Facing a tough election next year, Paul Ryan is seeing his wild Washington journey coming to an end. And while he’s on the verge of achieving his long-sought legislative dream of cutting taxes for corporations and the wealthy Americans, he’s got his eyes on dismantling the social safety net once and for all.
Despite several landmark legislative wins this year, his close relationship with President Donald Trump has made him toxic, and he knows it. In fact, Ryan has made it known to some of his closest confidants that he fears this will be his final term in Congress, Politico Reports. So he’s poised to destroy Medicaid… while he can.
Medicaid — the program that provides health insurance mostly to people who are poor or near-poor — is the largest insurer in the country, with enrollment that now approaches 70 million, or over one in five Americans.
Tinkering with the social safety net is a bold undertaking, particularly in an election year. But Ryan has good reason for stabbing the poor in the back: His time in Congress is running short.
Make no mistake, this is something Republicans desperately want to do. Paul Ryan wants it. President Trump wants it. It’s the cornerstone of their effort to eviscerate the social safety net, which is the second-most-important Republican policy goal (after cutting taxes for the wealthy, which is always and forever number one). They’ve been waiting for this for a long time, and now they’ve finally got their chance.
The vehicle for the destruction of Medicaid as we know it is the conversion of the program to “block grants” which would be used to both cut benefits and kick enrollees off their insurance — by the millions. It may be the kind of wonky story most people pass over as they peruse the news, but it would be one of the most radical changes to the safety net in decades.
Some quick background: Medicaid is jointly administered by the federal government and the states, each of which pay about half the program’s cost. Before the Affordable Care Act, every state could set its own eligibility levels, which meant that if you were lucky enough to live in a blue state, you could get the insurance if you were poor or near-poor, but if you lived in a red state, you might have to be practically eating cat food to survive before you could be eligible. For instance, in Texas an adult with children is only eligible if their income is below 15 percent of the poverty level, which means if you’re in a family of four and you make more than $3,645 a year, you’re too rich to get the benefit.
But the key point is this: Once you’re on Medicaid, your state can’t kick you off, and the program has comprehensive health benefits that are set by the federal government. It’s an “entitlement,” which means if you qualify you’re entitled to the benefit. In the case of Medicaid, that means each state’s program doesn’t have a fixed cost. If someone walks through the door in December and is eligible, the state can’t say, “Sorry, we used up all our Medicaid money for the year.”
That’s what block grants would destroy. Instead of a program serving anyone who qualifies, Republicans would like to give each state a block of money they can spend as they see fit. If you’re the state of Texas and you want to kick half the beneficiaries off their insurance? Go ahead. You want to cut back on the benefits Medicaid provides in your state? Be our guest.
Indeed, for many Republicans, that’s the whole point. They don’t like big government programs, and they don’t much like helping poor people.
One word you’ll hear a lot from Republicans as they talk about this is “flexibility,” but when you hear them say they want states to have flexibility, you should ask: Flexibility to do what? Because in most cases, what it means is flexibility to cut benefits and kick people off Medicaid entirely. Under current rules, states can’t do that. But with the “flexibility” of a block grant, they could. Many states — particularly those run by Democrats — wouldn’t do that, but states run by Republicans would.
We know that because of how they reacted to the ACA’s expansion of Medicaid. Nineteen Republican-run states refused to accept it, even though the federal government was offering them a huge pot of money to insure their poor citizens at almost no cost to them. Indeed, independent analyses showed that accepting the expansion would save state governments money, because they’d have a more productive workforce and they wouldn’t have to pick up the cost of uncompensated care (i.e. uninsured people turning up in emergency rooms). But these Republican states refused, because they would rather see their own citizens go without insurance than give Barack Obama the satisfaction of seeing them helped by his signature law.
Paul Ryan and his Republican allies in Congress and the administration probably believe that setting this bomb off under the health coverage 70 million Americans depend on is something they can get away with. We’re going to find out soon.