Republicans Kicking Americans Off of Medicaid

Yesterday (28th) I introduced the 1st half of Charles Gaba commentary. In case you forgot what it was, you can find it here: Twenty-one Million Americans to Lose Healthcare – Angry Bear for reread. Charles does a thorough job of discussing what Repubs are planning to do to a sizeable number of citizens.

To the right, I have included the Pie Chart (from the first post) which shows the 21 million citizens, the Republicans are going to rip healthcare away from so as to help subsidize tax breaks for the upper 5% of taxpayers mostly targeting the upper 1%. Click on iy to enlarge. A listing of those funds is in the first commentary. Link above or here.

Lets move on to part 2.

Republicans have decided which 21 million Americans should lose their healthcare Part 2

Charles Gaba

ACA Signups

There are 42 House Republicans who won their seats last November by 15 points or less (see below). These are the most vulnerable Republicans. Meanwhile, Democrats have been outperforming their districts by an average of over ten points in special elections so far this year.

Combine these data points with the growing backlash and as you can imagine, some House Republicans in swing districts (and not-normally-considered swing districts) are understandably nervous about ripping healthcare coverage away from up to 60% of their constituents (that’s not a typo . . . check out CA-22).

The optics look even worse for Republicans when Democrats have been successfully calling attention to the huge numbers of children, the elderly and the disabled who rely on Medicaid, as noted by my friend & colleague Andrew Sprung (Andrew Sprung is a good one to read as he offers up great detail).

Here is the core defense in a letter from Families USA, co-signed by more than 300 advocacy groups, to Senate Majority Leader John Thune, asking him to reject the house budget resolution:

Medicaid is a lifeline for communities across the country. It provides affordable health insurance to almost 80 million Americans—1 in 5 people living in the United States—and serves as a financial backbone of the health care system, including for the clinics and hospitals on which we all rely. Medicaid delivers essential care to 37 million children, 14 million people living in rural areas and more than 8 million people with disabilities. It supports 7 million seniors and 12 million Medicare enrollees. It also covers more than 40 percent of all births and is the single largest payer to community clinics, for long-term care, and for mental health and substance use disorder services in the country.

So, what’s a Republican House member to do? They have to have their massive tax cuts for millionaires & billionaires, after all; that’s not even up for debate in their minds!

Well, as Sprung goes on to note, the very advocacy for these vulnerable groups of Americans has also provided the “solution” to Republicans’ problem in their eyes:

Republicans are out there proclaiming that “able-bodied” adults don’t deserve coverage, that the 90% federal match rate for the expansion that made it financially viable for states sucks resources from “traditional” Medicaid beneficiaries (it doesn’t), that defunding the expansion is just cutting “waste, fraud, and abuse” — that is, that low-income adults without affordable access to employer insurance are effectively human waste. The copious benefits to expansion beneficiaries themselves and to state healthcare systems and finances stemming from the expansion need to be defended directly.

Sure enough, just a couple of days ago, Punchbowl News reported that:

A dozen House Republicans are warning GOP leaders that they won’t back a reconciliation package that includes massive cuts to Medicaid, according to a letter first obtained by Punchbowl News.

(Sidenote: Punchbowl doesn’t appear to understand just how “massive” the cuts to Medicaid these dozen House Republicans are OK with would be, as I’ll explain below).

.“We support targeted reforms to improve program integrity, reduce improper payments, and modernize delivery systems to fix flaws in the program that divert resources away from children, seniors, individuals with disabilities, and pregnant women — those who the program was intended to help.

“However, we cannot and will not support a final reconciliation bill that includes any reduction in Medicaid coverage for vulnerable populations.”

…“There’s reasonable actions we can support like work requirements for able bodied adults without children and auditing the Medicaid list,” Bacon told us. “But there will not be the votes to cut Medicaid for those who need it or to the hospitals that we need to preserve.”

Kim said in a statement that a reconciliation package “that does not protect vital Medicaid services for the most vulnerable citizens in my community will not receive my vote,” adding she’s made that clear to constituents and GOP leadership.

…Van Drew later told reporters that Johnson promised not to cut Medicaid for individuals who are “qualified” to receive the benefit. LaLota told us that the speaker vowed to take a “compassionate approach.”

In other words, of the 8 ideas House Republicans were playing around with back in January, it sounds an awful lot like they’re gonna boil it down to two: Reducing the FMAP matching rate and imposing work reporting requirements for the ACA expansion population . . . while presumably “showing mercy” on the non-expansion population.

As Jason Sattler aka LOLGOP notes (and as I alluded to above). The way Punchbowl frames this makes it sound like these dozen Republicans are to be praised. Praising them for “only” tearing away healthcare coverage from up to 21 million people who are “undeserving” of it for some reason or another.

This is the same type of “logic” which the Trump Regime has been using in trying to justify denying due process to people who they (falsely in most cases) have accused of being “gang members” and which Republicans writ large have been using to justify kidnapping & imprisoning people in a foreign gulag because they “aren’t U.S. citizens.” As if only U.S. citizens are “entitled” to be treated as . . . well, as human beings. (And of course they’ve been kidnapping some U.S. citizens as well, I should note).

In short, the talking point that Congressional Republicans have settled on is to go after ACA Medicaid expansion specifically.

Jonathan Cohn of The Bulwark concurs:

Then Johnson went on Fox and, after the obligatory promise “to protect Medicare, Social Security, Medicaid for people who are legally beneficiaries of those programs,” said the following:

We have to root out fraud, waste, and abuse. We have to eliminate people on, for example, on Medicaid who are not actually eligible to be there — able-bodied workers, for example, young men who are—who should never be on the program at all.

When you have people on the program that are draining the resources, it takes it away from the people that are actually needing it the most and are intended to receive it. You’re talking about young, single mothers, down on their fortunes at a moment — the people with real disabilities, the elderly. And we’ve got to protect and preserve that program. So we’re going to preserve the integrity of it.

That may sound like a defense of Medicaid and the people who need it, and surely that’s how Johnson hopes the public will interpret it. But that is also the language Medicaid critics have been using to describe a big, controversial downsizing of the program — one that would undermine what was arguably Obamacare’s single biggest achievement.

So, what would actually happen if “all” they end up doing was reducing the percent of Medicaid costs. Those costs paid by the federal government for the expansion population from 90% down to whatever the non-expansion FMAP rate is for each state?

Well, for starters:

Twelve states currently have “trigger” laws in place that would automatically end expansion or require changes if the federal match rate were to drop, but coverage would be at risk in other states given the substantial loss of federal funding. Not all trigger laws would immediately end the Medicaid expansion, but enrollees in states with trigger laws are at greater risk of losing coverage. States are actively debating their Medicaid expansion trigger laws, with some states working to remove and others working to establish the automatic termination of Medicaid expansion coverage if federal support declines.

Here’s the 12 states (below) with trigger laws. Barring legislation by the individual states, between 3.8*- 4.4 million Americans would be kicked off of Medicaid from these states right out of the gate…up to 13.6% of their entire populations. It’s worth noting that one of these is North Carolina, which just implemented Medicaid expansion a little over a year ago.

Update*: I forgot that about 18% of those enrolled in Medicaid via ACA expansion were actually already legally eligible to enroll before the ACA was passed, and presumably still would be if ACA expansion ended in their state; the other ~82% are only or newly eligible specifically via ACA expansion. I’ve updated the table below to reflect this (below).

The second immediate consequence would be that the 10 remaining non-expansion states (AL, KS, MS, FL, GA, SC, TN, TX, WI & WY), where over 1.4 million low-income adults have been caught in the “Medicaid gap” for over a decade now would absolutely never expand their programs.

OK, but what about the 16.6 million Medicaid expansion enrollees in the other 19 states which did expand Medicaid?

Well, according to this analysis by KFF, here’s how much every expansion state (including the 12 w/trigger laws) would have to come up with on their own in order to fill in the $626 BILLION in lost federal funding if they wanted to keep their current expansion populations covered:

These estimates are for a ten year period, but even so, not many states have several hundred million dollars in extra cash lying around each year (or several billion per year in the case of the larger states). A few of the deeper blue states might find some way to cover the lost funds, but it would only be a fraction of what’s needed, and my guess is most won’t even bother to try.

Update: Nationally, of the ~21 million enrolled in Medicaid via ACA expansion, around 3.6 million were already eligible and would theoretically be able to stay on their state’s non-ACA Medicaid program, bringing the number of Americans losing coverage in the event of every state dropping expansion down to perhaps 17.6 million.

On the other hand, this would still cause an increased strain on the budgets of those states which would likely lead to reduced services for their remaining Medicaid populations.

The “beauty” of this from a sociopathic MAGA Republican point of view is that a) none of the Republicans representing the 10 non-expansion states would have to sweat it, since they never expanded their programs in the first place; and b) since technically there’s nothing in the legislation which actually reduces Medicaid eligibility for any specific population, they get to (try to) shift the blame to the states for not coming up with the extra funds necessary to keep the program running.

This post is getting pretty lengthy, so I’ll (Charles Gaba) address the “work reporting requirement” scheme (as well as the looming expiration of the ACA’s IRA subsidies) separately, but in the meantime, here’s what targeting the ACA Medicaid expansion portion of the population looks like nationally