Las Vegas Sun

March 28, 2024

In health bill’s defeat, Medicaid comes of age

Medicaid

Maddie McGarvey / The New York Times

Tracie Scott, who is covered by Medicaid, holds her 3-day-old daughter Izabella at the ProMedica Defiance Regional Hospital in Defiance, Ohio, March 15, 2017. Medicaid is a behemoth that provides for the medical needs of one in five Americans.

When it was created more than a half century ago, Medicaid almost escaped notice.

Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine.

But during the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of 1 in 5 Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.

Medicaid also played a major, though far less appreciated, role in last week’s collapse of the Republican drive to repeal and replace the Affordable Care Act, also known as Obamacare. While President Donald Trump and others largely blamed the conservative Freedom Caucus for that failure, the objections of moderate Republicans to the deep cuts in Medicaid also helped doom the Republican bill.

“I was not willing to gamble with the care of my constituents with this huge unknown,” said Rep. Frank A. LoBiondo, R-N.J., a member of the centrist Tuesday Group caucus, noting that in three of the counties in his district in the state’s more conservative southern half, more than 30 percent of all residents are covered by Medicaid.

In the Senate, many Republicans, echoing their states’ governors, had worried about jeopardizing the treatment of people addicted to opioids, depriving the working poor, children and people with disabilities of health care and in the long run reducing funding for the care of elderly people in nursing homes.

The Republican bill would have largely undone the expansion of Medicaid under the ACA, which added 11 million low-income adults to the program and guaranteed the federal government would cover almost all of their costs. It would have also ended the federal government’s open-ended commitment to pay a significant share of states’ Medicaid costs, no matter how much enrollment or spending rose. Instead, the bill would have given the states a choice between a fixed annual sum per recipient or a block grant, both of which would have almost certainly led to major cuts in coverage over time.

The nonpartisan Congressional Budget Office predicted that the Republican bill would have cumulatively cut projected spending on Medicaid by $839 billion and reduced the number of Medicaid beneficiaries by 14 million over the coming decade.

Many Republicans could not stomach those consequences. Even some conservatives — Christopher H. Smith of New Jersey, for example, and Daniel Webster of Florida — expressed concerns about the number of Medicaid recipients who could suffer.

The Trump administration will likely still seek to rewrite Medicaid rules and give states more leeway to limit benefits or eligibility, for example, allowing them to require certain adults in the program to have jobs or pay monthly premiums. And many Republican governors and members of Congress remain determined to curb Medicaid spending, including by methods proposed in the bill. In 2015, the nation spent more than $532 billion on Medicaid, of which about 63 percent was federal money and the rest from the states.

Still, last week’s defeat reflected how hard it is to take away an entitlement. It also showed the reach of Medicaid, which covers about six times as many people as the private marketplaces created under the ACA created by President Barack Obama.

Medicaid provides medical care to 4 out of 10 American children. It covers the costs of nearly half of all U.S. births. It pays for the care for two-thirds of people in nursing homes. And it provides for 10 million children and adults with physical or mental disabilities. For states, it accounts for 60 percent of federal funding — meaning that cuts hurt not only poor and middle-class families caring for their children with autism or dying parents, but also bond ratings.

The program not only pays for 16 percent of all personal health care spending nationwide, but also accounts for 9 percent of federal domestic spending.

Because it has always covered a patchwork of groups, Medicaid lacks the unified political constituency that Social Security and Medicare have.

In Kaiser’s polling since 2005, the percentage of people who support cutting Medicaid spending has never exceeded 13 percent.

Trump led the charge for the bill that would have slashed Medicaid, but he recognized the program’s political potency during his campaign, proclaiming when he announced his candidacy that Medicaid should be saved “without cuts.”

“It’s health care for a huge chunk of the country,” said James A. Morone, a political-science professor at Brown University.

Facing Need Back Home

As he waited to see what would happen to the Republican proposal last week, Myrone Pickett said, “I’ve got a question mark hanging over my head.”

Pickett, of Bloomfield, New Jersey, got health insurance under the ACA’s expansion of Medicaid, and has used it for monthly shots of Vivitrol, a drug that reduces cravings for opioids and alcohol. A heroin addict for 16 years, Pickett, 51, said the treatment had helped him stay clean for the past year, get medication for bipolar disorder and land a job at a grocery store.

The ACA offered a tempting deal to states that agreed to expand Medicaid eligibility to everyone with incomes up to 138 percent of the poverty level — $16,400 for a single person — mostly low-wage workers like cooks, hairdressers and cashiers. The federal government would initially pay 100 percent of the costs of covering their medical care, and never less than 90 percent under the terms of the law. Over the past three years, 31 states and the District of Columbia took the deal.

The move was especially helpful to states overwhelmed by the opioid epidemic. It required Medicaid to cover addiction and mental health treatment for those newly eligible.

Announcing his vote against the GOP proposal last week, Rep. Brian Fitzpatrick, who represents a politically moderate district north of Philadelphia, said his top concern was “the impact on the single most important issue plaguing Bucks and Montgomery counties, and the issue that I have made my priority in Congress: opioid abuse prevention, treatment and recovery.”

The Battle Against Medicaid

This was the third major effort by Republicans to end Medicaid as an open-ended entitlement. The first was under President Ronald Reagan; the second was in 1995, after President Bill Clinton’s unsuccessful attempt to expand health care coverage. But this was the first time Republicans tried it while they controlled the White House and both houses of Congress.

At first, Medicaid helped states provide medical care only for single parents and children on welfare.

But Democrats gradually pushed to expand benefits.

By the 1980s and ‘90s, health insurance was becoming prohibitively costly, and wages were starting to stagnate. Employer-based health insurance was eroding. States led by Republicans as well as Democrats began to expand their Medicaid programs.

In 1996, Clinton expanded Medicaid to cover more working families as part of his welfare overhaul.

The expansion of Medicaid in the Children’s Health Insurance Program, passed with Republican sponsorship in 1997, set the stage for the expansions of the Affordable Care Act 13 years later.

Gradually, Republican-led states have adopted the expansion. And now that the law known as Obamacare has survived the effort to repeal it, more states, such as Maine and Kansas, may choose to expand Medicaid.

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