HEALTH CARE/Joan Retsinas

Medicaid-Speak: Words as Bullets

In the Battle of Trumpville, a.k.a. Rich against Poor, the fight zeroes in on Medicaid. And the bullets? Words. Words can enrage an angry constituency, pressing solons to slash budgets. Medicaid is a bureaucratic word. But say “entitlement,” and watch conservatives shudder at “government bloat”. Couple “entitlement” with “poor people,” and the indignation mounts. What are poor people entitled to? Surely not all the bounty Uncle Sam now bestows upon them.

So, in this Battle of Trumpville, Medicaid comes up for scrutiny. As an entitlement, Medicaid insures the healthcare of poor people. Unlike Medicare, the entitlement is not robust: the federal government sets a threshold of benefits, but states can – or cannot – exceed those benefits. (Dental care, for instance, is optional.) And while states must cover residents with income at 100% of poverty, states can – or cannot – go higher. Similarly, the courts have held that “aggrieved” Medicaid recipients have limited access to sue, unlike aggrieved Medicare recipients.

Nevertheless, since 1965, the federal government has picked up roughly half the tab for states’ expenditures (higher in poorer states, lower in wealthier states).

No more. On the horizon: cuts. But cuts framed in Medicaid-speak – words that obscure the harm.

A Medicaid-speak word: work requirement. Every person who receives Medicaid should work. We have done it more or less with welfare; why not with Medicaid? If all the slug-a-beds got jobs, the Medicaid rolls would shrink. As of March 2017, four states had formally requested Medicaid waivers to allow work requirements: Indiana, Arizona, Kentucky and Pennsylvania. ( But more states, including Florida and Arkansas, see this path to solvency. Of course, the reality is that 70% of recipients are elderly, blind and/or disabled. Medicaid picks up half the tab of all nursing home costs, much of the costs of group homes. Do we intend to transform nursing homes into piece-work cottage industries?

More Medicaid-speak: co-payments. The middle class pays them, from $15 to $20 a visit. The goal: to deter frivolous visits, which will decrease “utlilization,” which will decrease costs. Why not require co-payments for Medicaid recipients? In Indiana, when Governor Pence launched this great idea, supporters conjured up images of Medicaid recipients surfing the net on cell phones. One caveat: Medicaid recipients are poor – the outlandish caricature is often outlandish. Another caveat: people may avoid primary care visits, only to end up in emergency rooms, requiring expensive treatments. Pregnant women who skip pre-natal visits to save the co-payment risk complications. And children need vaccinations, well-baby visits, oversight of diseases like asthma. Public health officials have been trying to link Americans to “medical homes,” where primary care physicians treat problems before they become catastrophes. Co-payments work against that linkage; in spite of the rosy fiscal predictions, co-payments may spike costs.

The final Medicaid-speak word, and the one with the most impact: block grants. Congress need not meddle in the micromanagement of the cutbacks: it can hand states the weapon. With block grants states will have less money, but flexibility, presumably to be more efficient. “Flexibility,” though, is Medicaid-speak for cuts. States will have the linguistic cover to drop enrollees, decrease benefits or pay providers less. Wealthy states may elect to spend more state revenue on the poor. In effect, those states will continue with their status quo operations, regardless of federal “block grant” cuts. But states facing budget deficits must either cut payments, drop enrollees or eliminate services.

Nursing homes merit attention in this block-grant nirvana. States generally pay nursing homes far below “market” rates. Those that serve a majority of “private-pay” patients can weather even lower Medicaid payments. Those that serve predominantly Medicaid residents will be hard-pressed to deliver “quality” care. Ironically, the legislators who cut Medicaid funds to nursing homes will be the loudest to decry the nursing home scandals of poor care.

Arkansas is not atypical in its enthusiasm for block-grant flexibility. Under Obamacare, Arkansas expanded Medicaid to cover people up to 135% of poverty. Today the state is expected to pay 10% of the costs, with the federal government picking up the rest. Budget-cutters, though, propose ratcheting back the income eligibility to 100% of poverty; they expect those axed recipients to get insurance via the Obamacare “exchanges”’ subsidies – not grasping the possibility that those subsidies may well disappear. Crucially, these legislators see only budgetary savings.

In Medicaid-speak, ironies abound. The politicians who argue that “entitlements” sap personal initiative often were born a few rungs up Horatio Alger’s ladder of success. The Medicaid recipients who draw the most ire – the pregnant women and children, not the elderly or disabled – cost far less than comparable populations covered by private insurance. Finally, Medicaid is counter-cyclical: expenditures rise during recessions, fall during periods of prosperity.

Medicaid-speak may win this battle of Trumpville, but the victory may be Pyrrhic.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, June 1, 2017

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