Ah Medicaid! What can we say about it? Until the last couple of weeks, the press has said almost nothing. It’s not sexy; not fun to write about. It affects poor people who don’t bring in traffic. And it can get us tangled in the weeds pretty fast.
But lately we’re on the case. Perhaps one reason is Bill Clinton’s address at the Democratic National Convention, when he pointed out that while Medicaid is best known as a program for the poor, the majority of its spending goes to the elderly and people who are disabled. The Kaiser Family Foundation says these two groups account for 25 percent of the program enrollees, yet for two-thirds of Medicaid spending. Maybe that reminded the press that it should take a look. Or perhaps it was the realization that the Romney-Ryan ticket could change the program as we know it.
Whatever the reason, we’re glad that some news outlets have begun to regard Medicaid as newsworthy. The California Healthline, a service sponsored by the California HealthCare Foundation, almost chastised the press for spending too much time on Medicare instead of Medicaid, arguing that the “Candidates’ Real Difference Are on Medicaid.” That goes a bit too far, in my opinion; Medicare is so important, and there are real differences between Obama’s approach and Romney-Ryan’s ideas for it. But it is true that their differences on Medicaid, which covers some 60 million Americans, are significant.
As The New York Times reported, in a piece by Abby Goodnough:
The outcome of the election will probably have a more immediate and profound effect on Medicaid, the joint state-federal program that provides health care to poor and disabled people. Few other issues present a starker difference between the Republican and Democratic tickets.
To review: Medicaid covers healthcare for those with low incomes who qualify by passing an income and asset test. People don’t get benefits if their incomes are too high and assets too great. Medicaid also pays for—and this is a big deal that is not well understood—more than half of all nursing home stays. Middle class people often qualify for Medicaid nursing home coverage by “spending down” their assets and income on care, making themselves poor enough to qualify.
While states and the feds share in financing Medicaid, the GOP plan is to upend this arrangement by giving each state a block grant—a fixed sum of money—that they can use to cover healthcare for the poor, nursing home stays for the middle class, or for other needs. Sketchy details make it hard to predict exactly what the states would do, but it’s possible they could restrict eligibility so that fewer people qualify. The devil will be in the details, and the press will need to find where they lurk.
And then there is this: Block grants usually reduce the amount of funds going to a particular program. Robin Rudowitz, associate director of the Kaiser Commission on Medicaid and the Uninsured, told me “programs with capped federal funding do not keep pace with the need for them, and they don’t provide guarantees for benefits the way entitlement programs do.” She added “You can see it with the TANF (Temporary Assistance for Families) block grant, which hasn’t kept pace with demand.”
Medicaid, in its current form, is an entitlement. During the recession, as enrollment has grown, federal funding has been there for those who needed it. However, with a block grant, funding may not be available to everyone who needs healthcare. The tradeoff: The government saves money, but people don’t get treatment.
After the Supreme Court ruled in June that states did not have to participate in an expansion of Medicaid called for by the Affordable Care Act, Medicaid got a bit of a news bump. The story narrative focused on why the states would turn down federal dollars to cover more people, and news outlets did a lot of prognostication about which ones would balk at covering more of their residents. While it’s important to signal which states may refuse to expand Medicaid, some of those pieces did not go far enough and zoom in on what would happen to those left out.
In the last few weeks the Medicaid narrative has changed. Some news outlets are starting to report on Medicaid’s role in paying for long-term care, which consumes such a large chunk of program dollars. Medicaid’s role is crucial, since the US does not have a program to finance long-term care. (The Obama administration supported a provision in the 2010 health reform law called the CLASS Act. This was a voluntary program, in which people could begin to prefund their long-term care expenses. However, the administration subsequently found it to be unworkable. The House later repealed it. )