The GOP Guts Medicaid

Medicaid and the Myth of GOP Cost Cuts

Terrance Heath — Mon, 20 Jun 2011 14:58:55 -0400

In the first post in this series, I noted that in the "Path to Prosperity" — which Republicans approved unanimously — Rep. Paul Ryan cited Medicaid as one of the biggest drivers of our national debt. The Republican budget formerly known as the Ryan budget, it followed, was all about putting the brakes on "What Drives Our Debt," as the "scare graph" that drove the point home was titled.

There are at least two problems with Republican's assertions about Medicaid. Like I said earlier, Medicaid and Medicare are not the problem. They are part of of the bigger problem of skyrocketing health care costs. The problem is, Republican cuts to Medicaid don't lower health care costs. It increases them.

The First Cuts Are The Deepest

Republicans incessantly declare that their budget will not reduce benefits for anyone 55 years old and up, but it ain't necessarily so. The 55-and-up claim is designed to reassure seniors about the GOP's proposed cuts to Medicare for the rest of them. ("Sure, your children and grandchildren will feel the pain, but you'll be fine. Don't worry!") Cynical as that claim may be, in its assumption that our parents and grandparents are happy to let their children and grandchildren suffer the GOP cuts, it's also just plain wrong. The Republicans make deeper and more immediate cuts to Medicaid that will matter a great deal to Americans 55 years old and up. Not to mention their children and grand children.

Like I said earlier, look at the distribution of Medicaid dollars.

Republicans can call Medicaid "welfare" all they want, but nearly 70 cents of every Medicaid dollar is spent on the elderly and disabled. That means Medicare is not "just a program for poor people." It's an important program to middle- and working-class families too.

We all have parents or grandparents. As they age, the medical care most of them will need will only get more expensive. Some of them will need long-term care or nursing home care, the cost of which will outstrip our families already stressed financial resources.

A year in a nursing home costs an average of $72,000, according to the Department of Health and Human Services, and that's if there aren't an additional costs beyond just getting a bed in a nursing home. Medicare pays for about a month. It's not hard to see how easily and quickly our parents and grandparents can "spend down" their assets to quality for Medicaid.

We love our parents and grandparents, and we won't want their lack of resource or ours to keep them from getting the they need. Families USA's report, "Cutting Medicaid: Harming Seniors and People with Disabilities," shows that Medicare is a big part of how our parents and grandparents get the care they need.

Medicaid is the primary payer for an estimated 63.6 percent of all nursing home residents. In all states but one, Medicaid is the primary payer for more than 50 percent of nursing home residents.

In seven states and the District of Columbia, Medicaid is the primary payer for more than 70 percent of all nursing home residents. Those states are the District of Columbia (80.1%), Mississippi (74.7%), Alaska (73.8%), Louisiana (73.0%), New York (72.3%), West Virginia (72.2%), Georgia (71.9%), and Hawaii (70.1%).

It all means that Medicaid is an important program for middle- and working-class families, too.

As columnist Harold Pollack underscores, people with disabilities are part of our families and communities too. Already in line to suffer as states slash Medicaid budget, they would suffer even more under the Republicans' proposed budget.

An excellent Chicago Tribune story by Rex Huppke details the impact of cuts to home and community-based services in Illinois. Huppke recounts the story of 81-year-old Lorraine Phifer, who cares for her son William, who has cerebral palsy. Phifer has a wheelchair van, but she can't maneuver him into it by herself anymore. He has also required help with a wheelchair lift to get into and out of bed. Staff from the University of Illinois at Chicago Assistive Technology Unit have come out to the Phifer home and provided valuable help. That unit now faces a 70 percent budget cut.

UIC's intellectual disabilities family clinics, which offer a range of services that are hard to access elsewhere, also face deep cuts. My intellectually disabled brother-in-law occasionally uses these facilities, too. I'm not a disinterested observer.

...Nearly everyone involved has a parent or other relative who receives Medicare. And most expect to rely on Medicare, too, when they grow old. Seniors are a powerful constituency. If they find a proposed policy too unsettling, it probably won't happen.

The tone and the politics change when things turn to Medicaid and related safety-net services. Dozens of states are making painful cuts right now. The disadvantaged people most directly affected are playing conspicuously small parts in the accompanying political process. In Washington and in state capitals, too, few influential stakeholders have any strong personal stake in such matters. Few have sat on either side of the counter in some welfare office, county hospital or public health clinic.

Given Medicaid's low per-person cost and its relatively restrained projected cost growth, there's little room to comfortably cut. Safety-net services are already shoestring operations. Under-funded and stressed, they have many shortcomings. There is no way to meet the above spending reduction targets without shifting costs and risks onto the states, covering markedly fewer people and services, or further underpaying Medicaid providers.

No one can firmly say how states would respond to the reduced federal support. I fear that's precisely the point. Block grants provide both states and the federal government with useful political cover to cut important benefits. If a particular state eliminates Medicaid home care services or by dropping the working poor from coverage, Congressional Republicans can say: "Don't blame us. That's what this state chose to do." Meanwhile governors can say, with equal justification: "Don't blame us. We're doing the best we can, given limited federal resources."

I wish that Rep. Paul Ryan, R-Wis., architect of the House Republican budget plan, could accompany my wife and her brother to waste hours sitting in a gritty welfare office. I wish he had the responsibility of helping an intellectually disabled person with a nasty toothache, when the state Medicaid program no longer covers dental care.

If Paul Ryan can't Pollack's brother in law, he could probably accompany a constituent in his own district where 12,900 seniors and persons with disabilities will lose benefits, along with 1,900 whose nursing home expenses are paid by Medicaid, plus 47,000 children (including 3,900 newborns), if the GOP successfully uses Medicaid cuts to shift costs on to their shoulders.

Cost-Shifting Is Not Cost-Cutting

The CBO estimates that the Republican budget's $771 billion in Medicaid cuts over ten years amounts to a 35% cut in Medicaid funding to states. The transformation of Medicaid into a block grant program, ensures that funding will decline because the Republican budget increases these grants annually at the rate of inflation, adjusted for population growth — not the rate of inflation for health care, which is far above the general inflation rate.

In other words, it's build into the budget that states won't be able to keep up with the costs of the program under the Republican budget, because the Republican budget doesn't take the rate of growth in health care costs into consideration. So, states cut back on the very Medicaid services that the elderly and disabled, and their families, rely upon.

The GOP budget cuts a total $2.17 trillion from Medicaid and related health care programs — $771 billion in Medicaid cuts, plus $1.4 trillion from nixing the Medicaid expansion in health care reform — Some of it by eliminating health care coverage for at least 32 million people, and some through drastic cuts in nursing home care coverage.

Seniors: An overwhelming majority of Medicare beneficiaries who live in nursing homes rely on Medicaid for their nursing home coverage. Because the Ryan plan would require such deep cuts in federal Medicaid funding, it would inevitably result in less coverage for nursing home residents and shift more of the cost of nursing home care to elderly beneficiaries and their families. A sharp reduction in the quality of nursing home care would be virtually inevitable, due to the large reduction that would occur in the resources made available to pay for such care.

Persons with disabilities are up for deeper cuts too, and sooner than the GOP would like us to think.

People with disabilities: These individuals constitute 15 percent of Medicaid beneficiaries but account for 42 percent of all Medicaid expenditures, mostly because of their extensive health and long-term care needs. Capping federal Medicaid funding would place significant financial pressure on states to scale back eligibility and coverage for this high-cost population, many of whom would be unable to obtain coverage elsewhere because of their medical conditions.

Children — 49% of Medicaid enrollees — aren't spared either.

Children: Currently, state Medicaid programs must provide children with health care services and treatments they need for their healthy development through the Early Periodic Screening, Diagnostic and Treatment (EPSDT) aspect of Medicaid, which provides regular preventive care for children and all follow-up diagnostic and treatment services that children are found to need. A block grant would likely permit states to drop EPSDT coverage, meaning that children, particularly those with special health care needs, would not be able to access some care that medical professionals find they need (because Medicaid would no longer cover certain health services and treatments for children, and their parents wouldnt be able to afford to pay for that care on their own).

Passing those costs to the elderly and disabled on Medicaid is really passing it on their families, who will have to assume responsibility for their care and/or paying for it. Imagine a middle class family with two working parents making just enough to keep themselves afloat — treading water, economically speaking, rather than breast-stroking their way to greater prosperity and security. In this economy, They're lucky that both parents are working, even if one of them has already been furloughed for a week, and the other has taken a significant pay cut to keep his job.

Now imagine them having to figure out what to do now that grandma no longer has Medicaid to pay for her nursing home care. Perhaps one parent ends up dedicating her salary almost solely to keeping grandma where she's getting the care she needs. Maybe both parents end up contributing a portion of their salary to cover the annual cost of $72,000. And this is assuming that one or both parents earn move than the $50,221 median annual income for American families. .

Perhaps one parent quits his job, and brings grandma home to care for her, but under all the same circumstances mentioned above. Now the family is down one income. So, how does that affect, the mortgage and utilities? Not to mention their own health care costs, and one of the kid's just got braces. How about those college savings? Now suppose one of the kids has an accident, or the remaining employed parent gets sick, or loses his or her job?

Cost Sharing Is Cost Shifting

"Cost Sharing" — which basically means imposing premiums on Medicaid recipients — is like to increase if Republicans simultaneously slash Medicaid funding to states and give states the "flexibility" to slash Medicaid benefits. Again, it may mean fewer government dollars are spent on health care, but it's cost shifting passed off as cost cutting.

If the goal is simply to get people off Medicaid rolls, then cost sharing can be said to work. A recent study showed that imposing even a 3% premium on participants in Wisconsin's Badger Care program would result in 49,422 fewer children and parents being enrolled in the program. Some of those families might find coverage elsewhere, but the declining levels of employer-provided coverage for low-income workers means that many of them would probably become uninsured. But they're off Mediciad, right? So, the government's not paying for their health care. Thus, costs go down.

Sort of. But look at Oregon. Its experiment in cost-sharing cause an exodus of low-income participants from its Medicaid program. The problem is, those people still needed medical care, eventually. So they used emergency rooms instead of primary care.

Republicans from George W. Bush to Mississippi Governor Haley Barbour have long been fond of saying all Americans have access to health care, because we can all go to the emergency room. But the uninsured have already been overwhelming emergency rooms, and in many cases they land there because of health problems developed into acute conditions, the treatment of which is far more expensive than the primary and preventative care that Medicaid covers.

The result is that hospitals are hit with huge unpaid medical bills, because since 1986 emergency rooms are required to treat all patients regardless of ability to pay. So, hospitals pass those costs on to paying customers, or those of us who have health insurance, which means we all pay more in the end. The only difference is that instead of supporting Medicaid with our tax dollars, for a far cheaper price than private insurance, we actually up paying more for emergency room care for the uninsured.

That's bad enough, but the Republican budget actually makes it worse by handing hospitals an $84 billion loss of Medicaid revenue at the same time it increases the ranks of the uninsured, who will eventually make their way to — you guessed it — hospital emergency rooms.

So, we go from "cost sharing" to more cost shifting, and with a huge mark-up.

Republican Cuts Increase Costs

Finally, as if to add insult to injury, the Republicans' manage to cut nearly everything but health care costs. Those, it turns out, go up.

Former OMB director Peter Orszag explained how Medicare beneficiaries would pay more.

As the government paid relatively less for Medicare, beneficiaries would bear an increasing share of the cost of their care. It is no great accomplishment, however, merely to shift health expenditures from the federal government to consumers, without doing anything to decrease them in total.

The CBOs analysis of the Ryan plan confirms that federal expenditures would be reduced, by a lot. By 2030, payments for a typical beneficiary would be more than 20 percent lower than current projections, according to the report, and the beneficiarys personal costs would increase.

So far, nothing unexpected. On the critical metric of whether the Ryan plan would reduce total health-care costs, though, the CBO conclusion is shocking: The plan would not only fail to decrease health-care costs per beneficiary, it would increase them - by an astonishingly large amount that grows over time. By 2030, health spending on the typical beneficiary would be more than 40 percent higher under the Ryan plan than under existing Medicare, according to the CBO report.

Health-care costs would not be reduced on the backs of seniors; they would be raised on the backs of seniors.

And the CBO explained how Medicaid beneficiaries — low-income families, the elderly, children and people with disabilities — would pay more too.

If states reduced spending for their Medicaid programs, there would be a number of potential implications for both providers and beneficiaries. Given that payment rates for providers under Medicaid are already generally lower than they are under Medicare and private insurance, if states lowered payment rates even further, providers might be less willing to treat Medicaid enrollees. As a result, Medicaid enrollees could face more limited access to care. If states reduced benefits or eligibility levels, beneficiaries could face higher out-of-pocket costs, and providers could face more uncompensated care as beneficiaries lost coverage for certain benefits or lost coverage altogether.

That's where the real cost sharing kicks in. When out-of-pocket costs skyrocket for our elderly parents and our brothers and sisters with disabilities, they skyrocket for us too. Those middle class families who are already struggling through this recession will -- some immediately -- have to assume massive health care costs of loved ones who will no longer receive the services Medicaid has paid for.

The Republican budget only cuts the amount of money our government spends on health care for low-income, elderly, and disabled Americans. It won't reduce what our families spend on health care. It won't reduce our loved ones' need for health care, or their need for health coverage. In that sense, it actually emulate the "successful" 1990s-style welfare reform it's modeled after.

In the unlikely event that Ryan's budget proposal becomes actual policy, it's going to have the same effect as the late 90s welfare reform that Ryan uses as his model. The primary measure of its success will be the declining numbers of people receiving services from the programs Ryan is targeting.

It's highly unlikely that those people — the elderly, the disabled and children — will be better off. That goes for their families, too. As DailyKos' Joan McCarter points out, a quarter of Medicaid spending pays for long term care for the elderly. Without Medicaid, families who are already taxed more under Ryan's plan, have to pick up those costs. That's an added burden for middle class families.

Taking Medicaid funding from families with disabled children and parents and grandparents in nursing homes compounds that.

Plenty of middle-class families only remain middle class because they're spared crippling medical and long-term care costs. A decade or two of the Ryan plan, and there will be no more middle class in America.

But that's why it will be a success. Making people better off, by reducing their need for assistance, isn't the point of conservative welfare reform. The point of conservative welfare reform is reducing the fewer people receiving help, not the reducing the need for help. That's why it's so successful, if you're a conservative like Paul Ryan. Because all you have to do is cut.

...Eric Cantor made headlines when he said of Social Security, "We're going to have to come to grips with the fact that these programs cannot exist if we want America to be what we want America to be."

Paul Ryan is saying the same thing, though not as succinctly, in his plan. He and conservatives like him are showing us what they want America to be. And it's not an America where fewer people need help, because more of them are working at jobs that offer, livable wages, good benefits, and a chance to raise their economic standing. It's an America where fewer people are getting help.

If Medicaid, Medicare, and Social Security cease to exist in any recognizable form, America will be what Republicans want it to be, Nearly all of us will pay a high price for it, and benefit little from it.

Death By 1,000 Medicaid Cuts

Terrance Heath — Thu, 16 Jun 2011 15:32:49 -0400

TAKE ACTION. Tell Vice-President Biden: No Bad Deals. No Cuts to Medicaid, Medicare or Social Security.

Budget-cutting can be a bloody business, depending upon where and how deeply one cuts. It can be a deadly business too. Not for the budget-cutters, though. That's especially true for Medicaid. To understand that, you need look no further than Arizona.

It was just earlier this year that Arizona was grabbed the spotlight as an example of just how deep GOP lawmakers were willing to cut. Rania Khalek recounts Arizona's recent history in an Alternet post that reads like a budget cutting body count.

Meanwhile, Arizona was busy denying life-saving treatment to tens of thousands of low-income residents. After being the only state in the entire country to eliminate the Children's Health Insurance Program (CHIP), effectively denying health care to 47,000 low-income children, Arizona Governor Jan Brewer signed a bill to end financing for certain organ transplants covered under Medicaid. The decision amounted to a death sentence for some low-income patients, who had little chance of survival without transplants and lacked the hundreds of thousands of dollars needed to pay for them. Two patients taken off the organ transplant waiting list died as a result of the shameful measure, leading many to accuse Governor Brewer of implementing death panels through budget cuts.

Governor Jan Brewer — famous for declaring government a "necessary evil" and Arizona "headless body farm" due to illegal immigration — defended the cuts, claiming "We have no choice," all while signing into law tax breaks that would cost the state $538 million in the next seven years, and ignoring other possible solutions.

ARIZONA: Last October, as she ignored 26 other possible funding solutions, Gov. Jan Brewer (R) implemented painful cuts to the state’s Medicaid program, which resulted in 2 deaths and left 98 Arizonians waiting for transplant funding. After months of protests, Brewer finally agreed to set aside $151 million in an “uncompensated-care pool to pay health-care providers for ‘life-saving’ procedures, including transplants.” However, House Republicans refused to restore funding for organ transplants because, as House Appropriations Committee chair Jon Kavanagh (R) said, “not enough lives would be saved to warrant restoring millions in budget cuts.” Then, while peoples’ lives were in danger, Brewer eagerly signed tax cuts for businesses that will cost the state $538 million.

Pleas from transplant hopefuls and survivors wasn't enough to get funding restored. Arizona did eventually restore transplant funding, but not before efforts to recall Brewer started up, and only after Brewer counted with a proposal to restore funding for the 98-person transplant program, if the state could kick an additional 280,000 out of its Medicaid program.

In the next few years, Arizona may be looked upon as the first shot in a battle that promises to rage across the country between now and November 2012. The Republican budget isn't likely to get the vote to pass Congress. But, as its author said, "This isn't a budget. This is a cause." It may be a lost cause in Congress, for now. (If Republicans make significant gains in 2012, and win the White House, all bets are off.) But, like another famous lost cause, it probably won't die anytime soon. Instead, it will spark battles in state after state, leaving collateral damage in its wake.

Overall Impact

An overview of the likely impact gives a 10,000 foot view of the collateral damage that's likely to be the result of the kind of cuts Republicans want to inflict on Medicaid.

Up to 44 million could lose health coverage. Federal spending on Medicaid would fall by $1.4 trillion, or 34% by 2021. States would receive $243 billion less per year. Cuts would produce decreases in Medicaid enrollment, resulting in 31 million to 44 million to lose coverage.
By 2013, 400,000 would lose vital health care services by 2013, according to the CBO.
By 2016, 1.7 million children will lose health insurance. If the Republican plan becomes law the CBO estimates that 1.7 million children will lose health insurance by 2016, as half the states could eliminate their CHIP programs, and remaining states could roll back coverage.
As many as 15 million could be forced off Medicaid rolls, according to state-by-state analysis.
Cuts would seriously impact seniors and people with disabilities. Some 14 million seniors and people with disabilities depend on Medicaid to pay for nursing home care and assisted living — which costs about $72,000 a year, on average. In fact, 70% of nursing home patients are Medicaid recipients. Deep cuts would mean less coverage for nursing home residents, shifting more of the cost on to the elderly and disabled beneficiaries and their families. Sharp reduction in the quality of nursing home care is another likely result. Many elderly and disabled recipients would be unable to obtain coverage elsewhere because of pre-existing conditions.

If it's true that the GOP's plan to gut Medicaid doesn't have the votes to pass the Senate, then it won't become law. Not federal law, anyway. Remember what Paul Ryan said, "This is isn't a budget. This is a cause." That cause may be defeated in D.C. (for now), but it promises to live on in several states, and may yet rise again on the federal level.

State Scenarios

Even if it fails in Congress, the Republican plan to gut Medicaid is already serving as a model for Republican governors to do on the state level what may be blocked on the federal level. Medicaid, after all, differs from Medicare in that Medicare is a state governed program. While the federal government contributes significant funding, and regulates states' management of Medicare, state governments have a lot of power over how their Medicaid program are administered. Thus, states are an important part of the GOP's strategy on Medicaid.

Ultimately, Republicans want to give states more power to administer Medicaid. It's usually couched in rhetoric about giving state's more "flexibility" to manage Medicaid, and presented as a two-part strategy. First, Republicans want to repeal "maintenance of effort" provisions in the health car reform law, which prevent states from reducing Medicaid eligibility before 2014, when the Medicaid extension in health care reform kicks in. Second, turning Medicaid into a block grant program would basically allow states to use the federal money they receive for Medicaid as they see fit.

But that "flexibility" comes with far less funding. Remember that federal funding of Medicaid would fall by 34%, or $1.4 trillion, by 2014. By then states would receive $243 billion a year less by 2021. So much for "flexibility".

"Under the House Budget Plan, the Medicaid block grant would reduce and cap federal Medicaid spending, substantially reducing states’ ability to provide coverage to low-income Americans," said Diane Rowland, Executive Vice President of the Foundation and Executive Director of the Kaiser Commission on Medicaid and the Uninsured. "The repeal of the ACA combined with the adoption of the Medicaid block grant would add millions more to the number of uninsured Americans and compromise Medicaid’s role as the health safety net in the next recession."

Only in the conservative mind does less funding mean more "flexibility" and more "freedom." For most people, and institutions, having less money means having fewer options, and thus a lot less "flexibility." But that's what Republican governors are asking for. And some of them aren't waiting for Congress. They're putting parts of the Republican plan to gut Medicaid into action in their own states.

Mississippi: Though nearly one in four Mississippi residents earned less than the federal poverty level — $10,830 a year — and 18% the state population lacks access to primary care, governor Haley Barbour has dismissed the idea that his state could benefit from more federal Medicaid funding. The state has one of the strictest income limits for Medicaid eligibility; an adult in a two-person family can't earn more than 44% of the poverty level, about $6,472 annually, and qualify for Medicaid in Missippi. Barbour, who holds that some Medicaid recipients in his state drive BMWs, has advocated charging Medicaid recipients co-pays for pharmaceuticals, and has been a leader in the Republicans' war on Medicaid.
Florida: Governor Rick Scott signed a landmark Medicaid overhaul giving managed care companies unprecedented control over Florida's Medicaid program, despite a five county pilot program that produced widespread complaints and little evidence of savings. One of the companies that stands to benefit, Solanic, was founded by Scott.
New Jersey: Governor Chris Christie is taking a chainsaw to New Jersey's Medicaid budget, in an attempt to cut $300 million by tightening eligibility requirements for recipients. In a move that would make Mississippi look generous by comparison, Christie's proposal would deny coverage to new adult enrollees who earn more than $5,317 annually — about 1/5 of the current income requirement.
Texas: Conservative legislators in Texas have demanded the state drop out of Medicaid — which pays for all childbirths in the state — to alleviate the state budget shortfall. (So much for the "Texas Miracle.") This month, the legislature passed a measure that converts its existing Medicaid structure to a capped block grant that would increase only for population and the general inflation rate (not the medical inflation rate), and exempt the state from Medicaid's benefit rules and all Medicare rules. In other words, a virtual copy of the Republican plan for Medicaid.
Wisconsin: Governor Scott Walker has proposed a measure to grant the Wisconsin's Department of Health services (DHS) sweeping authority to change the states Medicaid program. The measure would allow DHS to use "emergency powers" to restrict eligibility, raise premiums, and change reimbursements.

Some of these state measures may fail, but others will likely stand and ensure that the debate over Medicaid will continue between now and 2012. Those state that survive will be difficult to remove once implemented, and will have a devastating impact on those state residents who rely on Medicaid for vital services.

Deep Cuts Hit Home

Perhaps nothing illustrates more effectively what the Republicans' cuts would mean for many of the 60 million Americans who benefit from Medicaid than the impact in Rep. Paul Ryan's own district, taken from the House Democrats district-by-district breakdown of the Medicaid Cuts in the Republican budget.

In Ryan's own district his budget would:

Reduce coverage for 12,800 dual eligible seniors and individuals with disabilities who rely on Medicaid to supplement their Medicare coverage or pay their Medicare cost sharing.

Jeopardize nursing home care for 1,900 whose expenses are paid by Medicaid.

Impair the health care of 47,000 children, including 3,900 newborns each year, who receive coverage under Medicaid.

Cut payments to hospitals for 32,000 emergency room visits paid for by Medicaid each year.

Cut payments to hospitals for 10,700 inpatient visits paid for by Medicaid each year.

Reduce jobs and hurt economic growth by eliminating $1.4 billion in Medicaid spending.

None of these numbers look like a death sentence. But when it comes to Medicaid, and beneficiaries who will likely have nowhere else to turn if their benefits are lost, it comes down to a choice between providing care and not providing care.

Of course this doesn’t mean that cutting Medicaid won’t save money. It very well might. Thanks to Paul Ryan some families who can currently afford to take their kids to see the doctor won’t be able to take their kids to see the doctor. That will reduce aggregate health care expenditures and increase aggregate “kids get sick and die” nationwide. Of course a lot of kids who get sick and don’t get treated won’t die. It’s not as if the death rate from illness and accidents was 100 percent in the era before modern health care. People just suffer and life goes on. And with the extra budgetary headroom created, rich people can pay lower taxes and buy more really expensive refrigerators.

The Republicans' Medicaid cuts might not kill you, but then again they might. Either way, it's a chance that the GOP is willing to take, and a price it's willing to have countless Americans pay — all for $4.2 trillion in tax cuts.

Senate Democrats Stand Up For Medicaid

Terrance Heath — Mon, 13 Jun 2011 10:32:56 -0400

Every once in a while, something extraordinary happens in Washington, D.C.: Lawmakers actually pay attention to what Americans really want, and then stand up for policies that reflect what most Americans want. It looks like that's what happening with Medicaid and the Republican proposal that would eviscerate a program that's vital to millions of low-income, middle- and working-class Americans.

Democrats Stand Up For Medicaid

In the furor over the GOP's proposal to end Medicare as we know it, it seemed Democrats were quiet about the even deeper cuts for Medicaid. No more. Forty-one Senate Democrats are urging President Obama to reject the Republican's cuts to Medicaid.

Forty-one Senate Democrats are urging President Barack Obama to reject GOP proposals to dramatically change Medicaid, marking the party’s strongest defense yet of the federal-state health care program.

The clear message: Medicaid block grants or other caps on federal Medicaid spending cannot get through the Senate.

But on Thursday morning, Sen. Jay Rockefeller (D-W.Va.), one of Medicaid’s strongest defenders in the Senate, announced that 41 Democrats — in separate letters — are taking a stand against Medicaid cuts.

In the main letter, Rockefeller and 36 other senators say they oppose block granting Medicaid and enacting other spending caps — and urge the White House not to make Medicaid the “sacrificial lamb.” Four other Democratic senators sent similar letters to the White House, Rockefeller’s office said.

The 36 Senators who signed the Rockefeller letter plus the four separate letters by Sens. Dianne Feinstein (Calif.), Mark Udall (Col.), Michael Bennet (Col.), and Amy Klobuchar (Minn.), shows that Senate Democrats have the votes to block the GOP's Medicaid overhaul by ensuring it won't have the votes to get out of filibuster.

Standing with the American Majority on Medicaid

By standing up to the GOP's attempt to gut Medicaid, Senate Democrats are standing with the overwhelming majority of Americans who oppose drastic cuts to Medicaid. I'm not necessarily claiming credit, but Democrats clearly get one of the points I made in my earlier post about what Republicans want to do to Medicaid.

The Republican cuts to Medicaid are just as unpopular as the Republican cuts to Medicare. Democrats compromise with Republicans on Medicaid cuts at their peril.

As encouraging the Senate news is, it just shows that Democrats have been paying attention, because Americans — when anyone's bothered to ask them — have made it clear where they stand on Medicaid.

Americans know the difference between Medicaid and Medicare.

Americans know the difference, because Medicaid is imporant to the majority of Americans.

Fifty-nine percent of the American people said Medicaid was either "very important" to them or their families (39%) or "somewhat important" (20%).

That's because most Americans have been helped by Medicaid or know someone who has. Half of Americans have personal ties to Medicaid. One in five Americans personally have received Medicaid benefits. About 60% of Americans have a friend or family member who's been on Medicaid.

So, it's not hard to figure out why 60% of Americans reject the Republican plan to block grant Medicaid, and want to keep Medicaid the way it is. They know it's not "just a program for poor people".

All of this is probably because the more Americans hear about the Republican Budget proposal, the more the realize what it would mean for them, their families, and communities. But That's for another post.

Senate Democrats seem to "get" that the GOP cuts to Medicaid will have a devastating impact on their constituents, and eventually hurt them at the polls the way it's promising to hurt the GOP.

Democrats are winning the battle over Medicare, and it looks like they've figured out how to win the coming battle over Medicaid: by standing with the majority of Americans, and stopping the Republican plan to gut Medicaid.

Medicaid: The Next Battleground

OurFuture.org Staff — Wed, 08 Jun 2011 13:34:35 -0400

Medicaid: It's Not "Just For Poor People"

Terrance Heath — Thu, 02 Jun 2011 15:39:49 -0400

In my previous post, I covered what Republicans want to do to Medicaid. In this post, I intend to delve into why Republicans want to gut Medicaid.

Republicans present their budget proposal as a solution to the "problems" of Medicaid and Medicare, which their budget cites as two of the biggest drivers of national debt. But, as I demonstrated in my previous post, Medicaid and Medicare aren't the problem. They're part of the much larger problem of rising health care costs — a problem the GOP budget doesn't solve. (More on that in an upcoming post.)

If Republicans are intent on ignoring the white-coated elephant in the room, and solving "problems" that exist in their minds only, that raises an important question about their plans for Medicaid.

Why Republicans Want To Gut Medicaid

Why does the GOP want to gut Medicaid? Because conservatives have hated Medicaid since its inception in 1965, for reasons Paul Waldman aptly summarized.

...The primary objection here isn't budgetary; it's moral. Many conservatives feel that poverty is a moral failing, and if you're getting help from a government program, you're probably some kind of scamming welfare queen sucking off people who work for a living, getting a benefit you don't deserve. [emphasis added]

Conservatives like Paul Ryan have repeatedly said their goal is "strengthening welfare for those who need it." But what the Republican budget reflects is much closer to House Minority Leader Eric Cantor's statement that Medicaid and Medicare amount to "a safety net in place in this country for people who frankly don’t need one."

But Jim Wallis reminds us that, "a budget is a moral document," that "reveals what your fundamental priorities are: who is important and who is not; what is important and what is not." And the Republican budget casts Medicaid recipients as "the undeserving poor." Cutting aid for those who need it most makes perfect sense, if you believe those who need help the most deserve it the least. (For a more in-depth explanation, I recommend George Lakoff.

The budgetary justification for gutting Medicaid is weak. As I pointed out in the previous post, the cost-per-beneficiary for Medicaid is lower than private insurance. But the GOP thinks that "Medicaid is the easiest to win consensus on." That's because their perception of Medicaid is that it's "just a program for poor people."

Paul Ryan himself gave that much away when he said in his Wall Street Journal op-ed that Medicaid reform is really welfare reform. He gives much more away with his desire to model the GOP's "Medicaid reform" on the "successful" welfare reform of the late 90s. As wrote in a previous post, what Ryan sees as the "successful" welfare reform of the 90s was really a classic conservative "catastrophic success."

See, there's the problem with this is that the welfare reform of the late 1990s was not a success. Not unless you're a conservative. And even then it was at best a "catastrophic success" — defined here as "success" that's actually catastrophic for those it's purported to help. That's also what makes it a success. That is, if you're a conservative.

What makes it a success? Well, in a sense, failure. It works if it doesn't work, in other words, especially if it doesn't work for the right people — because the right people are the wrong people. Follow me? No?

...Paul Ryan, in his WSJ op-ed, says that with his roadmap we "strengthen and improve welfare programs for those who need them, we eliminate welfare for those who don't." It's curious, because it really does sound like he wants to duplicate the catastrophic success of the welfare reform of the 1990s. The "success" was getting people off welfare rolls, not necessarily improving their condition. It was about reducing the number of people receiving government assistance, not reducing the need for assistance. Simply put, it's fewer people getting help, instead of fewer people needing help.

It's like the right wing version of a Zen kōan that cannot be understood by the rational mind, and only makes sense to the conservative mind. It only makes sense if you believe that those who need help the most deserve it the least, and their need itself is the greatest evidence of that.

Then, not only does it makes economic sense to slash Medicaid beyond recognition, it makes moral sense. In fact, it seems like common sense. So much so, that it seems safe for Republicans to assume most people will see that Medicaid is "just a program for poor people," and cutting it is both an economic and a moral necessity.

Unfortunately, for the GOP, most people are not "Zen Republicans" and don't see the world through the same distorted lens.

Medicare Is Not "Just For Poor People"

Gutting Medicaid won't be an easier than slashing Medicare, as David Callahan pointed out, because when people think about it.

Yes, Medicaid was designed for the poor during Lyndon Johnson's War on Poverty and still serves as a lifesaver -- literally -- for millions of low-income Americans. But it also benefits legions of seniors, primarily by covering nursing-home stays. And this group -- along with their kids -- will go on the warpath if Congress slashes Medicaid. Democrats foolish enough to sign on to big cuts -- say, out of desperation to keep the government from defaulting -- could find themselves in political trouble.

Lawmakers who have set Medicaid on the chopping block might want to bear in mind a few basic facts before they start swinging the ax.

First, the bulk of Medicaid benefits — two-thirds — go to the elderly and disabled. Drilling down further, a quarter of Medicaid spending helps seniors. So forget the idea that this is a program that mainly caters to poor adults and children.

In turn, many of Medicaid's benefits for seniors pay for nursing-home stays. Some 70 percent of America's 1.4 million nursing-home residents are on Medicaid, according to the Kaiser Family Foundation. And it's well known that plenty of middle-class and even upper-middle-class people turn to Medicaid for nursing-home coverage — either after exhausting their savings or impoverishing themselves by transferring assets to others.

This isn't hard to figure out. For starters, Republicans could look at the actual distribution of Medicaid dollars.

For that matter, Republicans could step outside of their beltway conservative bubble-within-a-bubble (that means outside their congressional offices, and at least several blocks away from Capitol Hill) and ask actual middle- and working-class people. When I every forty-and-above co-worker I had told me to make sure I mention exactly what David Callahan pointed out: that plenty of middle class and upper class people turn to Medicaid for nursing home coverage after "spending down" their assets and "impoverishing themselves" sufficiently to qualify for Medicaid.

Callahan also cites an April 2011 Kaiser Family Foundation poll which shows Medicaid is a popular program and suggests why.

Strong public support of Medicaid appears a dividend of many Americans either receiving assistance from the program or knowing a family member or friend who has. While 56 million Americans are enrolled in Medicaid at one time, about 69 million are enrolled at some point during the year as people go in and out of the program.

About half of respondents say they or a friend or family member has received Medicaid, and a similar share say the program is important to their family. Among the one in five respondents who personally have been covered by Medicaid, 86 percent reported a "very" or "somewhat" positive experience, the survey found.

A more recent Kaiser poll from just last month showed that 1 in 5 Americans have received Medicaid benefits.

Support for maintaining the current program may be due at least in part to the public's personal connections to Medicaid and a strong sense of the program's importance. About half of Americans say they or a friend or family member has received Medicaid assistance at some point, and a similar share say the program is important to their family. Among the 20 percent of adults who personally have been covered by Medicaid, reported experiences are positive.

"If you watch the debate about the deficit and entitlements, you would think that almost everyone has a problem with the Medicaid program and wants to change it, or cut it -- or both," said Kaiser President and CEO Drew Altman. "The big surprise in this month's tracking poll is that one group who does not want to cut Medicaid is the American people."

"With about 69 million people expected to be covered by Medicaid this year, it is no longer the -welfare-linked program it once was," Altman added. "Medicaid may not be the lower-hanging fruit that many who want to reduce federal entitlement spending have assumed it is."

Medicaid Is Important To The Middle Class

My office is not exactly an ideological cross section of the country, but what was foremost in my coworkers minds is something that the Kaiser poll reflects and something that most Americans understand about Medicaid.

This is mostly a program for the elderly and the disabled. It's the main way we finance long-term care in this country. If you don't directly benefit from it, you very likely have a parent or grandparent who does and whose financial needs will simply tend to fall on you if the program is cut.

We all have parents or grandparents. As they age, the medical care most of them will need will only get more expensive. Some of them will need long-term care or nursing home care, the cost of which will outstrip our families already stressed financial resources.

A year in a nursing home costs an average of $72,000, according to the Department of Health and Human Services, and that's if there aren't an additional costs beyond just getting a bed in a nursing home. Medicare pays for about a month. It's not hard to see how easily and quickly our parents and grandparents can "spend down" their assets to quality for Medicaid.

We love our parents and grandparents, and we won't want their lack of resource or ours to keep them from getting the they need. Families USA's report, "Cutting Medicaid: Harming Seniors and People with Disabilities," shows that Medicare is a big part of how our parents and grandparents get the care they need.

Medicaid is the primary payer for an estimated 63.6 percent of all nursing home residents. In all states but one, Medicaid is the primary payer for more than 50 percent of nursing home residents.
In seven states and the District of Columbia, Medicaid is the primary payer for more than 70 percent of all nursing home residents. Those states are the District of Columbia (80.1%), Mississippi (74.7%), Alaska (73.8%), Louisiana (73.0%), New York (72.3%), West Virginia (72.2%), Georgia (71.9%), and Hawaii (70.1%).

It all means that Medicaid is an important program for middle- and working-class families, too.

It's not just us forty-somethings-and-up who see it that way. It's our parents and grandparents too. Many of them realize what the cost of long-term care or nursing home care out would mean to their children, and their grandchildren.

Medicaid pays the bill for 66% of all nursing home residents. And these aren't the indigent — most\many of them are the result of middle-income people who have already run through their own money paying for their nursing home costs, and then become eligible for Medicaid. If Medicaid doesn't pick that up anymore, who's left? The children of the residents? Who are trying to send their kids to college and saving for their own retirement? Not that Paul Ryan cares, but essentially, states will need to choose between basic healthcare for low-income people and nursing home care for formerly-middle-income people with no money left. ...Imagine their reaction when they learn (too late?) that the Medicaid changes Paul Ryan and the Republicans want to make would mean they have to pay several hundreds of dollars a day to keep their parents in the nursing home they have been in for months\years?

This is true for millions of middle class Americans, and it's what makes Medicaid a program that helps support the middle class. Most of us are children of parents who worked hard to attain or maintain middle class status, and to pass its advantages. Most of our parents know that what kind of economic burden the Republicans' proposed cuts would mean for us and their grandchildren — a reversal of the life they worked so hard for us to have in the first place.

Not only do we have have parents and grandparents whom we love, and who love, many of us also have children with disabilities who benefit from Medicaid. At Peter Peterson's recent Fiscal Summit, White House National Economic Council Director Gene Sperling explained what the "tyranny of the math" means for our families on that front.

And I say this to everybody in this room, there is enormous discussion about the revenue side and the Medicare side. But from a policy perspective, from a values perspective, we should be very deeply troubled by the Medicaid cuts in the House Republican plan. I want to make clear what they are. This is not my numbers, this is theirs.

After they completely repeal the Affordable Care act, which would take away coverage for 34 million Americans, according to the Congressional Budget Office. After they've completely repealed that, they do a block grant that would cut Medicaid by $770 billion. In 2021, that would cut the program by 35 percent. Under their own numbers, by 2030, it would cut projected spending in Medicaid by half. By 49 percent. So, of course– I don't think– or imply any negative intentions or– lack of compassion. But there is a tyranny of the numbers that we have to face.

And here's the tyranny of the numbers. Sixty-four percent of Medicaid spending goes to older people in nursing homes or families who have someone with serious disabilities. Another 22 percent goes to 35 million very poor children. Now I ask you, how could you possibly cut 35 percent of that budget and not hurt hundreds of thousands, if not millions of families who are dealing with a parent or a grandparent in a nursing home, or a child with serious disabilities. How is the math possible.

If you tried to protect them mathematically, you would have to eliminate coverage for all 34 million children. Now I know some people didn't like when– the President mentioned that this was going to be very negative for families, for those amazingly brave parents. And he may be one of them in our country, who have a child with autism or Down's and who just are enormously committed and dedicated to doing everything they can to give their child the same chance– every other child has.

But here's the reality. Medicaid does help so many families in those situations. Over the years, we've allowed more middle class families who have a child with autism to get help in Medicaid. There's a medical needy program that says when you spend down– we'll– we'll count the income after you've spent down medical costs.

There's a Katie Beckett (PH) program that was passed by President Reagan that says if you have a child that's in need of institutional care– you can get help from Medicaid. This is– this is a life support for many of these families. But these are the optional programs in Medicaid. These are the ones that go to more middle class families. If you're going to cut 49 percent of projected Medicaid spending by 2030, do you really think these programs will not be seriously hurt.

So when we say that there– that the tyranny of the math is that these– these– this Medicaid– program, this Medicaid cut will lead to millions of poor children, children with serious disabilities, children with autism– elderly Americans in nursing homes losing their coverage or being– or– or having it significantly cut, we are not criticizing their plan. We are just simply explaining their plan.

Digby asked simple question after Sperling's remarks: "Can any American know that that none of these things will ever happen to them?"

Of course we can't. That's why Medicaid isn't just an important program for poor families. It's an imporant part of the social contract for middle-class and working-class Americans too.

What You Should Know About What Republicans Want To Do To Medicaid

Terrance Heath — Fri, 27 May 2011 16:01:50 -0400

Stan Collender is right. The NY-26 election special election will change the budget debate. In fact, it already has. Democrat Kath Hochul's victory over Republican Jane Corwin, in a solidly Republican district, in special election that became a referendum on Rep. Paul Ryan's budget proposal — which Corwin endorsed — turned up the volume on the debate over the Republican plan to "destroy Medicare as we know it." The Medicare rhetoric will only get louder.

Though we'll all hear more about the GOP's dastardly plans for Medicare, we'll probably hear less about their equally destructive plans for Medicaid. That's dangerous, because Medicaid is just as important as Medicare, and the GOP's plans for it could have devastating consequences for millions of Americans.

Forewarned is forearmed. Here's what you need to know about Medicaid and the Ryan/GOP Budget.

Medicaid is not the problem. It's part of a larger health care cost problem.
Medicaid is not "just a program for poor people." It's also important to most middle- and working-class Americans.
The Republican cuts to Medicaid don't lower health care costs. They shift costs to poor, elderly, middle- and working-class Americans.
The Republican cuts to Medicaid are just as unpopular as the Republican cuts to Medicare. Democrats compromise with Republicans on Medicaid cuts at their peril.

I'll address each of these in upcoming posts.

What Republicans Want To Do To Medicaid

It's not really a question of "what". If the Republican budget (which shouldn't be called the Ryan budget, since House and Senate Republicans voted for it almost unanimously) "ends Medicare as we know it," it effectively guts Medicaid. That's the "what"; ending Medicare as we know it, and gutting Medicaid — a program that provides health care for nearly 60 million low-income seniors, children, and low income families.

The Republican Budget, according to a Families USA report, would:

Convert Medicaid into block grants to states starting in 2013.
Eliminate federal regulations prohibiting states from trimming their Medicaid rolls or erecting new barriers to enrollment.
Cut federal Medicaid funding to states by $771 billion over ten years.
Cut federal
Cut Medicaid by a total $1.4 trillion over the next decade.
Eliminate the Affordable Care Act's expansion of Medicaid.

Medicaid Is Not The Problem

In "The Path to Prosperity," Paul Ryan cites Medicaid as big drivers of our debt, and thus a huge problem. He even includes this "scare graph" to drive his point home.

Yeah, but Paul Krugman, borrowed a chart from the Centers for Medicare & Medicaid Services, and he says Medicaid and Medicare are big. Big parts of a bigger problem, that is.

Ezra Klein is right, of course, to say that Medicare and Medicaid costs are part of a larger health cost problem. But it’s worth bearing in mind a point I’ve written about before: we’re already more than half way to a system of government health insurance. Here’s the data:

What Is Medicaid?

Medicaid was created — along with Medicare — on July 30, 1965, when President Lyndon Johnson signed the Social Security Act of 1965 into law at the Harry S. Truman Library in Independence, Missouri, with former President Truman by his side. Johnson held the ceremony there to honor Truman's commitment to health insurance, which he first proposed in 1945.

What's the Difference Between Medicare and Medicaid?

One of the biggest difference is that Medicaid is a state governed program, while Medicare is a federal governed program.

Here are some other differences.

Medicaid is for low income:

Pregnant women
Children under the age of 19
People 65 and over
People who are blind
People who are disabled
People who need nursing home care

Medicaid is applied for at a state's Medicaid agency.

Medicare is for:

People over 65
People of any age who have kidney failure or long term kidney disease
People who are disabled and cannot work

Medicare is applied for at the local Social Security office.

Some people qualify for both Medicaid and Medicare. Medicaid is sometimes used to help pay for Medicare premiums. People who qualify for both programs are called 'dual eligible'.

Back in 2007, Krugman reminded us that "there is no such program as Socialsecuritymedicareandmedicaid." Now it falls to Ezra Klein to remind us that "The problem is not Medicareandmedicaid. It's health care."

So I'd take Krugman's point a step further: There sort of is a program called MedicareandMedicaid. But it's very difficult to imagine a world in which the costs for Medicare and Medicaid have slowed but the costs for private health-care insurance haven't. The right analogy, perhaps, is food prices. If the cost of food skyrockets, my grocery bills will go up, and so too will school-lunch programs go up. The same goes for health care: So long as health-care costs are rising, Medicareandmedicaid and The Washington Post and IBM will all see costs going up. The reason? They're all buying the same product.

There's also a practical reason Medicare and Medicaid's spending can't look too different from the private sector's: imagine a world in which a doctor gets paid $50 to see a Medicare patient and $150 to see a patient covered by Aetna. Which doctor is going to remain in the Medicare program? As Joe Newhouse puts it, "Part of the reason that the sustainable growth rate" -- which would have held Medicare's costs down -- "has not been sustainable politically is the need to keep Medicare rates within striking distance of commercial rates." Either everyone pays less or no one does.

But let's say you somehow managed to solve the cost problems in MedicareandMedicaid without solving it in the broader health-care system -- and, incidentally, I'd like to know how you did it -- America's health-care cost problem isn't solved. Washington has a bias towards problems that are "on-budget" for the federal government, and for good reason: Washington is where the federal government's budget gets written. But the budgets of businesses and households matter, too. If they get crushed by health-care costs, but Washington manages to escape, America is still in bad shape. "Thinking of it as a budget deficit problem misses the point," writes Jon Bernstein. "Shut down Medicare completely and you solve the budget deficit part of it, but you still have an important dysfunctional situation with regard to health care."

Ryan, in the Republican budget, offers a helpful explanation of the difference between "debt" and "deficit," before he goes on to blame Medicaid for driving one and thus causing the other.

When the government spends more than it takes in through taxes, it has to borrow money to cover the shortfall. The deficit is how much the nation has to borrow to fund the gap between spending and revenue in a given year. The debt is the total amount outstanding that the government owes – it represents the accumulation of deficits over time.

But our fiscal problems didn't start in 2010, and have more to do with the continued contribution of conservative policies than with Medicaid. In fact, Medicaid is already cheaper than most insurance products.

Critics of Medicaid argue that program costs are growing out of control and that the current federal financing structure is a prime cause, because the federal government will pick up a percentage of states’ Medicaid costs however high those costs are. They also contend that the financing structure remains highly vulnerable to “gaming,” under which states use creative financing mechanisms to maximize federal funding. They claim that the only way to control federal Medicaid spending growth is to block-grant or cap federal funding.

These claims do not fare well under scrutiny. For example, over the past 30 years, average annual Medicaid cost growth per beneficiary has essentially tracked health-care cost growth systemwide.[3] In fact, in recent years, costs per beneficiary in the Medicaid program have been rising less rapidly than costs in private insurance.[4]

In addition, the average cost per Medicaid beneficiary is significantly lower than under private insurance (after adjusting for differences in health status), despite Medicaid’s more comprehensive benefits and significantly lower cost-sharing charges, because of Medicaid’s lower payment rates to providers and lower administrative costs (see Figure 1).[5] Since Medicaid cost-growth largely mirrors health care cost growth systemwide, slowing the rate of growth in Medicaid costs over the long run requires controlling costs throughout the U.S. health care system, which the health reform law takes some significant initial steps to achieve. Addressing Medicaid in isolation from the rest of the system would sharply shift costs and risks to states, beneficiaries, and providers, as explained below.

And the CBO concluded, the Ryan/Republican Budget would not lower costs.

Don’t take it from me. Take it from Robert Reischauer, who directed the Congressional Budget Office from 1989 to 1995 and now leads the Urban Institute. “If this is a competition between Ryan and the Affordable Care Act on realistic approaches to curbing the growth of spending,” Reischauer says, “the Affordable Care Act gets five points and Ryan gets zero.” But Ryan would repeal the Affordable Care Act and replace it with his own wishful plan. In doing so, he makes it harder, not easier, for us to balance the budget.

To understand why Reischauer gives Ryan a zero, you need to understand the technical trick that gives Ryan his savings. His proposal says the federal government’s contributions to Medicare and Medicaid can’t grow at more than the rate of inflation. Then he told CBO to score his plan based on that assumption. That’s where his money comes from. But it’s nonsense.

Health-care costs don’t grow at the rate of inflation. Ever. Previously, Ryan acknowledged that. His Roadmap capped federal contributions between inflation and the actual cost of medical care. He then developed a more bipartisan version of the idea with Alice Rivlin, who founded the Congressional Budget Office and directed the Office of Management and Budget under Bill Clinton. That one was capped at the growth of GDP plus 1 percentage point. Both targets were far more plausible than the fantasy target Ryan is now using.

So why the switch? He has not said. I suspect he couldn’t make the numbers add up without tax increases. The problem now, however, is that his numbers don’t add up at all. Rivlin — a budget hawk’s budget hawk — has abandoned the proposal that Ryan says she helped write. “The growth rate is much, much too low,” she says.

So, if Republicans aren't gutting Medicaid to save it, or even to save money, why gut Medicaid?

I'll try to answer that in my next post.