
By: Ezra Klein, The Washington Post, April 5, 2011
When Lies Don’t Work, Try “Bait And Switch”: What Paul Ryan’s Budget Actually Does
Paul Ryan’s plan for Medicare and Paul Ryan’s plan for Medicaid rely on the same bait-and-switch: They use a reform to disguise a cut.
In Medicare’s case, the reform is privatization. The current Medicare program would be dissolved and the next generation of seniors would choose from Medicare-certified private plans on an exchange. But that wouldn’t save money. In fact, it would cost money. As the Congressional Budget Office has said (pdf), since Medicare is cheaper than private insurance, beneficiaries will see “higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.”
In Medicaid’s case, the reform is block-granting. Right now, the federal government shares Medicaid costs with the states. That means their payments increase or decrease with Medicaid’s actual rate of spending. Under a block grant system, that’d stop. They’d simply give states a lump sum at the beginning of the year and that’d have to suffice. And if a recession hits and more people need Medicaid or a nasty flu descends and lots of disabled beneficiaries end up in the hospital with pneumonia? Too bad.
In both cases, what saves money is not the reform. It’s the cut. For Medicare, the cut is that the government wouldn’t cover the full cost of the private Medicare plans, and the portion they would cover is set to shrink as time goes on. In Medicaid, the block grants are set to increase more slowly than health-care costs, which is to say, the federal government will shoulder a smaller share of the costs than it currently does. The question for both plans is the same: What happens to beneficiaries?
Remember how the Affordable Care Act was really, really, really long? There was a reason for that. It was full of delivery-system reforms meant to make the health-care system cheaper and more efficient — things like bundling payments for illnesses and reducing reimbursements to hospitals with high rates of infection and creating a center tasked with seeding cost-control experiments throughout Medicare and encouraging the formation of Accountable Care Organizations. The hope is that those reforms will cut costs, which will make the rest of the bill’s cuts possible (more on that here). Republicans, notably, have been skeptical that these reforms will work, and have argued that the cuts won’t stick because beneficiaries will revolt.
To my knowledge, Ryan’s budget doesn’t attempt to reform the medical-care sector. It just has cuts. The hope is that those cuts will force consumers to be smarter shoppers and doctors to be more economical and states to be more innovative. But all that’s been tried, and it hasn’t been enough. That’s why the Affordable Care Act had to go so much further, digging deep into the delivery system, and why Republicans had at least a plausible case that some of its cuts wouldn’t stick. But now the GOP needs to apply the same skepticism to their own programs: Cuts aren’t enough, and if they somehow manage to distract people from the cuts by repeating the words “block grants” and “flexibility” and “premium support” over and over again, they’ll simply end up seeing their cuts ignored when it becomes clear that they’ll mean leaving the old and the poor without health care. What Ryan has here isn’t so much a plan to control spending as a plan to cut spending, whatever the consequences.
By: Ezra Klein, The Washington Post, April 4, 2011
Government Shutdown: A Hostile Act Against A Civil Society By A “Band Of Rebels”
Shutting down the federal government is a hostile act against civil society.
The Civil War started 150 years ago in April 1861, and we are still getting over it, still talking about it, still writing about it. Some in the South have still not made peace with the end of the Civil War and hold fast to “heroes,” notably General Robert E. Lee. President Abraham Lincoln showed what he thought of Lee when he seized Arlington, Lee’s stately home and slave plantation across the Potomac River, and started burying the dead Union soldiers in the ground there.
Lincoln’s message could not be clearer: Leading an assault on the Union was not a Sunday picnic in the country. Serious consequences followed, hitting home.
Now we have a band of rebels—87 of them newcomers—in the House Republican majority, who are fixin’ for a fight. Spoiling to see the Capitol Dome go dark. Acting as if that’s the mission, the reason they crossed lines to come into the heart of the enemy. Washington is a staging ground for their defiant anger at the Union. The republic is under a new kind of siege.
If they have their way, the federal government will be closed this time next week, not what we need right now with so many American households hanging by a thread.
Now a few facts to concentrate the mind. First, the Tea Party is part of the problem. But hold the whole lot of House Republicans and their leaders responsible. If there are any grown-ups in the House, they are allowing their most radical element, unschooled freshmen, to dominate in a delicate showdown looming with the Senate and the White House.
Second, remember the Senate is controlled by a Democratic majority, a fact conveniently forgotten by the lower chamber, whose members often brag about the last election. The 2010 outcome was actually an evenly divided government, with a Democratic president to play his part in final outcomes, laws, and budgets. That’s the way it should be, if Senate Democrats and President Obama will only stand up to the rebels.
Third, the scope of the House Republican “defunding” demands is tantamount to waging war on our civil society as we know it. I don’t mean just NPR. Some of the priceless “commons” are at risk, in the proposed degradation of environmental programs. Social programs like family planning and women’s health are on the chopping block in an offensive against women’s health and reproductive rights. Chris Van Hollen, a House Democrat from Maryland, reads it right: Across the aisle is an extreme agenda to impose a right-wing ideology on town and country, using budget cuts as a vehicle.
Fourth and finally, whether $33 billion or $60 billion is cut from the budget, it will be too much. For the collective health of the nation, either number is like going on a diet when you’re starving. It’s really no use the two congressional chambers meeting in the middle, because the rebels can say they won the day—and they might be “right” in more ways than one. They skewed the debate by passing their draconian budget early and talking it up every day since.
What the GOP House freshmen lack in knowledge, they make up with sophomoric enthusiasm. They are so gung ho to camp out in the dark. Remembering Lincoln, don’t let the rebels take over and turn the lights out on us.
By: Jamie Stiehm, U.S. News and World Report, April 4, 2011
KSM Decision: Place The Blame Where Blame Is Due
Many in the media, and many more of President Obama’s detractors from the left, are hitting his administration pretty hard today for this reversal. The development is obviously disappointing, but if we’re assigning blame, let’s at least direct at those responsible.
In a major reversal, the Obama administration has decided to try Khalid Sheikh Mohammed for his role in the attacks of Sept. 11 before a military commission at Guantanamo Bay, Cuba, and not in a civilian courtroom.
Attorney General Eric H. Holder Jr. is expected to announce on Monday afternoon that Mr. Mohammed, the self-described mastermind of the attacks, and four other accused conspirators will face charges before a panel of military officers, a law enforcement official said. The Justice Department has scheduled a press conference for 2 p.m. Eastern time.
Mr. Holder, who had wanted to prosecute Mr. Mohammed before a regular civilian court in New York City, changed his mind after Congress imposed a series of restrictions barring the transfer of Guantanamo detainees into the United States, making such a trial impossible for now, the official said.
Even that last sentence is awkward — the Attorney General “changed his mind” after Congress “imposed a series of restrictions”? That’s a bit like saying I changed my mind about getting up after I was tied to my chair.
Holder told reporters this afternoon that his original decision was still the right one, but blamed Congress for “tying our hands.”
He happens to be right. Even today, Holder wants to do the right thing, and so does President Obama. And yet, Gitmo is open today, and KSM will be subjected to a military commission in the near future, not because of an administration that backed down in the face of far-right whining, but because congressional Republicans orchestrated a massive, choreographed freak-out, and scared the bejesus out of congressional Democrats. Together, they limited the White House’s options to, in effect, not having any choice at all.
There’s plenty of room for criticism of the administration, but those slamming Obama for “breaking his word” on this are blaming the wrong end of Pennsylvania Avenue.
By: Steve Benen, Political Animal, Washington Monthly, April 4, 2011
A SUCKER’S BET: Are Republicans Really Prepared To “Gamble On Entitlement Reform”?
The effort to pass a budget for the remainder of the fiscal year will be the principal challenge for policymakers over the next few days, but while that work continues, congressional Republicans will also start a massive fight over the next budget.
We’ll have more on this later — sneak preview: the GOP wants to gut entitlements — but as the process gets underway, it’s worth pausing to appreciate the politics here. The Weekly Standard‘s Stephen Hayes has a lengthy new report, arguing that Republicans are prepared to “gamble on entitlement reform,” and the GOP thinks it can win this time.
If there is one thing that political strategists, pollsters, and elected officials of both parties have agreed on for decades, it’s that entitlement reform is a sure political loser. Social Security is the “third rail” — touch it and you die. Suggest changes to Medicaid and you don’t care about the poor. Propose modest reforms to Medicare and you’re the target of a well-funded “Mediscare” campaign that ensures your defeat.
No longer.
“People are getting it that these things are unsustainable,” says Karl Rove. “For so many people, debt is no longer abstract. It’s more concrete. I don’t know if it’s seeing Greece on TV or what. It’s still tough, but it’s not the political loser it used to be.”
Other influential Republicans go further. They believe that getting serious about entitlement reform can be politically advantageous.
“I think it can be a real winner for Republicans if we handle it the right way,” says South Carolina senator Jim DeMint.
The piece goes on to quote all kinds of Republicans, all of whom genuinely seem to believe there’s a public appetite for their entitlement agenda. GOP officials have been too scared to tackle this in earnest before, the theory goes, but bolstered by public support, this time will be different. This time, they say, Americans want entitlement cuts, and Democratic criticisms will fall on deaf ears.
Time will tell, I suppose, but all of the available evidence suggests these folks have no idea what they’re talking about, and are poised to pursue one of the most dramatic examples of political overreach we’ve seen in a very long time.
Republicans can presumably read polls as easily as I can, but let’s focus for a moment on the latest CNN poll, released late last week. Asked, for example, about Medicaid funding, a combined 75% want funding levels to stay the same or go up. For Social Security, 87% of Americans want funding levels to stay the same or go up. For Medicare, 87% want funding levels to stay the same or go up — and most want funding to increase, not stay the same.
For some reason, Hayes and his allies look at numbers like these and think Republicans will benefit from pushing entitlement cuts. No, seriously, that’s what they think. GOP leaders are not only arguing this, they’re actually counting on it as part of a larger political strategy.
Karl Rove, ostensibly the GOP’s most gifted strategist, believes Americans may be “seeing Greece on TV,” and suddenly find themselves favoring Medicare cuts.
I don’t think he’s kidding.
Hayes noted in his piece, “So have things really changed? We’ll soon find out.”
On this point, we agree.
By: Steve Bensen, Washington Monthly, April 4, 2011
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