By THE ASSOCIATED PRESS JUNE 27, 2017, 3:15
A.M. E.D.T.
WASHINGTON — Somewhere along the way, the
Republican crusade to repeal "Obamacare" also turned into an effort
to limit the future growth of Medicaid. That bit of mission creep is complicating
prospects for the GOP, and could lead to deadlock.
The federal-state program for low-income
people has long been stigmatized as substandard. But over time it has grown and
changed to become a mainstay for hospitals, nursing homes, insurers, and now
drug treatment centers confronting the opioid epidemic. With about 70 million
enrolled, Medicaid covers more people than Medicare, from newborns to nursing home residents.
Republicans including Sens. Susan Collins of
Maine, Dean Heller of Nevada, and Govs. John Kasich of Ohio, Charlie Baker of
Massachusetts, and Doug Ducey of Arizona have all expressed misgivings about
the Senate's GOP health care bill.
"Medicaid cuts hurt most vulnerable
Americans," tweeted Collins, announcing she would vote against the bill.
In her state, Medicaid covers about 1 in 5 people.
The National Association of Medicaid
Directors, a nonpartisan group that represents state administrators of the
program, is calling the legislation unworkable, a "transfer of risk,
responsibility, and cost to the states of historic proportions."
A Congressional Budget Office estimate
released Monday said the Senate bill's biggest impacts on spending would come
from Medicaid. Federal contributions would be reduced by $772 billion over a
decade. In 2026, 15 million fewer people would be covered through Medicaid.
But Republican leaders are unlikely to
retreat, for political and practical reasons. Although the House and Senate
bills differ on timing and some key details, they would basically achieve the
same goals:
—Phasing out the extra financing that former
President Barack Obama's health care law provides to states that
expand Medicaid. Thirty-one states have taken advantage of a generous federal
matching formula, expanding their programs to mainly benefit low-income adults.
About 11 million people have gained coverage. Under the GOP bill, states could
continue to serve this group, but would have to accept a lower match from
Washington.
—Putting a limit on future federal financing
for the entire program, through a per-beneficiary cap that would be adjusted
for inflation. That would effectively end Medicaid's status as an open-ended
entitlement, under which the federal government matches a share of what each
state spends. The formula for annual adjustments has sparked a particularly
sharp reaction, with critics saying that the Senate decision to use a broad
measure of annual inflation simply won't keep up with faster increases in
health care costs.
On the Medicaid expansion, there's wide
agreement among Republicans that Obama's federal matching rate of no less than
90 percent amounts to wasteful spending. The regular Medicaid matching rate
averages about 60 percent.
More broadly, many Republicans are strong
believers in limiting the future growth of federal health care programs. House
Speaker Paul Ryan has long advocated a voucher-like option for Medicare that
would also restrain spending. But President Donald Trump had promised not to
cut the health program for seniors. That left Medicaid, with total annual
spending of more than $550 billion.
"The present system is unsustainable; we
don't have enough money to continue what's being done," said Sen. Mike
Enzi, R-Wyo., the budget committee chairman. Medicaid "was set up for poor
women, for children and disabled people. Obamacare used it as a dumping ground
for able-bodied people."
States would gain much greater flexibility
over how to spend their Medicaid dollars under the Republican approach.
But liberals see another agenda. On the
practical side, the Medicaid cuts in the GOP bills facilitate rolling back
hundreds of billions in tax increases on upper-income people and corporations
that helped finance coverage for Obama's legislation.
"Cutting Medicaid leaves more room to
repeal some of these taxes," said Paul Van de Water, a policy expert with
the Center on Budget and Policy Priorities, which advocates for low-income
people.
As the outcry grows, the White House and some
Republican leaders are pushing back hard, arguing that it isn't fair to call
their legislation a Medicaid cut. They say spending on the program would keep
growing, just not as fast.
"In fact, this is slowing the growth of
Medicaid and allowing governors more flexibility," White House counselor
Kellyanne Conway asserted on Fox.
"I'm not going to allow people and
detractors and Trump haters to call me a liar because they don't want to do the
homework and look at what is actually happening to Medicaid," Conway
added.
The claim involves some budgetary sleight of
hand that both parties have resorted to.
If a bill changes the rules to reduce what
government was otherwise expected to spend, that meets the definition of a cut.
In fact, Republicans called it a cut when
Democrats reduced Medicare payments to providers to help finance Obama's health
overhaul. Democrats responded they were reducing wasteful spending to extend
Medicare's solvency.
But the argument worked in favor of
Republicans, helping them win the House in the 2010 midterm elections.
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