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Killing Granny: The GOP’s “One Size Fits All” Death Panel for Health Care

In this post we’re going to be taking another [1] look [2] at the GOP’s health care reform agenda. And since it’s the GOP’s health care reform agenda it’s inevitably going to include an examination of how it’s actually a privatization agenda that “saves health care” by reducing access to affordable health care and thus reducing the overall health care costs (and then probably letting you die early from the lack of health care via pre-existing condition waiver loophole [3]).

We’ll be returning to [2] the “block granting” of Medicare and Medicaid to the states and then having those states either erode the programs over time or issuing another “block grant” to individuals in the form of a voucher.

But we’re also going to look at another dimension to the GOP’s health care reform agenda: reforming who is going to carry that health care cutting agenda out and, in turn, reforming who gets blamed. Specifically, how the GOP plans on transferring blame for that agenda from Congressional Republicans to state-level governors and lawmakers by block granting Medicaid and Medicare to the states – but not letting those block grants grow fast enough to keep up with rising health care cots – and letting state governors and legislators decide what specifically gets cut. Blame redistribution/diffusion is a key part of this agenda but it could have interesting consequences. In addition to the predictably tragic consequences of cutting health care costs by cutting health care.

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Change is coming to Washington DC. Mostly horrible changes. But as we’ll see in this post, there is one very significant and positive change coming as a consequence of the unified GOP control of the White House and Congress: GOP is actually going to start getting the blame it deserves for all the damage its pro-oligarch/anti-everyone-else agenda routinely inflicts upon the American people. Politics can be frustrating for a myriad of reasons, but one of the biggest sources of frustration is the cloud of perpetual obfuscation and confusion that tends to permeate the political discourse and collective understanding of what’s actually happening, why it’s happening, and who should be rewarded or blamed for it. But for the next couple of years, at a minimum, it’s going to be very clear who to blame for the damage DC is about to unleash, and it’s not just going to be Donald Trump [4]:

Talking Points Memo
Editor’s Blog

The Republican Congress is Responsible

By Josh Marshall
Published January 28, 2017, 4:00 PM EDT

For political and moral reasons, it is important to remember that very little of what the President is now doing is possible without a compliant Congress. Executive orders in most cases fill in the blanks that legislation leaves to the President’s discretion. So this isn’t just a matter of the sway a Congress of the President’s party can exercise over him, which is substantial. In many or most cases, Executive Orders and Actions can literally be overruled with new legislation.

Since President Trump is unpopular, Democrats have a clear political incentive to tar the Republican Congress with Trump’s unpopularity. But this is not simply a political gambit. They make his actions possible. They are responsible for virtually everything he’s doing.

How unpopular is he? The latest reputable poll (Quinnipiac) puts Trump’s approval rating at 36% [5], an unheard of level of unpopularity for a new President. Gallup’s number has generally been more favorable to Trump. But according to numbers released today, his net approval rating dropped 8 points during his first week in office. Again, virtually unheard of.

Meanwhile a new AP-NORC poll shows weak for repealing Obamacare and that 56% of American are either “extremely” or “very” worried that many Americans will lose their health care coverage if Obamacare is repealed. An additional 27% are “somewhat” concerned.

The President is unpopular. His main policies are unpopular. His behavior is unpopular. The Congress makes everything he’s doing possible. Most of them are up for reelection in less than two years.

“Since President Trump is unpopular, Democrats have a clear political incentive to tar the Republican Congress with Trump’s unpopularity. But this is not simply a political gambit. They make his actions possible. They are responsible for virtually everything he’s doing.

Yep, the American people didn’t just elect a new man-child for president. They also reelected the Republican-controlled Congress that’s going to be carrying Trump’s water and giving him a green light to carry out his agenda.

And what is that agenda? Well, for the most part, it’s the classic GOP agenda of privatizing entitlements, slashing taxes on the rich, and burning down the social safety-net. Sure, Trump didn’t actually campaign on privatizing entitlements and gutting the safety-net, but as we’re going to see in the article excerpts below, he’s now made it abundantly clear that the GOP’s agenda is his agenda too…especially when it comes to entitlements and the safety-net. And the GOP Congress will be holding his hand and guiding his path every step of the say. So when the GOP-controlled Congress is carrying water for Trump they’re actually carrying their own water…without the help of the Democrats to take the blame like they might have been with divided control of the federal government in case everyone becomes all wet.

The Republicans Appear to Have a Guilty Conscience Fear of Getting Caught on Health Care Especially

So the GOP and Trump have a particularly precarious mutual water-carrying operation ahead of them. And the fact that the water the GOP and Trump are carrying happens to be poisonous water – both politically poisonous – isn’t going to make it any easier. Especially when it comes to all the poisonous water they’re going to carrying in relation to health care reform since that’s going to be literally poisonous for the health and well-being of their constituents and therefore extra politically poisonous too.

And while it’s clear that the GOP doesn’t actually care about the physical harm it inflicts upon the American people they really do care about the political harm they’re about to inflict upon themselves [6]

The Washington Post

Behind closed doors, Republican lawmakers fret about how to repeal Obamacare

By Mike DeBonis
January 27, 2017 at 11:08 PM

PHILADELPHIA — Republican lawmakers aired sharp concerns about their party’s quick push to repeal the Affordable Care Act [7] at a closed-door meeting Thursday, according to a recording of the session obtained by The Washington Post.

The recording reveals a GOP that appears to be filled with doubts about how to make good on a long-standing promise to get rid of Obamacare without explicit guidance from President Trump or his administration. The thorny issues with which lawmakers grapple on the tape — including who may end up either losing coverage or paying more under a revamped system — highlight the financial and political challenges that flow from upending the current law.

Senators and House members expressed a range of concerns about the task ahead: how to prepare a replacement plan that can be ready to launch at the time of repeal; how to avoid deep damage to the health insurance market; how to keep premiums affordable for middle-class families; even how to avoid the political consequences of defunding Planned Parenthood, the women’s health-care organization, as many Republicans hope to do with the repeal of the ACA.

“We’d better be sure that we’re prepared to live with the market we’ve created” with repeal, said Rep. Tom McClintock (R-Calif.). “That’s going to be called Trumpcare. Republicans will own that lock, stock and barrel, and we’ll be judged in the election less than two years away.”

Recordings of closed sessions at the Republican policy retreat in Philadelphia this week were sent late Thursday to The Post and several other news outlets from an anonymous email address. The remarks of all lawmakers quoted in this article were confirmed by their offices or by the lawmakers themselves.

“Our goal, in my opinion, should be not a quick fix. We can do it rapidly — but not a quick fix,” said Sen. Lamar Alexander (R-Tenn.). “We want a long-term solution that lowers costs.”

Sen. Rob Portman (R-Ohio) warned his colleagues that the estimated budget savings from repealing Obamacare — which Republicans say could approach a half-trillion dollars — would be needed to fund the costs of setting up a replacement. “This is going to be what we’ll need to be able to move to that transition,” he said.

Rep. Pete Sessions (R-Tex.) worried that one idea floated by Republicans — a refundable tax credit — would not work for middle-class families that cannot afford to prepay their premiums and wait for a tax refund.

Republicans have also discussed the idea of generating revenue for their plan by taking aim at deductions that allow most Americans to get health insurance through their employers without paying extra taxes on it. Sen. Bill Cassidy (R-La.), who has drafted his own bill to reform the Affordable Care Act, said in response, “It sounds like we are going to be raising taxes on the middle class in order to pay for these new credits.”

Rep. Kevin Brady (R-Tex.), who chairs a key tax-writing subcommittee, countered, “I don’t see it that way,” adding that there is “a tax break on employer-sponsored health care and nowhere else” equal to $3.6 trillion over 10 years.

“Could you unlock just a small portion at the top to be able to give that freedom [to self-employed Americans]? That is the question,” Brady said.

Rep. John Faso (R-N.Y.), a freshman congressman from the Hudson Valley, warned strongly against using the repeal of the ACA to also defund Planned Parenthood. “We are just walking into a gigantic political trap if we go down this path of sticking Planned Parenthood in the health insurance bill,” he said. “If you want to do it somewhere else, I have no problem, but I think we are creating a political minefield for ourselves — House and Senate.”

The concerns of rank-and-file lawmakers appeared to be at odds with key congressional leaders and Andrew Bremberg, a top domestic policy adviser to Trump, who have laid out plans to repeal the ACA using a fast-track legislative process and executive actions from the administration. However, these leaders acknowledged in Thursday’s meeting, as they have before, that Obamacare cannot be fully undone — or replaced — without Democratic cooperation.

House Speaker Paul D. Ryan (R-Wis.) dismissed the concerns aired in the meeting during an interview at a Politico event Friday.

“We have a responsibility to work for the people that put us in office,” he said. “That’s the oath we take: to defend the Constitution, to fight for the people we represent, and this is a fiasco that needs to be fixed.”

Of particular concern to some Republican lawmakers was a plan to use the budget reconciliation process — which requires only a simple majority vote — to repeal the existing law, while still needing a filibuster-proof vote of 60 in the Senate to enact a replacement.

“The fact is, we cannot repeal Obamacare through reconciliation,” McClintock said. “We need to understand exactly: What does that reconciliation market look like? And I haven’t heard the answer yet.”

Several important policy areas appeared unsettled. While the chairmen of key committees sketched out various proposals, they did not have a clear plan for how to keep markets viable while requiring insurers to cover everyone who seeks insurance.

At one point Cassidy, a physician who co-founded a community health clinic in Baton Rouge to serve the uninsured, asked the panelists a “simple question”: Will states have the ability to maintain the expanded Medicaid rolls provided for under the ACA, which now provide coverage for more than 10 million Americans, and can other states do similar expansions?

“These are decisions we haven’t made yet,” said House Energy and Commerce Committee Chairman Greg Walden (R-Ore.).

Rep. Tom MacArthur (R-N.J.) worried that the plans under GOP consideration could eviscerate coverage for the roughly 20 million Americans [8] now covered through state and federal marketplaces and the law’s Medicaid expansion: “We’re telling those people that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them.”

Republicans are also still wrestling with whether Obamacare’s taxes can be immediately repealed, a priority for many conservatives, or whether that revenue will be needed to fund a transition period.

And there seems to be little consensus on whether to pursue a major overhaul of Medicaid — converting it from an open-ended entitlement that costs federal and state governments $500 billion a year to a fixed block grant. Trump and his top aides, including counselor Kellyanne Conway, have publicly endorsed that idea. But doing so would mean that some low-income Americans would not be automatically covered by a program that currently covers 70 million Americans.

Many of the concerns aired Thursday were more political than policy-oriented. Faso’s remarks about Planned Parenthood generated tepid applause. Ryan said this month that he expects the House to pursue the organization’s defunding [9] in the reconciliation bill.

Those expressing qualms included some of the top congressional leaders who are in line to draft the health-care legislation. Alexander, for one, is chairman of the Senate Health, Education, Labor and Pensions Committee.

Ryan and other leaders have said they intend to pursue a piecemeal approach, following the reconciliation bill with smaller ones that address discrete aspects of reform.

Faso warned that by defunding Planned Parenthood in the reconciliation bill, “we are arming our enemy in this debate.”

“To me, us taking retribution on Planned Parenthood is kind of morally akin to what Lois Lerner and Obama and the IRS did against tea party groups,” he said, a reference to accusations that the Internal Revenue Service improperly targeted conservative political groups for audits.

Faso continued: “Health insurance is going to be tough enough for us to deal with without having millions of people on social media come to Planned Parenthood’s defense and sending hundreds of thousands of new donors to the Democratic Senate and Democratic congressional campaign committees. So I would just urge us to rethink this.”

““We’d better be sure that we’re prepared to live with the market we’ve created” with repeal, said Rep. Tom McClintock (R-Calif.). “That’s going to be called Trumpcare. Republicans will own that lock, stock and barrel, and we’ll be judged in the election less than two years away.””

Is the GOP prepare to “live with the market we’ve created”? Well, it’s not quite the right way to phrase the question since it’s the American public, and not the GOP members of Congress, who are going to have to be “living” with the market the GOP creates. Or dying with it. The question is whether or not the GOP is ready to politically own what they’re about to do to American health care.

And if the concerns expressed by the congressmen above are any indication of an answer to that question, no, the GOP is not ready to politically own what they’re about to do. In part because they really, really want to block grant Medicaid and get another doomed grand experiment in neoliberal austerity but are very mixed about keeping the Obamacare Medicaid Expansion [1]. By block granting it and putting the grand game of federal-state Medicaid-cuts Political Hot Potato started. You don’t want to rush a game of Hot Potato of that nature. And set it on a path towards privatization. They aren’t sure they’re ready to start that quite yet. But Trump’s already on board so that’s not going to be an obstacle:

Rep. Tom MacArthur (R-N.J.) worried that the plans under GOP consideration could eviscerate coverage for the roughly 20 million Americans [8] now covered through state and federal marketplaces and the law’s Medicaid expansion: “We’re telling those people that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them.”

Republicans are also still wrestling with whether Obamacare’s taxes can be immediately repealed, a priority for many conservatives, or whether that revenue will be needed to fund a transition period.

And there seems to be little consensus on whether to pursue a major overhaul of Medicaid — converting it from an open-ended entitlement that costs federal and state governments $500 billion a year to a fixed block grant. Trump and his top aides, including counselor Kellyanne Conway, have publicly endorsed that idea. But doing so would mean that some low-income Americans would not be automatically covered by a program that currently covers 70 million Americans.

And here’s the thing: when you hear GOPers fretting about “We’re telling those people that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them,” don’t forget that all the GOP’s plans for health care reform involve pulling the rug out. It’s just supposed to happen slowly. That’s what block granting is all about. So concern about pulling the rug out too quickly aren’t really concerns about pulling the rug out from underneath their constituents. They’re concerns about doing it so rapidly and noticeably the the public realizes what’s happening and the GOP ends up owning their politically poisonous policies.

It’s a Matter of When, Not If, the GOP Block Grants Medicaid and the Death Spiral Begins. So Says Team Trump

But it’s just a question of when, not if, the GOP has to seriously wrestle with the political consequences block granting Medicaid and setting it on a path towards a death by a thousand state-level cuts since Trump’s team is already signally its ready to carrying the GOP’s water on to the Medicaid block grant plan [10]:

The New York Times

Trump’s Health Plan Would Convert Medicaid to Block Grants, Aide Says

By ROBERT PEAR
JAN. 22, 2017

WASHINGTON — President Trump’s plan to replace the Affordable Care Act will propose giving each state a fixed amount of federal money in the form of a block grant to provide health care to low-income people on Medicaid, a top adviser to Mr. Trump said in an interview broadcast on Sunday.

The adviser, Kellyanne Conway, who is Mr. Trump’s White House counselor, said that converting Medicaid to a block grant would ensure that “those who are closest to the people in need will be administering” the program.

A block grant would be a radical change. Since its creation in 1965, Medicaid has been an open-ended entitlement. If more people become eligible because of a recession, or if costs go up because of the use of expensive new medicines, states receive more federal money.

If Congress decides to create block grants for Medicaid, lawmakers will face thorny questions with huge political and financial implications: How much money will each state receive? How will the initial allotments be adjusted — for population changes, for general inflation, for increases in medical prices, for the discovery of new drugs and treatments? Will the federal government require states to cover certain populations and services? Will states receive extra money if they have not expanded Medicaid eligibility under the Affordable Care Act, but decide to do so in the future?

Ms. Conway, speaking on the NBC program “Sunday Today,” said that with a block grant, “you really cut out the fraud, waste and abuse, and you get the help directly” to intended beneficiaries.

Medicaid covers more than 70 million people at a combined cost of more than $500 billion a year to the federal government and the states. More than 20 million people have gained coverage under the Affordable Care Act, more than half of them through Medicaid.

As a candidate, Mr. Trump said he wanted to “maximize flexibility for states” so they could “design innovative Medicaid programs that will better serve their low-income citizens.” On Friday, in his first executive order [11], he directed federal officials to use all their authority to “provide greater flexibility to states” on the health law.

As part of their “Better Way” agenda, House Republicans said in June that they would roll back the Affordable Care Act’s expansion of Medicaid and give each state a set amount of money for each beneficiary or a lump sum of federal money for all of a state’s Medicaid program — “a choice of either a per capita allotment or a block grant.”

Governors like the idea of having more control over Medicaid, but fear that block grants may be used as a vehicle for federal budget cuts.

“We are very concerned that a shift to block grants or per capita caps for Medicaid would remove flexibility from states as the result of reduced federal funding,” Gov. Charlie Baker of Massachusetts, a Republican, said this month in a letter to congressional leaders. “States would most likely make decisions based mainly on fiscal reasons rather than the health care needs of vulnerable populations.”

Gov. Robert Bentley of Alabama, a Republican, said that if a block grant reduced federal funds for the program, “states should be given the ability to reduce Medicaid benefits or enrollment, to impose premiums” or other cost-sharing requirements on beneficiaries, and to reduce Medicaid spending in other ways.

In Louisiana, Gov. John Bel Edwards, a Democrat, said he was troubled by the prospect of a block grant with deep cuts in federal funds. “Under such a scenario,” he said, “flexibility would really mean flexibility to cut critical services for our most vulnerable populations, including poor children, people with disabilities and seniors in need of nursing home and home-based care.”

Gov. John W. Hickenlooper of Colorado, a Democrat, said that block grant proposals could shift costs to states and “force us to make impossible choices in our Medicaid program.”

“We should not be forced to choose between providing hard-working older Coloradans with blood pressure medication or children with their insulin,” Mr. Hickenlooper said.

“Governors like the idea of having more control over Medicaid, but fear that block grants may be used as a vehicle for federal budget cuts.

That’s some healthy fear right there. And why shouldn’t governors, especially GOP governors, fear what there federal GOP brethren have planned for them? It’s a plan that makes the governors and state legislatures the new leaders in implement all those cuts the GOP has been trying to do at the federal level for decades

“We are very concerned that a shift to block grants or per capita caps for Medicaid would remove flexibility from states as the result of reduced federal funding,” Gov. Charlie Baker of Massachusetts, a Republican, said this month in a letter to congressional leaders. “States would most likely make decisions based mainly on fiscal reasons rather than the health care needs of vulnerable populations.”

Gov. Robert Bentley of Alabama, a Republican, said that if a block grant reduced federal funds for the program, “states should be given the ability to reduce Medicaid benefits or enrollment, to impose premiums” or other cost-sharing requirements on beneficiaries, and to reduce Medicaid spending in other ways.

“Gov. Robert Bentley of Alabama, a Republican, said that if a block grant reduced federal funds for the program, “states should be given the ability to reduce Medicaid benefits or enrollment, to impose premiums” or other cost-sharing requirements on beneficiaries, and to reduce Medicaid spending in other ways.”

Ok, so Governor Bentley of Alabama doesn’t appear to fear actually making the cuts to block granted programs like Medicaid. Instead he fears not being able to make those cuts when the GOP cuts the per-capita block grant size that the federal government is inevitably going to make, which is a somewhat silly fear since getting the states to cut health care expenditures is the whole point of block granting these programs.

But what about the rest of the GOP governors like Governor Baker of Massachusetts? Are they also going to readily embrace the freedom to “reduce Medicaid benefits or enrollment, to impose premiums” or other cost-sharing requirements on beneficiaries, and to reduce Medicaid spending in other ways,” like Governor Bentley clearly had no problem doing? We’ll find out, but that’s all part of the GOP’s plan: convert Medicaid to a block grant and then let the state governors and legislators carry the water on implementing the actual cuts. It’s a GOP-style redistribution scheme: a scheme for the permanent redistribution from Congress to the states of the political fallout that will inevitably come from the implementation of the GOP’s dream of slowly, but eventually, killing the safety-net [12]:

The Washington Post

The GOP plan to fund Medicaid through block grants will probably weaken it

By Ryan LaRochelle
January 18, 2017

Republicans in the 115th Congress are wasting no time trying to remake the social policy landscape. Barely a week after the new Congress was sworn in, GOP members took an initial step [13] toward repealing aspects [14] of the Affordable Care Act [7], the major domestic piece of President Obama’s legacy.

Republicans seem likely to set their sights on other components of the U.S. welfare state, including Medicaid, Medicare [15] and Social Security. President-elect Donald Trump may not go along with congressional Republicans if they try to alter Medicare and Social Security.

But many key Republicans are especially interested in changing Medicaid, the nation’s health insurance program for the poor — including Trump, House Speaker Paul D. Ryan (Wis.) and Tom Price (Ga.), Trump’s nominee to head the Department of Health and Human Services. Each of those three has proposed converting Medicaid from a program funded jointly by the federal government and the states into a block grant program. Doing so would send a set amount of money to each state, thus capping total Medicaid spending, and would let each state decide how to disburse those funds.

Turning Medicaid into a block grant would result in less funding. Here’s how we know.

Under the current arrangement, the federal government pays states a certain percentage of program expenditures based on criteria, such as per capita income. The percentages are regularly adjusted at three-year intervals based on changes in the economy. How would changing that into a block grant change the program?

1. Data shows that the move to block grants leads to less funding over time.

Historical data suggest that a shift to block grants would result in a gradual decline in Medicaid funding. A 2016 report [16] by the Center on Budget and Policy Priorities (CBPP) showed that when the federal government uses block grants, the funding for the programs shrinks over time:

[O]ur analysis of the 13 major housing, health, and social services block grant programs that policymakers have created in recent decades shows that funding for all but one has shrunk in inflation-adjusted terms since their inception, in some cases dramatically. … Overall funding for the 13 block grants has fallen by 37 percent since 2000, adjusted for inflation and population growth.

Does that mean that the switch to block granting is the factor that drove down spending? It’s hard to say. But here’s one example that is instructive. From 1935 to 1996, under Aid to Families With Dependent Children, the federal government matched state expenditures based on need. Poorer states received a higher federal match rate than wealthier states. And federal expenditures responded to cyclical variation in the economy. From 1970 until the mid-1990s, state and federal expenditures for AFDC were relatively stable [17].

But in 1996, the Clinton administration and congressional Republicans teamed up to replace it with Temporary Assistance for Needy Families (TANF), in which funding was distributed via block grants so that states could experiment with how they would deliver it. As the CBPP report points out, after adjusting for inflation, TANF funding has dropped by 32 percent since its inception. Or to put it differently, before the federal government converted AFDC into the TANF block grant, 68 out of 100 poor families received cash assistance. By 2014, only 23 out of 100 poor families did.

2. Reformers argue that block grants need less funding because they reduce costs. But they don’t.

When reformers propose switching a program to a block grant, they increasingly ask to have the funding reduced at the same time.

In the 1960s and 1970s, both Democratic and Republican administrations used block grants primarily to consolidate existing programs, which did not automatically result in funding reductions. In some cases, block granting actually increased funding for the programs involved — as happened with the Community Development Block Grant and the Omnibus Crime Control and Safe Streets Act.

But since the 1980s, most new block grant proposals have gone in the other direction. Proponents argue that the difference would be made up by increased efficiency and administrative savings.

That’s the approach with Medicaid, as well. Trump’s health-care reform website claims that under a Medicaid block grant, “States will have the incentives to seek out and eliminate fraud, waste and abuse [18] to preserve our precious resources.”

Public administration scholar Carl Stenberg’s analysis of block grants [19], however, found no empirical evidence that the shift to block grants reduced total administrative costs. Rather, these costs are passed from the federal government to the states.

3. Block granting leads to drops in funding because the policies don’t get regular tuneups.

Cornell political scientist Suzanne Mettler’s research [20] shows that just like cars and houses, policies need periodic upkeep to remain effective. Legislators can maintain policies by reauthorizing them to guarantee funding streams, adjusting them for inflation, and periodically reassessing and reforming them.

But legislators often don’t maintain existing policies, leaving them to fall into disrepair. That neglect is not unique to block grants [21]. But certain features of block grants make them particularly susceptible to deferred maintenance and policy drift. Block grants typically do not keep pace with inflation, population changes, rising poverty rates or increased housing costs.

Further, many block grant programs are designed to help low-income people — a group that is least likely to mobilize politically. [22] Unlike, say, the elderly — drawn from every economic strata — the people who rely on poverty programs probably won’t organize to protect their programs from cuts or call for improvements. And so those programs atrophy.

With TANF, for instance, research [23] finds that what citizens need isn’t the factor that pushes states to make sure its policies are effective. Rather, three factors make the difference in how well TANF is designed: the race of most of the state’s beneficiaries, the state’s political ideology and the state’s wealth. Poor, conservative states with a high proportion of African Americans tend to have less generous benefit packages, firmer eligibility rules and stricter work requirements than comparatively well-off states that are more racially homogeneous. Some states take better care of their low-income residents than others because of race, ideology and capacity, not because of need.

In other words, while proponents argue that block grants let states better respond to their residents’ needs, the results show significant inequality across the states.

“Public administration scholar Carl Stenberg’s analysis of block grants [19], however, found no empirical evidence that the shift to block grants reduced total administrative costs. Rather, these costs are passed from the federal government to the states.”

And that, right there, is part of sinister cleverness of the GOP’s grand poisoned water political fallout redistribution scheme: Congress passes a law now that will set in motion a multi-decade long cycle of benefit cuts and squeezed state budgets that will eventually eviscerate programs like Medicaid and state legislatures and governors will be taking a big share of the blame. But not all of the blame obviously, and there’s going to be plenty of blame to go around since this is an incredibly unpopular agenda that Trump and the GOP are about to impose. It’s why the GOP Congress, and Trump, still have major reasons to be seriously worried about any of the blame for their poisonous agenda.

The Beginning of the End of Medicaid Could Be the Beginning of the End of the GOP’s Own Voters. Especially the New Ones

And let’s not forget one of the other significant factors in the federal-to-state blame redistribution scheme: The GOP controls most of the states. Not only that, but the counties where Donald Trump pick up the most support vs the 2012 election happen to be poorer counties that will be most heavily impacted by the GOP’s poison agenda [24]:

The Washington Post

Trump’s plan to roll back Medicaid will especially affect his voters

By Andrea Cerrato, Francesco Ruggieri and Federico Maria Ferrara
January 27, 2017

On Sunday, the Trump administration [25] signaled [10] its intention to convert Medicaid to a block-grant program, giving states more flexibility in how they finance health care for low-income residents. If implemented as part of an Obamacare [7] repeal, the change would likely result in overall less funding [26] for the states.

Although the details of an overhaul would determine where and how large any cuts would be, President Trump may have reason to worry about the electoral effects of a Medicaid rollback.

Our research shows that a significant portion of Trump’s support in 2016 came from low-income areas that would likely be harmed by cuts to Medicaid. And even though those voters did not abandon Trump during the campaign because of his opposition to Obamacare, an actual reduction in benefits is easier said than done.

The politics of Medicaid expansion [27]

Medicaid has been a major political issue since its creation in the 1960s, but it became even more contentious after the passage of the Affordable Care Act in 2010.

Under the ACA, the program was expanded to include all non-disabled adults whose Modified Adjusted Gross Income [28] (MAGI) is below 138 percent of the federal poverty level [29]. After a 2012 Supreme Court decision, [30] states had the choice to implement the new eligibility standards in exchange for additional federal funds, or to opt out altogether. As of today, 31 states and the District of Columbia [31] have adopted the Medicaid expansion.

Given Trump’s campaign pledge to repeal Obamacare, one might have expected him to perform poorly in states where the ACA’s expansion of Medicaid gave low-income Americans better access to health care. But our analysis suggests that Trump did not lose support among low-income voters in Medicaid expansion states.

How Medicaid expansion played out (or didn’t) in the election

The Medicaid expansion was implemented in January 2014, so we examined Trump’s performance relative to that of 2012 Republican nominee Mitt Romney. In particular, we compared the president’s gains in counties where Medicaid has not been expanded to his showing in counties where more adults are now eligible to benefit from the program. By taking the difference in vote share between Trump and Romney, we tried to capture Republican voters’ sensitivity to the Obama administration’s health-care policies.

We also collected demographic and financial data from IPUMS-CPS [32], an integrated set of individual and household-level variables in the United States. Following IRS guidelines, we estimated the national share of non-disabled adults whose MAGI is below 138 percent of the federal poverty level, the threshold for Medicaid expansion eligibility.

Then, we weighted these shares using a county-level indicator of poverty, which produced a measure of the degree of potential eligibility for the Medicaid expansion in each county, shown in the map below.

[see map of potential eligibility for expanded Medicaid [33]]

Low-income households are concentrated in the Southeast (Mississippi, Louisiana, Arkansas, Alabama, Georgia, Florida, South Carolina, North Carolina), in the Southwest (New Mexico, Arizona, California), and in the Northwest (Oregon, Washington, Montana). Thus, darker counties are located in both traditionally Democratic and Republican states.

Finally, we performed a regression analysis [34] to estimate the effect of extended Medicaid eligibility on the shift in the Republican vote share between 2012 and 2016. We weighted the observations for each county’s population and added controls for ethnic and racial composition and educational attainment, as well as state fixed effects.

Perhaps surprisingly, Trump’s gains were uniform across counties with more low-income households, regardless of whether they were in Medicaid expansion states. Indeed, on average Trump outperformed Romney in traditionally Democratic states that extended health-care eligibility.

This counterintuitive result corroborates one of the main trends of the 2016 presidential election. Overall, Trump performed better [35] than any other Republican candidate in the recent past among low-income voters. His opposition to Obamacare had a negligible effect in areas that one would expect to be affected by Medicaid expansion.

Why Medicaid cutbacks could be risky

On the one hand, this could suggest that Trump has little to worry about if the GOP converts Medicaid to a block grant, effectively reducing the size of the entitlement program. After all, if low-income voters were not concerned about Trump’s opposition to Obamacare during the campaign, why would they be now?

But two factors suggest caution might be in order. First, a pledge to roll back a welfare benefit may not have the same impact as its actual repeal. As political scientist Paul Pierson [36] has argued [37], “frontal assaults on the welfare state carry tremendous electoral risks.”

One reason is that interest groups and voters often oppose direct threats to welfare programs. And already, the specter of a reduction in health-care benefits appears to have mobilized [38] unhappy constituents in some parts of the country.

Second, to the extent that a reduction in Medicaid benefits weakens Trump’s support among low-income voters, their shifting allegiances could prove pivotal, either in the 2018 midterms or in the 2020 presidential election. This is especially true in light of his narrow margin of victory in key battleground states.

“Our research shows that a significant portion of Trump’s support in 2016 came from low-income areas that would likely be harmed by cuts to Medicaid. And even though those voters did not abandon Trump during the campaign because of his opposition to Obamacare, an actual reduction in benefits is easier said than done.”

Yep, while it might take years for the the GOP’s health care attrition agenda to get fully implemented via this ‘death by a thousand cuts’ block grant strategy and the political fall out to be fully felt, it may not take very much fall out to start seriously impacting the GOP. Especially since Trump’s gains for the GOP were often in counties with the most to lose from any cuts at all:


Perhaps surprisingly, Trump’s gains were uniform across counties with more low-income households, regardless of whether they were in Medicaid expansion states. Indeed, on average Trump outperformed Romney in traditionally Democratic states that extended health-care eligibility.

This counterintuitive result corroborates one of the main trends of the 2016 presidential election. Overall, Trump performed better [35] than any other Republican candidate in the recent past among low-income voters. His opposition to Obamacare had a negligible effect in areas that one would expect to be affected by Medicaid expansion.

So after Trump makes big gains for the GOP with low-income voters, the GOP and Trump immediately start working together to screw over that exact group in a massive way that will only get worse for years to come. It’s hard to see how implementing a scheme to shift future blame for safety-net cuts from Congress to the states is going to blunt the immediate fall out for immediately implementing that scheme. And even if the GOP decides to skip the Medicaid block granting scheme for now and instead just do the Obamacare “repeal and replacement” alone, that’s still probably going to involve rolling back the Medicaid expansion in these same low-income counties that swung for Trump.

And After Medicaid, It’s Medicare on the Block Grant Chopping Block. Of Course

All in all, it’s extremely unclear what the GOP can do at all to avoid massive blame if they actually implement their agenda which is probably why they haven’t decided yet on what exactly they’re going to do and when they’re going to do it. Their agenda is a politically Phyrric victory. And the more of it they implement the Pyrric it’s going to be. Which could be extremely Pyrrhic [39]:

The Huffington Post

Not Just Obamacare: Medicaid, Medicare Also On GOP’s Chopping Block
The health care safety net as we know it could be bound for extinction.

Jonathan Cohn Senior National Correspondent, The Huffington Post
Jeffrey Young Senior Reporter, The Huffington Post
11/15/2016 11:50 am ET | Updated Nov 15, 2016

Donald Trump and Republican leaders in Congress have made clear they are serious about repealing Obamacare, and doing so quickly. But don’t assume their dismantling of government health insurance programs will stop there.

For about two decades now, Republicans have been talking about radically changing the government’s two largest health insurance programs, Medicaid and Medicare.

The goal with Medicaid is to turn the program almost entirely over to the states, but with less money to run it. The goal with Medicare is to convert it from a government-run insurance program into a voucher system – while, once again, reducing the money that goes into the program.

House Speaker Paul Ryan (R-Wis.) has championed these ideas for years. Trump has not. In fact, in a 2015 interview [40] campaign website highlighted, he vowed that “I’m not going to cut Medicare or Medicaid.” But the health care agenda on Trump’s transition website, which went live Thursday, vows [41] to “modernize Medicare” and allow more “flexibility” for Medicaid.

In Washington, those are euphemisms for precisely the kind of Medicare and Medicaid plans Ryan has long envisioned. And while it’s never clear [42] what Trump really thinks or how he’ll act, it sure looks like both he and congressional Republicans are out to undo Lyndon Johnson’s health care legacy, not just Barack Obama’s.

Of course, whenever Trump or Republicans talk about dismantling existing government programs, they insist they will replace them with something better – implying that the people who depend on those programs now won’t be worse off.

But Republicans are not trying to replicate what Medicaid, Medicare and the Affordable Care Act do now. Nor are they trying to maintain the current, historically high [43] level of health coverage nationwide that these programs have produced. Their goal is to slash government spending on health care and to peel back regulations on parts of the health care industry, particularly insurers.

This would mean lower taxes, and an insurance market that operates with less government interference. It would also reduce how many people get help paying for health coverage, and make it so that those who continue to receive government-sponsored health benefits will get less help than they do now.

It’s difficult to be precise about the real-world effects, because the Republican plans for replacing existing government insurance programs remain so undefined. Ryan’s “A Better Way” proposal [44] is a broad, 37-page outline [45] without dollar figures, and Senate Republican leaders have never produced an actual Obamacare “replacement” plan.

But the Republican plans [46] in circulation, along with the vague – and shifting – health care principles Trump endorsed during the campaign, have common themes. And from those it’s possible to glean a big-picture idea of what a fully realized version of the Republican health care agenda would mean.

Obamacare

Obamacare has expanded and bolstered health insurance mainly through two sets of changes: a straightforward expansion of Medicaid eligibility, which the 31 states and the District of Columbia [47] now offer, and a makeover of the insurance market for people buying private coverage on their own rather than through employers. The net effect of the Affordable Care Act is an estimated 20 million fewer uninsured [48] than before the law.

Obamacare’s makeover included writing new rules for insurers: All policies must now include comprehensive benefits, for example, and carriers can no longer deny coverage to people with pre-existing conditions nor charge them higher rates than healthy people.

The newly reformed insurance system also offers subsidies: to assist people who could never afford coverage before; and to offset the higher prices insurers charge now that they must cover more services, without turning away the people most likely to use them.

Repealing the law outright would increase the number of uninsured Americans by 22 million, according to the Congressional Budget Office [49]. Republicans have vowed to replace Obamacare with something better – “great health care for much less money,” as Trump put it on “60 Minutes” [50] Sunday.

But GOP plans would scale back the federal commitment to Medicaid, then unwind the changes to the individual insurance market by reducing the regulations on coverage. GOP plans would also eliminate the health insurance exchanges through which more than 10 million people get access to private insurance and those all-important subsidies. Republican schemes envision new forms of financial assistance, but generally lower income people would get less money [44], and (depending on the details) many middle-income people would too..

Some of the regulatory changes would be indirect. Allowing insurers to sell across state lines [51] – an idea Trump mentioned frequently – would let all insurers relocate to states with the fewest rules, effectively gutting [52] requirements more progressive states might impose on coverage. Overall, the result would be less coverage and protection than Obamacare provides.

And while some people would benefit, others would suffer. To take one example, healthy 25-year-olds could buy cheaper, skimpier policies than the law now allows. But 55-year-olds with high blood pressure would tend to face higher premiums – because insurers could resume charging them more [53] – and bigger copayments at the pharmacy.

Republicans talk a lot about preserving Obamacare’s most popular provisions, like protections for people with pre-existing conditions.

But the fine print of their proposals shows their guarantee is different – and less ironclad. Insurers could still turn away people who don’t maintain “continuous coverage [54].” That’s no small thing. People who lose jobs frequently let coverage lapse [55] – and it’d happen more commonly in a world without the generous financial assistance Obamacare provides.

Conservatives say they have a solution for this: They would create special insurance plans, called “high-risk pools [56],” for people insurers won’t cover.

This idea has been tried before, at the state level – and it didn’t work very well [53]. The plans typically offered weaker coverage at higher prices, and required vast infusions of money that state governments rarely provided. Tellingly, Ryan’s budget allocates just $25 billion over 10 years for high-risk pools. Even conservative [57] experts believe it would take far more money [58] for the pools to be the viable alternatives that Republicans imagine.

In September, RAND Corp. [59] researchers analyzed Trump’s health care reform principles and determined that his plan would increase the number of uninsured by 16 million to 25 million people, with a particularly tough impact on people with serious medical conditions who would face higher out-of-pocket charges.

That’s a very rough guess, and a worst-case scenario. You can find analysts [60] who make assumptions more favorable to conservative plans and end up more sanguine [61] about the results. But the basic effect of all GOP replacement plans is clear: fewer people with insurance, less protection for people who have it, or some mix [52] of the two.
Gallup

Medicaid

As of August, 73 million Americans [62] had benefits from Medicaid or the Children’s Health Insurance Program, according to the Centers for Medicare and Medicaid Services, which doesn’t break up the numbers for the two programs. All but around 16 million [62] of them are covered by pre-Obamacare rules, but all Medicaid beneficiaries stand to be affected by the GOP’s plans.

Until the Affordable Care Act, working-age adults without disabilities were ineligible for this benefit [63] in most cases, with some exceptions, including low-income pregnant women and very poor parents [63] of children who qualified for Medicaid or CHIP.

As an entitlement like Medicare and Social Security, Medicaid gets however much money [64] it takes to cover the medical expenses for everyone enrolled.

Over a 10-year time period, the Medicaid plan the House Budget Committee approved [65] this year would reduce federal spending on the program by about one-third, or roughly $1 trillion [66], not even counting the effects of repealing Obamacare’s expansion of the program, according to the Center on Budget and Policy Priorities.

Repealing the Affordable Care Act and its Medicaid expansion fully would eliminate the coverage for the roughly 16 million people [62] the Centers for Medicare and Medicaid Services reports have enrolled under this policy.

The federal government paid for 62 percent [67] of the $532 billion [68] in Medicaid expenditures in fiscal year 2015, the most recent year for which such a breakdown is available. In 25 states [69], the federal share of spending is higher still [67], so even states that may want to maintain today’s Medicaid benefits would find it extremely difficult, if not impossible [70], to replace the federal dollars that would disappear under GOP proposals.

One result could be 25 million fewer [59] Medicaid beneficiaries, according to the RAND Corp.’s analysis of Trump’s plans.

Trump and other Republicans have long promoted “flexibility” that would enable states, which jointly finance and manage Medicaid with the federal government, to alter the program.

While this may seem on its face like simple federalism, the purpose is not to allow states to cover as many people as they do now in different ways, but to significantly reduce federal spending on Medicaid and to permit states to cut back on who can receive Medicaid coverage and what kind of benefits they have.

Ryan’s latest version [44] of this 35-year-old idea [71] idea would establish either “block grants” to states – that is, a flat amount of money each state would get from the federal government each year to spend on Medicaid as they like – or “per capita allotment” – meaning a flat amount of money for each person enrolled. These approaches would differ [72] in terms of how much money states would receive yearly and how much the funding would increase from year to year.

In any case, the funding wouldn’t be high enough to maintain current coverage, inevitably leading to millions of currently covered individuals losing their benefits. And the financing would grow at a slower rate than health care costs, portending more lost coverage over time. For those who remain on Medicaid, Ryan would permit states to charge them monthly premiums and add other strings [45], such as a work requirement.

Medicare

The Medicare revamp [73] in “A Better Way” would result in wholesale changes [74] to the entitlement – ones that would realize Ryan’s long-term goal of privatizing [75] the program.

Today, most of the 55 million Medicare beneficiaries enroll in the traditional, government-run program and then buy private supplemental insurance to cover remaining out-of-pocket costs. A sizable minority opts to buy private insurance plans, through the Medicare Advantage program. The government regulates these plans tightly, to make sure they provide coverage at least as generous as the traditional Medicare program does.

Ryan would replace [76] this arrangement with a “premium support [77]” system, under which each senior would get an allotment of money – voucher, in other words – he can use to get insurance. When Ryan introduced the first formal version of his proposal, in 2010 [78], he envisioned ending the traditional government program altogether. Now he says it should continue to exist alongside the private plans, competing with them for business.

What would this mean for beneficiaries? A great deal would depend on details Ryan has yet to provide, particularly when it comes to the value of that voucher – and how quickly it would increase every year – compared to the cost of the insurance. But the whole point of the system is to ratchet down the value of the vouchers over time.

That would reduce spending on Medicare, which Ryan always says is a goal, and some seniors would likely end up saving money, because they could easily switch to cheaper plans. The question would be what happens to everybody else. Without adequate regulation [77] of benefits and other safeguards tailored to the special needs of an older, frequently impaired population of seniors, the consequence of moving to premium support could be higher costs for individual seniors who have serious health problems – with low-income seniors feeling it most intensely.

If at the same time Republicans shrink Medicaid, those seniors will suffer even more, since today the poorest seniors can use the program to pay for whatever medical bills Medicare does not.

Ryan promises that the proposal would not affect seniors who are 55 or older, since the new system wouldn’t begin operating for 10 years. But realistically the entire Medicare program would change once premium support took effect – private plans would almost certainly find ways to pick off the healthiest seniors, for instance – and, at best, the damage would simply take longer to play out.

Ryan’s Medicare scheme includes one other element – a provision to raise the eligibility age [79] gradually, so that seniors would eventually enroll at 67, rather than 65. Particularly in a world in which the Affordable Care Act no longer exists, 65- and 66-year-olds searching for private coverage would find it harder to obtain, more expensive and less generous than what they’d get from Medicare today.

The end result [80] would almost surely be higher out-of-pocket costs for those younger seniors – and a significant number of them, maybe into the millions, with no insurance at all.

“The Medicare revamp [73] in “A Better Way” would result in wholesale changes [74] to the entitlement – ones that would realize Ryan’s long-term goal of privatizing [75] the program.”

Privatized Medicare. That could actually happen. Soon. And almost certainly will happen soon if the GOP is confident it can avoid the fall out. But it’s very unclear how that fall out can be avoided unless the GOP can figure out how to sell the public on replace Medicare with a voucher. Although we do any an idea of what they might do: block grant Medicare while simultaneously offer the voucher privatized voucher system so they can claim that Medicare isn’t going away (while ignoring the fact that the whole point of the block grant scheme is to make sure Medicare eventually erodes away…along with the vouchers):


Ryan would replace [76] this arrangement with a “premium support [77]” system, under which each senior would get an allotment of money – voucher, in other words – he can use to get insurance. When Ryan introduced the first formal version of his proposal, in 2010 [78], he envisioned ending the traditional government program altogether. Now he says it should continue to exist alongside the private plans, competing with them for business.

What would this mean for beneficiaries? A great deal would depend on details Ryan has yet to provide, particularly when it comes to the value of that voucher – ant ome seniors would likely end up saving money, because they could easily switch to cheaper plans. The question would be what happens to everybody else. Without adequate regulation [77] of benefits and other safeguards tailored to the special needs of an older, frequently impaired population of seniors, the consequence of moving to premium support could be higher costs for individual seniors who have serious health problems – with low-income seniors feeling it most intensely.

So a few wealthier and healthier seniors might befit from Paul Ryan’s Medicare voucher plan, and every else gets screwed. Slowly. Or maybe quickly depending on how it all plays out. Either way, there’s going to be an abundance of political fall out that’s going to have to be redistributed over the coming decades if the GOP is going to maintain its grip on Congress.

That’s part of what’s going to make this whole fiasco so depressingly fascinating: the Congressional GOP’s plans for destroying the US health care system is simultaneously a plan to make the GOP-dominated governors and state legislators much, much less popular with the electorate. And while that might seem like a decent trade off if you’re a GOP congressman, don’t forget that one of the secrets to the GOP’s success at the federal level is all the gerrymandering that’s almost guaranteed the GOP a lock on the House of Representatives. And future GOP gerrymandering requires state-level control.

And don’t forget that one of the other secrets of the GOP’s success at the state level is political posturing against “DC” and all the things that happen at the federal level that voters are paying more attention to than state-level issues. But with this block granting scheme, one of the biggest political lightning rods in DC becomes a state-level lightning rod too and the kind of lightning rod that the GOP’s ‘kick the poor’ orthodoxy might not mesh well with. Especially after Trump and the GOP Congress finish off what’s left of the US middle class and the wealthy own basically everything. The more successful the Trump and the GOP are in implementing their broader socioeconomic agenda (which is still basically the Koch brothers’ agenda despite the Trumpian veneer [81]), the more political potency health care for the financially struggling is going to be in coming decades. So we really could be seeing the Congressional GOP’s federal-to-state block granting switcharoo scheme sowing the seeds for GOP’s future demise. The GOP controls the federal branch of government relies heavily on its control of the states, so if it loses its grip on state control the losses at the federal level are pretty much inevitable. That’s what happens if you undo egregious gerrymandering [82].

So if Paul Ryan and the GOP Congress screw this up massively – by first screwing up US health care and then screwing up their blame redistribution scheme – they’re obviously going to hurt their political prospects. But if they succeed – by first screwing up US health care (screwing it up is succeeding for the GOP) and then succeeding in their federal-to-state blame redistribution scheme – they might end up being even more screwed in the long run by losing control of state legislatures and governorships and losing the ability to gerrymander the hell out of the House of Representatives. Don’t underestimate how unpopular [83] state governments could become if they start carrying the Congressional GOP’s poisonous water. After all, the “premium support” (voucher) plan that Paul Ryan has for Medicare means that we’re not just looking at block-grants to states. Those states are going to in turn create block-grants for individuals. That’s what a voucher is: an individual block grant that’s designed to shrink over time and not be able to deal with sudden funding emergencies. Is a multidimensional block grant scheme political owned by federal and state GOPers going to endear that party to the American people?

It all raises the question of when the state-level GOP is going to join the rest of the country in opposing the likely ‘Trumpcare’ model of block granting entitlements and sending them into a planned slow-death spiral. Purely out of a sense of personal political survival. Otherwise it’s time for the GOP to play Poisonous Hot Potato Death Spiral. Do state-level GOP elected officials want to see programs like Medicare and Medicaid slashed and burned? Almost assuredly. They’re Republicans. But do they want to do those cuts themselves? That’s a very different question. But their Congressional brethren are about to make sure they do.

What should the GOP do? Well, they could stop having a psycho agenda, but since that’s apparently not an option it’s very unclear what they should do. It all raises the question of when the GOP’s voter suppression [84] agenda [85] is going to expand past minorities, the poor, and the youth, to include targeting the elderly too.

And, of course, there’s the question of what the GOP’s plan is after they’ve completed their entitlement privatization/evisceration agenda and adequate health care access is a pipe dream for tens of millions more Americans than were lacking health insurance in the pre-Obamacare era for the kinds of health care needs that even heartless oligarchs should want to see the rabble have access to. Like health care for communicable disease. Will hospital emergency rooms be just expected to pick of the slack? Forever? How about all the new communicable [86] diseases [87] of the future [88]? Do Trump and the and his fellow GOP travelers in Congress have a plan for that? Unfortunately, maybe [89].