As disabled protesters were being dragged, bleeding, from Senate Majority Leader Mitch McConnell’s office on Thursday after he released his version of Trumpcare, I sat at home working line by line through the 142-page bill. As many have observed, it contains deep cuts to Medicaid, redistributes wealth from the poorest to the richest, and guts all the hard-won protections on preexisting conditions, reproductive care and lifetime spending limits that the Affordable Care Act had brought. What struck me, though, is how familiar all the material on Medicaid looks. Republicans have been trying to gut funding for Medicaid for more than 35 years. The only difference is that this time, they might get away with it.
Medicaid is a promise. It promises the most vulnerable Americans that their basic needs for health care and disability-related supports will be met. For many poor and disabled Americans, it offers access to lifesaving health care, which is important enough. For people with disabilities, however, it also offers supports and services that can include wheelchairs, attendants to help people get out of bed or eat, equipment for schools to teach special education, housing in communities instead of institutions, and countless other critical supports. My son, a 10-year-old with Down syndrome, doesn’t need Medicaid yet — but he will. And you or one of your loved ones probably will, too.
It’s not a cheap promise, but it’s the kind of thing the richest nation on Earth should do for its citizens. Right now, states run Medicaid programs and pay for part of the costs themselves. But for every dollar of eligible expenditures, they receive $1 to $3 from the federal government (depending on whether it’s a rich state or a poorer state). The budget, in other words, is linked to what it actually costs to help people. Rather than cuts, Medicaid needs more funding, better organization and to be made accessible to more people. The ACA’s Medicaid expansion was a good start, but it wasn’t enough.
Since the election of President Ronald Reagan, though, the Republican approach to the promise of Medicaid has been to try to cut off funding by setting an arbitrary limit on costs. Instead of giving states money based on what they actually spend, the federal government would give each state a “block grant” of a fixed amount. They usually characterize this move as calculated to give “flexibility” or “control” to states and preach fiscal prudence — the current Senate bill calls their cuts a “Medicaid Flexibility Program,” for instance. But the bill lawmakers will consider this week undermines that message by tying the shift to block grants to deep tax cuts for the wealthy.
As detailed in a 2013 report by the National Council on Disability (a nonpartisan, federally funded advisory council) on Medicaid block grants and their effect on Americans with disabilities, the first attempt to turn Medicaid into a block grant came in 1981, in Reagan’s first year in office. It made it into a big omnibus budget bill, but was stripped out in a congressional committee. House Speaker Newt Gingrich (R-Ga.) actually got block grants passed in 1995 as part of his “Medigrant” proposal, but President Bill Clinton vetoed it (with strong backing from health policy experts), and it was dropped from the subsequent compromise bill. President George W. Bush and the Republican congresses of 2003 and 2005 could have passed block grants at any time, but sustained resistance from advocacy groups, Democratic leaders such as Rep. Henry A. Waxman (Calif.) and Edward M. Kennedy (Mass.) and the legislative distractions of forming Medicare’s prescription drug benefit kept the bill from advancing.
Moreover, at the time, many Republicans wanted to find bipartisan solutions whenever possible. Henry Claypool, who has been working on Medicaid policy in and out of government since the 1990s, told me that the Deficit Reduction Act of 2005 did include some Republican changes to eligibility, but also expanded support for home- and community-based services in ways that have helped many disabled Americans.
Today, everything has changed. House Speaker Paul D. Ryan (R-Wis.) has been proposing block grants since 2010, but he had no chance to get them enacted under President Barack Obama. Now, he and McConnell have co-opted the legislation intended to fulfill GOP promises to “repeal Obamacare” (which would be bad enough) as a way to sneak through decades-long assaults on the basic American promise of Medicaid.
This time, the phrasing is “per capita caps.” It’s not exactly the same as block grants, but it’s yet another attempt to use the language of “flexibility” as a way to cut costs significantly. Worse, Claypool said, states have responded to austerity by ending their own state-based Medicaid-like programs. Today, they are totally reliant on federal programs, which now face these deep cuts.
History, even wonky policy history, matters. Republicans have been trying to cut the safety net almost since it was first assembled. The current effort has nothing to do with Obamacare in all its complexities, but reflects the near-total capture of the current Republican Congress by its worst elements. With President Trump ready to sign any document put in front of him (even one he thinks is “mean”), the GOP is using the debate over health care to conceal an assault on Medicaid. Republicans must be persuaded to abandon this deception, or the American people should abandon them.