Medicaid works. It provides life-sustaining health coverage to low-income Americans and life-enabling support to both children and adults with disabilities, giving them the tools they need to live independently within communities, to go to school and to seek work in their chosen fields.
Few programs in history have done more good. Few dollars are spent with greater benefit. There are many ways in which we could strengthen the safety net that Medicaid provides, but right now, it basically works.
If the current version of the Republican replacement for the Affordable Care Act secretly slouching its way through the Senate mirrors the House bill, it will cut Medicaid by well over $800 billion. A recent report suggests the cuts could be even higher.
The Trump administration’s 2018 budget proposed cuts to Medicaid that reached as high as $1.4 trillion. But what possible reason could the Republican Party generate for gutting Medicaid? So far, the Republican senators who are deciding the future of American health care can’t say. They’re just going to do it because they can.
In the face of this existential threat, what are advocates supposed to do? One problem is that Medicaid’s future is linked to the GOP’s vow to repeal the Affordable Care Act, which expanded Medicaid. Multiple Republican elected officials have argued this expansion has enabled too many able-bodied people to receive Medicaid. That’s a myth, but even if it were true, focusing on expansion conceals the depths of the attack.
Beyond rolling back the expansion, both Trump’s budget and the various bills in Congress switch Medicaid from a system based on actual costs to an arbitrary cap. Right now, for every dollar that a state spends on Medicaid, the feds also contribute one to three dollars. Under “per capita caps” or “block grant” systems, states get a fixed sum per year. If expenses go up, due to rising health care costs for example, the federal funding stays flat. This will inevitably lead to rationing of care.
For disabled Americans, the fear is that the types of long-term support and services and preventative services that keep them healthy and integrated into society will be first to go under a per capita system. Alas, it’s been hard to attract public interest when it comes to the nitty-gritty details of federal reimbursement rates for state costs.
Austerity will drive disabled Americans into nursing homes, deny them attendants that make living in their own home possible, and make it harder for people with disabilities to work (and pay income tax!). Per capita payments will likely cost America more money in the long run with worse results for public health, trapping disabled Americans in unsafe but expensive institutions. Austerity kills. It also rarely actually saves money.
So what do we do? Disabled individuals, organizations and reporters often rely on sympathetic stories to try to make the impact of Medicaid more visible.
The Arc, a major disability rights group, told the story of Soojung and her daughter Alice, who has Rett syndrome. Alice Wong, founder of the Disability Visibility Project, wrote an article for The New York Times about all the ways Medicaid has made her a “fully engaged member of society.” Erin Hawley detailed the ways Medicaid enables her to live her life independently for Easter Seals. Huffington Post reporter Jonathan Cohn told the story of Justin Martin, a student at Kenyon College, explaining all the ways that Medicaid enables his education and fuels his career aspirations. Three health care professors illustrated for you — the reader — all the ways you’re likely to need Medicaid someday, if you don’t already, in a New York Times article. All of these stories are true. That’s because Medicaid works.
The American Civil Liberties Union is taking a slightly different tactic as it participates in both rallies and congressional briefings against capping care. It is arguing that this isn’t just about health care, but about the basic freedom to live among others. Ari Ne’eman, who is consulting for the ACLU, told me, “We have a strong commitment to the idea that people with disabilities have a right to live in the community.” The ACLU wants to move the conversation beyond the question of the optimal way to provide access to doctors and medicines, as important as those issues are.
All of these messages really ought to persuade the Republicans, or at least Republican voters, to change course. There are problems with Obamacare (in my mind because it’s based on a right-wing plan to provide health care through for-profit direct markets rather than a more sustainable single payer or public option system).
There are problems with Social Security systems related to disability (in my mind based on the links between disability, multigenerational poverty and income inequality).
Medicaid, though, basically works. When people on Medicaid struggle, they struggle from lack of resources — that’s not a problem cutting $800 billion to $1.4 trillion is going to solve.
Which brings us back to the question — why do it? We’re unleashing emotional, economic and legal arguments in defense of Medicaid to Republican lawmakers who just don’t seem to care about the facts. They aren’t gutting Medicaid because of any problem with the program, but because they want to give $800 billion in tax cuts to the richest Americans. They are going after Medicaid for the same reason bank robbers go after banks: because that’s where the money is.