Since the Republican Senate health care bill was released, there has been much discussion about its worst aspects. Is it the cutting 22 million people off health insurance? Is it doing away with pre-existing condition protections? Or is it the attack on essential benefits so health plans would no longer include key content like mental health or substance abuse treatment? I think it is none of these.
The worst aspect is what the Republican bill does to the Medicaid program.
Medicaid currently provides care to 74 million people nationwide, including the most vulnerable among us. The Republican Senate bill strips the entitlement from Medicaid. That alone would be devastating to low-income people, women, children, seniors and people with disabilities.
What does that mean to strip the entitlement? It means that there will be no guarantee of Medicaid services for the needy and vulnerable in New Hampshire and across America.
At present, Medicaid benefits cannot be taken away without due process of law. Individual Medicaid recipients have statutory and regulatory rights and a property interest under the Constitution.
As a result, Medicaid recipients have strong notice and appeal rights. These protections have been built up over the last half-century. There is an extensive body of case law delineating these rights. Medicaid recipients can appeal any unfair or improper denial of service through an administrative process, including fair hearings. If needed, Medicaid applicants and recipients, pursuant to their rights, can appeal to federal and state court as well.
The Republican health care plans in the House and Senate do away with these rights and demolish a 52-year body of law. Instead of an open-ended assurance for states, Medicaid would become a discretionary program. Whether the Republican plan is based on block grants or per capita caps, both of which would cap the federal funding for Medicaid, access would depend on the money not running out.
These changes would be a huge deal to all individuals on Medicaid, as well as those applying for the program. You would go from being a claimant with a well-defined set of rights to being a beggar and a pawn in rich peoples’ political games. Since these changes are buried in the complexity, claimants will not know until it is too late that their rights have been eviscerated.
In contrast to current Medicaid, which was designed to be a counter-cyclical program able to respond to downturns in the economy and state-level emergencies, the Republican plan would set a base year spending level. Then an index would be used to set yearly growth rates. These capped spending levels would cover a falling share of actual costs over time. If and when money ran out, and it would, the consequence would be cuts. States would have to decide whether to terminate eligibility categories (such as pregnant women, children, seniors or people with disabilities) or eliminate coverage for select vital services (like prescription drugs, mental health, inpatient medical services or cancer treatment).
Block grants and per capita caps set a fixed allotment for each state. They leave states at high risk for enrollment increases and for numerous other cost drivers such as medical innovations, new health conditions, disease outbreaks and the health impacts of any natural disaster.
The Senate bill also would end the Medicaid expansion that has allowed 31 states and the District of Columbia to provide coverage to 11 million low-income adults. Because of the Medicaid expansion, we are at an all-time low in the number of uninsured people in the United States.
The Medicaid expansion has been a tremendous bargain for the states that have adopted it. While some complain that states pay any share of the cost, the expansion limits state matching dollars to only 10 percent of the total cost. The federal government picks up 90 percent of the cost. By any fair evaluation, that is a great deal for the states. Typically in Medicaid, the federal government match is 57 percent.
Overall, Medicaid is now the largest source of health insurance coverage for individuals with substance abuse disorders, including opioid addiction. Since mid-2014, 23,000 people in New Hampshire have received substance abuse services from Medicaid. Given the magnitude of the substance abuse epidemic, it makes zero sense to end such an effective source of treatment.
President Ronald Reagan, a hero for conservatives, increased Medicaid coverage for lower-income and vulnerable Americans three different times. It is hardly conservative to take a meat cleaver to this intricate structure.
Jonathan P. Baird of Wilmot works at the Social Security Administration. His column reflects his own views and not those of his employer.