Republicans are coming for the Medicaid expansion

There’s an all-too-real chance that the most important expansion of the welfare state since the Johnson administration won’t survive a second Trump term:

But Medicaid is a joint federal-state program, with Washington putting up the majority of money and leaving administration to states, as long as they keep within certain guidelines. And for most of the program’s history, the majority of states stuck to the minimum requirements, or relatively close, meaning they limited coverage to certain categories of people, including children, young single mothers, and the elderly.

The Affordable Care Act’s designers sought to turn Medicaid into something much more ambitious: a program for all low-income Americans, so that it was open to any citizen with an income below or just above the poverty line, even if they were working-age men or fell into another demographic category the program had excluded previously.

To put it another way, they were out to transform Medicaid from a narrowly targeted welfare program into part of a universal coverage scheme.

But the interest in ending expansion funding is still there—in no small part because the money is still there—and in recent years especially Republicans have spun their efforts more as an attempt to preserve Medicaid for what they say are the truly vulnerable groups that need it.

One source for this argument is the Paragon Health Institute, one of several think tanks launched by alumni of the first Trump administration, whose researchers have argued that adding all of these working-age, childless adults to Medicaid has put extra financial strains on the program, while overwhelming the doctors and other providers who see Medicaid patients. As a result, these researchers say, the children, pregnant women, seniors, and people with disabilities who had previously depended on the program now have a harder time getting care.

In addition, Paragon’s researchers argue, the extra funding for Medicaid expansion effectively “discriminates” against the vulnerable, because it means the federal government is subsidizing working-age, childless adults at a higher rate than it is for children, pregnant women, and the elderly.

“For more than a decade, the Affordable Care Act’s (ACA) Medicaid expansion has shifted resources away from the most vulnerable Americans—single moms, infants, and the disabled—in favor of able-bodied adults without dependents,” Liam Sigaud, a Paragon adjunct scholar, wrote in February. “Congress has the capability to reverse this and ensure our safety-net programs focus on the most vulnerable.”

[…]

ARE THE CRITICS RIGHT about what Medicaid expansion has meant for the program’s traditional beneficiaries?

Lots of analysts disagree, for a variety of reasons—among them, the large and growing body of research showing the overall effects of the expansion include a financial boost for safety net providers, not to mention clear improvements in financial well-being, access to care, and (less conclusively) overall health among low-income people living in expansion states. (I find that evidence considerably more persuasive than Paragon’s, but you can decide for yourself by following all of those links.)

In the meantime, what’s not disputable is that taking away the extra matching funds will mean that the only way to preserve expanded Medicaid coverage would be for states to make up the difference—something most either couldn’t or wouldn’t do, given the expense and their resources.

So what then? Many and probably most of the people Johnson says “should never be on” Medicaid would have no other way to get insurance. Georgetown research professor Joan Alker—who not only studies Medicaid but spends a lot of time speaking with people who work on it—emphasized this in a recent telephone interview.

“The reality is that many of these folks are working in low-wage jobs and they don’t have access to affordable health insurance,” Alker said. “They’re working in a gig economy. They’re working in the service sector or agriculture, in places where they’re not getting health insurance.”

And it’s not like Johnson or his supporters are proposing an alternative way of covering all these people. Some would find their way to other forms of coverage, but the rest would end up uninsured. And while it’s tough to predict these sorts of things accurately, the number of newly uninsured would likely reach well into the millions and could easily exceed 10 million.

The idea that killing the Medicaid expansion is about “protecting the most vulnerable” is an incredibly cynical lie. Coverage for the groups still eligible for Medicaid would not improve, and their access to healthcare would decrease as a huge cut in federal funds causes hospitals (especially in rural areas) to close. The idea here is to make as many states as possible like Texas, where only a relatively small number of poor people qualify for Medicaid and everybody also is out of luck.

So, in other words, millions of people will be denied access to medical care to partially pay for another massive upper-class tax cut. I believe this is the new Republican Economic Populism (TM.)