Is the problem incompetence or malice?

When it comes to the Trump administration’s terrible health-care agenda, the answer appears to be both.

At least, that’s the takeaway from Vice President Pence’s comments at an Iowa diner last week, when he appeared to not know that his administration is working to cut, rather than expand, health coverage for the poor.

While Democrats debate the best path to universal health coverage, Republicans appear to remain laser-focused on taking insurance away from as many Americans as possible. They’ve adopted a multipronged approach, too.

There’s the lawsuit attempting to strike down the entire Affordable Care Act, including the law’s protections for patients with preexisting conditions. This is despite President Trump’s insistence that he “saved” said provisions and will “always protect” them. During an interview in Davos, Switzerland, last month, Trump also professed his interest in cutting Medicare if he gets elected to a second term. This too defies a campaign promise to leave the program untouched.

Finally, last Thursday, the Trump administration unveiled its latest scheme to slash spending on Medicaid, the program that provides health coverage to a fifth of Americans nationwide. It’s an idea the GOP has been pushing for decades, called “block grants.”

Up until now, states have received an open-ended federal match for Medicaid funding, with the exact amount of federal dollars fluctuating based on need. For example, federal Medicaid funding automatically rises when recession strikes and more people qualify for public coverage.

Under the new policy, that would change.

States could decide to instead get a flat amount from the feds to cover the Medicaid expansion population, regardless of year-to-year changes in enrollment or demand for services. States that choose this arrangement would also be newly allowed to cut benefits, such as by eliminating coverage of some prescription drugs or certain categories of preventive care. They could also impose new out-of-pocket costs on low-income enrollees.

In other words: Poor people would be forced to pay more and receive less.

The policy change — as with other Trump administration attempts to cut Medicaid — will almost certainly be challenged in court. It’s also quite unpopular, as you may recall from the last time the GOP proposed it as part of Obamacare repeal efforts in 2017. The backlash the idea received then is presumably why the Trump administration has rebranded block grants with a new Orwellian name: the “Healthy Adult Opportunity” initiative.

Nonetheless, this major news got largely buried by impeachment coverage last week. Even the vice president didn’t seem to know about it, based on an exchange later that day that has since gone viral.

While visiting Iowa for a Trump rally, Pence walked into a diner ready to glad-hand some locals. Unfortunately for him, one of the diner’s patrons was an emergency physician named Rob Davidson, who is also the executive director of an organization of doctors, medical professionals and activists called the Committee to Protect Medicare. Davidson was in town for a committee news conference on threats to health coverage.

The meeting was unplanned, but Davidson seized the opportunity. He asked Pence about Trump’s recent comments about Medicare and the Medicaid block grant announcement.

“I work in one of the poorest counties in Michigan, and my patients depend on expanded Medicaid, so how is that going to affect my patients?” Davidson, a former Democratic congressional candidate, asked politely.

Pence professed ignorance, saying he “hadn’t heard” about these policies. But just as Trump falsely claims he’s safeguarding rather than jeopardizing protections for preexisting conditions, Pence insisted that whatever the administration had just announced surely involved expanding Medicaid coverage, not cutting it. As proof, Pence repeatedly touted his earlier work as governor of Indiana, where he had indeed expanded Medicaid — something he was able to do, of course, only because of the Affordable Care Act that he’s now working to destroy.

Davidson explained that the policy announced that day would actually reduce access to care, not increase it. He expressed concern that increased out-of-pocket costs would make it harder for his patients to get insulin and other life-saving treatments.

The vice president remained unmoved. “Medicaid, as you know, has a lot of problems,” Pence said. The administration was merely promoting “state-based innovation and reform,” he added. And then he extricated himself from the conversation.

I asked Davidson afterward if he believed Pence genuinely hadn’t realized that the administration’s policy involved cuts to Medicaid coverage, or knew and didn’t care. Davidson said he assumed Pence’s ignorance was feigned, given that the architect behind the block grant proposal had previously worked for Pence in Indiana.

But, Davidson said, “Either answer is really distressing.”

Maybe the administration is confused. “Nobody knew health care could be so complicated,” after all. Maybe it’s just callous. At some point, the two excuses become indistinguishable.

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