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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.

*********************************

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].