Wednesday, June 07, 2017

As Republican moderates cave on Medicaid cuts, what can Dems do?

As I feared back in March, the "moderate" Republicans in the Senate who profess concern about plans to repeal the ACA Medicaid expansion and impose per capita caps on federal funding for Medicaid are going squish. They'll settle for slowing repeal of the expansion rather than stopping it, and perhaps for some partial easing of the per capita caps, such as exempting coverage for the disabled.

Now as in March, Republican senators in states that have benefited from the expansion speak as if repeal of the expansion and a steady erosion in federal funding for all Medicaid programs is a natural disaster that they must help their constituents cope with, rather than their own free choice to inflict suffering on vulnerable people to fund tax cuts for the wealthy.

Here's Bill Cassidy of Louisiana, until now the strongest defender among Republican senators of maintaining ACA-level funding, speaking to Matt Fuller and Sam Stein of the Huffington Post. Over 300,000 Louisianians have gained Medicaid coverage since incoming governor John Bel Edwards implemented the expansion, beginning July 1, 2016.

“What we’ve been told so far, states would have the ability, a lot more power than they do under Obamacare, to shape their future, and I think we’ve gotta return the power to the states,” Cassidy said, seemingly referring to a proposal to set per-capita limits on Medicaid, which would push states to put tougher restrictions on who’s eligible for that program.

Asked if the phaseout of the Medicaid expansion was still a concern of his, Cassidy said it was. “I think there’s obviously more to be done, but the phaseout is further down the road and states have a chance to adapt,” he said.
More ambivalent is Shelley Moore Capito of West Virginia, which has cut its uninsured rate by 58% since ACA implementation, mostly through the Medicaid expansion. WV is also ground zero for the opioid addiction epidemic. The WSJ's Stephanie Amour and Kristina Peterson report:
“A longer timeline would certainly be helpful,” Ms. Capito said, noting that she was not sure she would support phasing out Medicaid.
More callous is Rob Portman of Ohio, who apparently thinks that further reducing the ranks of the uninsured in his state (where 700,000 have gained coverage through the expansion) would be a waste of state resources or a giveaway to the unworthy. Back to the Huffpost:
Still, Sen. Ron Johnson (R-Wis.) said the Senate’s approach would strike a better compromise than the House did, by giving states the ability to come up with their own new restrictions on Medicaid.

“I don’t want to pull the rug out from under anyone,” Johnson said, “but let’s not leave the rug out there for a couple more years to have more people stand on the rug."
Ohio is also an epicenter of the opioid addiction epidemic, and Governor John Kasich has credited the Medicaid expansion (his doing) with being crucial to the state's efforts to fight it. But they're mostly just takers looking for a magic carpet, right?

What can Democrats do to stop the train?  Fuller and Stein report on their thinking:
With the prospect of that growing stronger on Tuesday, Democrats were left with their own predicament: whether to begin negotiating with GOP moderates on a separate bill in order to stave off a conservative, Republicans-only approach. For now, Democratic leadership said they would stay away from any negotiations until Republicans dropped their insistence on a full repeal of Obamacare.

“There is no appetite as long as they’re working towards repeal,” said one senior Senate Democratic aide. But there is great appetite as soon as they abandon it.
I don't understand why Democrats wouldn't engage with Republicans who are not working toward repeal -- at least in the context of their discussions with Democrats. The Cassidy-Collins bill was not a repeal bill. I continue to think that precisely because the relative moderates are so squishy, and under such intense pressure to get with the repeal program, that Democrats should give them some cause to believe -- or claim -- that compromise legislation addressing Republicans concerns is a possibility. If there were a bipartisan gang of eight working on such legislation, a handful of moderates would be more likely to reject an AHCA variant.

The legislative goal of such negotiations (as opposed to the diversionary goal) would be loosening up ACA innovation waivers in exchange for maintaining ACA taxes and the Medicaid expansion. Perhaps the state waivers in the AHCA have made such a trade more toxic to Democrats -- there's been excellent analysis spotlighting how letting states modify EHBs or allow medical underwriting under some circumstances would have a domino effect both within a state (as healthy people opt in to medical underwriting and nationally (as inadequate AHCA subsidies push states to take steps to lower premiums for some applicants at least).

And yet, if Democrats refuse to entertain the possibility of giving states more freedom to shape their nongroup markets, in a sense they're falling for Republicans' smokescreen: Focus everyone on nongroup market structure while they proceed to eviscerate Medicaid. Better to let states try to make the nongroup market work by methods of their choosing than to hobble Medicaid funding forever. More so than in March, it's triage time.

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