Former President Clinton advised the delegates to the 2012 Democratic Convention to listen carefully to what the Republicans were offering in regard to Medicaid, and those of us in Nevada should be “listening with both ears.” Here’s the description of the Medicaid program as stated by the Nevada Department of Health and Human Services, the program:
“Provides health care coverage for many people including low income families with children whose family income is at or below 133% percent of poverty, Supplemental Security Income (SSI) recipients, certain Medicare beneficiaries, and recipients of adoption assistance, foster care and some children aging out of foster care. The DHCFP also operates five Home or Community-Based Services waivers offered to certain persons throughout the state. The Division of Welfare and Supportive Services (DWSS) determines eligibility for the Medicaid program.”
Listing those categories focuses on the aims of the program — it is to serve (1) low income families with children; (2) elderly Nevadans; (3) low income Nevadans over 65 years of age; (4) families receiving assistance for adopted children; (5) children in foster care. Who was enrolled in Nevada’s Medicaid program as of fiscal year 2009:
What services were provided to those enrolled in Nevada’s Medicaid program?
During fiscal year 2010, 68.1% of the spending from the Medicaid program went for acute care, 25.6% was allocated for long term care, and 6.3% was used for “disproportionate care – hospital payments.”
The spending for long term care breaks down as illustrated in the following chart:
11.1% of the long term care funding was allocated to facilities for the intellectually disabled, 2.9% went to services for the mentally ill — and notice – 86% was used to provide home health & personal care, and nursing facility care. In other words, 86% of Nevada’s Medicaid expenses for long term care went toward serving those least able to care for themselves. The other 14% was used to provide intermediate and long term care for those unable to care for themselves because of intellectual limits or mental illness.
Here is exactly why President Clinton told his audience to “listen up:”
My view is get the federal government out of Medicaid, get it out of health care. Return it to the states.” – Romney, South Carolina GOP Primary Debate, Jan. 20, 2012.
In case anyone is remotely confused about what that statement from the former Massachusetts Governor means, he’s speaking about transforming the Medicaid program into Block Grants.
More specifically, the former Governor is adopting the block grant proposal for Medicaid set forth in his running mate’s “Path to Prosperity” budget plan:
“The plan also would repeal health system reform law provisions that will expand Medicaid coverage starting in 2014. Instead, states would receive block grants, which would free states “to tailor their Medicaid programs to the unique needs of their own populations,” the budget says.” [AMA]
The tailoring is to be done with less cloth:
The Ryan budget would cut $2.4 trillion from Medicaid and other health programs. Reduced spending would increase the number of uninsured dramatically, Park* said. “Those who retain coverage will have benefits scaled back and have higher cost-sharing.” [AMA] (emphasis added)
We can drill down further into what Governor Romney and Representative Ryan have in mind for the Medicaid program by looking at the Congressional Budget Office’s analysis of the Ryan position: Medicaid and the Children’s Health Insurance Program (CHIP)—from 2 percent of GDP in 2011 to 1¼ percent in 2030 and 1 percent in 2050.
Now is the moment to recall that 58% of those who receive Medicaid assistance for their health care needs in Nevada are children, and the AAP isn’t thrilled at cuts to that constituency:
“American Academy of Pediatrics President Robert W. Block, MD, said the proposal would undo investments in health programs for children. More than half of Medicaid recipients are children, but their care accounts for up to only one-quarter of the program’s costs.
“Whether considering fiscal year 2013 federal spending bills or reviewing long-term budget proposals, Congress must seize this opportunity to invest in the future of our country by protecting children’s health,” Dr. Block said.” [AMA]
Dr. Block has reason to be concerned, if we return to the Congressional Budget Office’s analysis we can see why. In two paragraphs from their analysis of the Ryan “Path” the non-partisan office explains why the proposal would make deep cuts, and place greater burdens on the states:
“The specified path (Ryan Plan) would cause federal spending on Medicaid and CHIP to decline relative to GDP in coming decades, rather than to rise sharply as in the other policy scenarios that CBO has analyzed, and would include no exchange subsidies (see Figure 3). As a result, by 2050, such spending would be 76 percent below what would occur for Medicaid, CHIP, and exchange subsidies under the baseline scenario and 78 percent below what would occur under the alternative fiscal scenario. Because spending on CHIP and exchange subsidies represents a relatively small share of the amounts in the baseline and alternative fiscal scenarios, most of the reduction would have to come from the Medicaid program.” [CBO] (emphasis added)
The Republicans do, indeed seem serious about eliminating Medicaid as a federal program and shifting the expenses for health care access to low income elderly, the disabled, the intellectually disabled, elders in nursing facilities, and children in poverty to the states. The CBO explains the nature of this shift:
The responses of the states would be of particular importance. If states were given additional flexibility to allocate federal funds for Medicaid and CHIP according to their own priorities, they might be able to improve the efficiency of those programs in delivering health care to low-income populations. Nevertheless, even with significant efficiency gains, the magnitude of the reduction in spending relative to such spending in the other scenarios means that states would need to increase their spending on these programs, make considerable cutbacks in them, or both. Cutbacks might involve reduced eligibility for Medicaid and CHIP, coverage of fewer services, lower payments to providers, or increased cost-sharing by beneficiaries—all of which would reduce access to care. (emphasis added)
Translation: Even if the states were able to achieve all the vaunted efficiencies a “flexible” plan might provide — the cuts proposed are so deep and so drastic that citizens in the United States who are lower income elderly or the disabled in nursing homes, and those who are low income and living in foster care, or families in poverty — would have reduced access to care. Period.
These aren’t generic numbers and pie in the sky statistics we’re talking about, we’re speaking of 25,841 elderly Nevadans, 40,898 disabled Nevadans, 55,626 adult Nevadans – mostly women, and 168,070 Nevada children.
So, here’s a question for Governor Romney and Representative Ryan — If no matter how much efficiency the state of Nevada squeezes from your block grants for Medicaid, Nevada and the other states will still have to either appropriate significantly more revenue, or drastically reduce services — how is your plan anything other than a proposal to shift the burden of health care costs, for the least able among us, from the federal treasury to the state treasuries and the pockets of low income Americans?
Where, Governor Romney and Representative Ryan, does the Nevada Legislature start cutting? From the acute care services for adopted or foster children? From the acute care for pregnant women? From acute care for children in poverty who have asthma, autism, broken arms, or sprained ligaments? From the long term care for the elderly who need home health care services and personal care to avoid institutional living? From the long term care for the indigent mentally ill? From elderly residents of nursing facilities? From disabled children who need home health care? Where?
Perhaps cuts aren’t the only option. Must the Nevada government raise the eligibility standards such that only those living at “25%” of the official federal poverty level can receive assistance? Here are the 2012 guidelines from the Department of Health and Human Services –
How much more should a family of four living on $1,920.83 per month have to pay for basic health care? How much more should a young man and his pregnant wife living on $1,260.83 per month have to pay for pre-natal care, and expenses associated with the birth of their first child? For a political party which lauds its “Pro-Life” stance — asking low income families to dig deeper to pay for health care to make up for federal and state budget issues (while proposing more tax cuts for the top 1% of American income earners), makes it sound as though the GOP is the Pro-Birth, not Pro-Life party.
How much more should a young family have to pay for health care before the cost of health care begins to impinge on the capacity to put a roof over their heads?
Or their ability to put food on the table? It’s likely going to cost our young family with two children under the ages of 19 approximately $366.40 to $578.40 per month to keep everyone fed. [USDA] Our hypothetical family might be lucky to have $764.43 per month remaining after housing and food for utilities, clothing, transportation costs (auto payments or bus fare) — that $764.43 translates to about $25.48 per day to cover ALL the basic family needs listed previously… including Health Care. But wait, the Romney/Ryan budget cuts nutrition assistance too, drawing fire from the U.S. Conference of Catholic Bishops:
“Cuts to nutrition programs such as the Supplemental Nutrition Assistance Program (SNAP) will hurt hungry children, poor families, vulnerable seniors and workers who cannot find employment. These cuts are unjustified and wrong.” [The Hill]
And what other program do the Republicans fantasize about turning into a Block Grant Program and then cutting? Housing subsidies. [TO.org] There was some discussion of the Ryan proposal on this topic at the March 21, 2012 House Budget Committee hearing:
“Rep. David Price (D-NC) asked Donovan what the implication of the Ryan budget cuts would be on HUD programs such as public housing, Choice Neighborhoods, HOME and others. Donovan responded that, under the proposed Ryan budget, approximately one million households could lose their housing. Of the one million households at risk under the Ryan budget, Donovan estimated that 585 thousand would come from the Housing Choice Voucher Program, 425 thousand from the Project-Based Voucher Program, and 110-180 thousand from homeless assistance programs. He also mentioned that an estimated 17 thousand jobs would be lost from CDBG, and cuts to the HOME program would mean tens of thousands of new affordable housing units would not be built.” [CLPHA] (emphasis added)
So, no help for financially fragile families for health care, or housing, or food — or anything, but tax payers in the top 1% of all our income brackets will get more, yet more generous, tax breaks. Little wonder the Bishops were annoyed. Less wonder Sister Simone Campbell from Nuns on the Bus received a standing ovation at the Democratic National Convention.
A person doesn’t have to be Roman Catholic to find the Republican proposals supported by Governor Romney and created by Representative Ryan astonishing in their parsimony and appalling in their avarice.
Perhaps one has to be incited by the fact that a family in Las Vegas might have an air-conditioner, or a DVD player, or a functional motor vehicle — “Look,” cry the miserly, “They have nice stuff, and they got it by doing nothing.” Not. So. Fast. As of 2010 not that many Nevadans were receiving public assistance. [Census] In fact, about 3% of Nevadans were receiving public assistance. [Census pdf]
Thus much for the Miserly Myth that “They’re all sitting around collecting welfare, and learning to be dependent on Guv’mint.” Perhaps we should add the usual follow up, “and they’re doing it on my hard earned tax dollars.” The latter portion is correct, we do pay taxes which support assistance programs for fragile families. However, the Grinches among us appear to believe they are the only ones chipping in.
S’cuse me Mr. Grinch, but I really don’t mind paying a fractional portion of my income to insure NO child goes to bed hungry, NO elderly person with dementia is left alone, NO foster child is left with an untreated case of pneumonia, NO pregnant woman is without pre-natal care, NO family is homeless, NO mentally ill person is abandoned, NO disabled child is without care.
This is what Democrats mean when we say, “Just Say No.”
References and Resources: * Edwin Park, CBPP. Congressional Budget Office, Ryan’s Specified Paths, March 2012. (pdf) “House Republican Budget Seeks to Slow Medicare, Slash Medicaid,” American Medical Association, April 2, 2012. Kaiser Family Foundation, State Health Facts, Database. “Public Assistance Relief,” Census, Department of Commerce, pdf. “HUD Secretary Defends FY13 Budget Before House Appropriators,” CLHPA. “Four Ways Romney and Ryan Would Roll Back the 20th Century ,” Jake Blumgart, AlterNet, September 5, 2012. “What Paul Ryan’s Budget Actually Cuts,” Brad Plumer, Washington Post, August 12, 2012. USDA, Cost of Food Plans, Center for Nutrition Policy and Promotion, May 2011 (pdf). ASPE, Department of Health and Human Services, HHS Poverty Guidelines 2012. Congressional Budget Office, “The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan,” March 2012, pdf. Kaiser Family Foundation, link to interactive database for state health care statistics.