By Rich Lowry
Tuesday, June 27, 2017
The Brezhnev Doctrine said that the Soviet empire could
only expand and never give back its gains. A domestic version of the doctrine
has long applied to the welfare state — and never so brazenly as in the debate
over the Republican health-care bill.
Its reforms to Medicaid are portrayed as provisions to
all but forcibly expel the elderly from nursing homes and send poor children to
the workhouse. Bernie Sanders has called the bill “barbaric,” a word that once
was reserved for, say, chattel slavery or suttee, but is now considered
appropriate for a change in the Medicaid funding formula.
The Republican health bills have two major elements on
Medicaid: rolling back the enhanced funding for the Obama Medicaid expansion,
and over time instituting a new per capita funding formula for the program. The
horror.
The Democrats now make it sound as if the Obama expansion
is part of the warp and woof of Medicaid. In fact, it was a departure from the
norm in the program, which since its inception has been, quite reasonably,
limited to poor children, pregnant women, the disabled, and the ailing elderly.
Obamacare changed it to make a priority of covering able-bodied adults.
Obamacare originally required states to enroll
able-bodied adults with incomes less than 138 percent of the federal poverty
line starting in 2014. The Supreme Court rewrote the law to make the expansion
voluntary, and 31 states and the District of Columbia took it up.
Traditionally, the federal government had paid more to
poor than rich states, with a match ranging from 75 percent for the poorest
state, Mississippi, to 50 percent for the rich states. Obamacare created an
entirely new formula for the Medicaid expansion population. It offered a 100
percent federal match for the new enrollees, gradually declining to a 90
percent match — supposedly, forever.
So, perversely, Obamacare has a more generous federal
match for the able-bodied enrollees in Medicaid than for its more vulnerable
populations.
“This higher federal matching rate,” writes health-care
analyst Doug Badger, “allows states to leverage more federal money per state
dollar spent on a nondisabled adult with $15,000 in earnings than on a
part-time minimum wage worker with developmental disabilities who earns barely
half that amount.” According to Badger, West Virginia received seven times as
much federal money for spending $1 on an able-bodied adult than for spending $1
on a disabled person.
This obviously makes no sense, and the Senate health-care
bill phases out the enhanced funding over several years. But it doesn’t end the
expanded Medicaid eligibility for the able-bodied. And a refundable tax credit
will be available for low-income people that is meant to pick up any slack from
Medicaid. This is hardly Social Darwinism.
The other, longer-term change in the House and Senate
bills is moving to a per capita funding formula for Medicaid, with the Senate
bill ratcheting the formula down to a per capita rate pegged to inflation — in
2025. Maybe this will prove too stringent, but it used to be a matter of
bipartisan consensus that the current structure of Medicaid creates an
incentive for heedless growth in the program.
The way it works now, Mississippi, for instance, gets
nearly $3 from the federal government for every $1 it spends. Why ever
economize? In the 1990s, the Clinton administration advanced what it portrayed
as an unobjectionable proposal to make Medicaid more efficient while preserving
the program’s core function — namely, a per capita funding formula.
“The president’s per capita cap proposal,” the liberal
lion Henry Waxman enthused at the time, “responds to the pleas of those who
want more cost discipline in Medicaid without terminating the guarantee of
basic health and long-term care to 36 million Americans.”
But that was before Obamacare lurched the program in the
other direction. The Brezhnev Doctrine dictates that what once was common sense
must now be unimaginable cruelty.
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