Even some Senate
Republicans acknowledge the changes in their repeal bill might never see the
light of day.
07/03/2017 05:10 AM EDT
POLITICO
MAGAZINE
The Senate health
care bill, if it becomes law, would set in motion a massive rollback of
Medicaid funding beginning in three years. But even some Republican supporters
acknowledge the full cuts might never happen.
Instead, they say it
could become another Washington fiscal cliff, where lawmakers go to the brink
of radical spending changes only to pull back — or have their successors pull
back — just before the point of inflicting real pain in the face of intense
pressure.
“We all expect that
no matter what we do, somebody is going to come back and say they want it
plussed up,” said Sen. John Cornyn (R-Texas), who believes the cuts are
essential. “We’re trying to take the only entitlement that we actually have a
realistic chance of putting on a sustainable path … and taking that opportunity
to get that done.”
One Congress can’t
stop its successors from changing the laws it passes. And there’s plenty of
precedent for postponing pain, especially since one Congress’ attempt at fiscal
responsibility may become a political liability to the next. One of the most
notorious examples was the decade-plus “doc fix” fiasco, in which Congress
repeatedly found money to avoid automatic cuts to doctors’ Medicare
reimbursements mandated by the 1997 Balanced Budget Act.
Facing other
“cliffs,” Congress has repeatedly prevented rules that bar many tax breaks from
hitting the middle class. Lawmakers also quickly undid military
pension cuts that were part of the 2013 bipartisan budget deal.
The Senate bill, if
passed into law, would certainly result in political pain — it would reduce
federal Medicaid spending by $772 billion over 10 years, shifting to an even
more frugal spending path over time. It would also for the first time cap, or
limit, the federal contribution to Medicaid, starting in 2020. And it would
unwind Obamacare’s Medicaid expansion.
It is expected that
those cuts would create huge gaps in state budgets, and governors would have to
make up the money somehow — or else drop people or trim benefits. Those
pressures have Republicans openly speculating that a future Congress would face
immense political pressure to block or delay the cuts.
But some Republicans
think the funding changes are reasonable. Federal spending for many other
programs is capped at the rate of inflation — the rate the GOP wants to set for
Medicaid starting in 2025, said Sen. Lamar Alexander (R-Tenn.), chairman of the
Senate Health, Education, Labor and Pensions Committee.
But even Alexander
admitted that could change for Medicaid.
Pegging spending to
grow at the regular inflation rate “has been a very sensible, prudent way to do
it,” he said. “In the case of defense, we’re going to have to increase defense
spending. We could make the same sort of decision about Medicaid if that turned
out to be necessary.”
Traditionally, health
care spending has grown faster than the rate of inflation.
The Medicaid portion
of the Senate’s plan has gotten less attention than the Obamacare repeal. But
the Medicaid overhaul would constitute the biggest changes to a program that
covers about 74 million people since it was established more than 50 years ago.
For decades, Republicans have sought to rein in the program’s spending and give
states more flexibility.
The bill would both
chop Obamacare’s enhanced Medicaid payments beginning in 2021 and convert the
entire program to a budgeted system based on a flat payment to the state for
each patient beginning in 2020.
“It’s a program that
has got to stop growing so fast so we can have it 10 years from now, 20 years
from now, 30 years from now,” said Sen. Roger Wicker (R-Miss.). “So to the
extent that we can give states an opportunity to experiment 50 different ways
and make it work better for the people, that’s a good thing.”
Still, some
Republicans admit they may not have the political stomach to go through with
the most dramatic changes.
“I don’t think it
will ever be instituted,” Sen. Dean Heller (R-Nev.) said of the Medicaid cuts
before he came out against the Senate bill.
“It’s kind of like
the Cadillac tax,” he said, referring to an unpopular Obamacare tax on
high-cost health care plans that Congress has already delayed as a result of
political pressure. Nevada is one of 31 states that expanded Medicaid under the
2010 health care law.
Democrats contend
that conservatives are being sold a bill of goods — that the health care bill
offers sweeteners such as scaling back Obamacare in the beginning while the
bigger cuts to Medicaid happen in the future.
The bill is "a whole
lot of short-term spending that is guaranteed to happen, and a whole lot of
promised, deeply unpopular, long-term structural reform that Democrats and
Republicans would work together to undo before they ever came to pass,"
said a senior Democratic aide. "We’ll see if conservatives end up willing
to once again be the suckers at the end of this backroom deal.”
That said, lawmakers
may not have many chances to stop the spending reductions before they begin to
take effect in 2020, if a bill passes. President Donald Trump's term doesn't
end for four years, so Republicans would still control at least one branch of
government. There would be competing pressures: The party's fiscal
conservatives have long sought the Medicaid spending rollback that may make
moderates queasy before an election.
On top of that, at
least eight states have automatic triggers to unwind their Medicaid expansion
programs if federal funding declines below Obamacare levels, many of them
immediately. Three million people in those states — Arkansas, Arizona,
Illinois, Indiana, Michigan, New Hampshire, New Mexico and Washington state —
gained coverage under the expansion.
And Republicans were
unable to undo much of Obamacare even after Democrats lost control of the
House.
“Once you get
something into statute, it’s hard to change it,” Wicker said. President Barack
“Obama lost the House two years after he got elected president and never got it
back. And it was still almost impossible to make those substantive statutory
changes to Obamacare. It’s on the books, and it takes a full action by the
House, Senate and signature by the president to get it done.”
Burgess Everett
contributed to this report.
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