Northwest Arkansas Democrat-Gazette - - PERSPECTIVE -

Q: I have a very sim­ple but what I fear may be a com­pli­cated ques­tion. What is Med­i­caid?

A: Med­i­caid is the fed­eral gov­ern­ment’s and states’ pro­gram to of­fer health in­sur­ance or help pay the med­i­cal bills of the poor. It now cov­ers about 1 in 5 Amer­i­cans, or about 78 mil­lion peo­ple. That’s a lot. It cov­ers half of the births in this coun­try. Two-thirds of nurs­ing home res­i­dents are on Med­i­caid. It’s not just the poor any more. It’s the dis­abled, it’s el­derly peo­ple in nurs­ing homes that have ex­hausted their sav­ings. So the Med­i­caid pop­u­la­tion now is re­ally quite broad.

Q: Where did Med­i­caid come from orig­i­nally? What is its his­tory?

A: Start­ing in the 1940s in this coun­try, em­ploy­ers started to of­fer peo­ple health in­sur­ance. But then the ques­tion be­came: What are we go­ing to do about peo­ple who can’t work—the el­derly and the poor?

When you look at sto­ries about Lyn­don John­son sign­ing this bill that cre­ated Medi­care and Med­i­caid in 1965, the sto­ries barely men­tion Med­i­caid. The el­derly was the big­gest ques­tion, and that was the big­gest fight. And af­ter the fight was over the bill be­came Medi­care, which is the gov­ern­ment health-care pro­gram for el­derly peo­ple.

Med­i­caid, oddly enough, was al­most an af­ter­thought thrown in, and no­body en­vi­sioned that it would be­come this huge pro­gram. Con­cern­ing the pub­lic de­bate about it now, you never would

have guessed that in 1965.

Q: So in 1965, at its birth, ex­actly who did Med­i­caid cover?

A: It re­ally was just the poor.

Q: How did Med­i­caid go from be­ing this foot­note, kind of a barely men­tioned thing in 1965, as you just de­scribed it, to be­ing some­thing that so many mil­lions of Amer­i­cans now rely on for health care?

A: The num­ber is 78 mil­lion Amer­i­cans. It was ini­tially ex­panded un­der Pres­i­dent Lyn­don John­son, a Demo­crat. In the ’70s, the Amer­i­can Med­i­cal As­so­ci­a­tion was very against the ex­pan­sion of Medi­care; they called it so­cial­ized medicine. One of the big­gest ad­vo­cates for their po­si­tion was Ron­ald Rea­gan, who was an ac­tor at the time, and Ron­ald Rea­gan recorded a record call­ing Medi­care so­cial­ized medicine.

Lo and be­hold, years later, some of the big­gest ex­pan­sions of Med­i­caid be­gan in the Rea­gan years as a re­sult of com­pro­mises worked out between Repub­li­cans and Democrats. One of the com­pro­mises was with Henry Hyde.

U.S. Rep. Henry Hyde (R-Ill., who died in 2007) is most known for the Hyde Amend­ment, which pre­vents fed­eral funds from be­ing spent on abor­tion. Henry Hyde doesn’t want to cover abor­tions with fed­eral money, so the Democrats say to him, if we are not go­ing to cover abor­tions with this money, we need to take care of preg­nant women and their chil­dren. So that’s one big ex­pan­sion.

Un­der Clin­ton, af­ter the fail­ure of Bill Clin­ton’s health-care plan, some­times called Hil­laryCare, there was an agree­ment between Democrats and Repub­li­cans that they didn’t want to pass what Repub­li­cans called so­cial­ized medicine/Hil­laryCare/Clin­tonCare, but there was an agree­ment that we wanted to in­sure chil­dren. So Clin­ton had the Chil­dren’s Health In­sur­ance Pro­gram (CHIP), which has be­come hugely pop­u­lar. That was a Bill Clin­ton ini­tia­tive.

Q: And an­other big ex­pan­sion.

A: Yes, an­other big ex­pan­sion. And the CHIP pro­gram paves the way for the largest Med­i­caid ex­pan­sion of all, which is Oba­macare, or the Af­ford­able Health Care Act, which was passed in 2010.


Q: So how does the Af­ford­able Care Act ex­pand or change Med­i­caid?

A: Orig­i­nally Med­i­caid was en­vi­sioned as a wel­fare pro­gram, and Democrats for years have been try­ing to sep­a­rate it from wel­fare. Democrats would say, “Hey, let’s make this our way

to pro­vide uni­ver­sal health in­sur­ance.” So that’s kind of what Oba­macare did—de-cou­ple Med­i­caid from wel­fare. Be­cause it was say­ing to peo­ple who weren’t maybe wel­fare-level poor but still pretty poor, “We are go­ing to help you get health in­sur­ance.”

Now, with Oba­macare, we have to be care­ful about one thing—there is the ex­pan­sion of Med­i­caid un­der Oba­macare, but there is also the health in­sur­ance ex­changes, right? That was not a Med­i­caid ex­pan­sion. So Oba­macare does two things in terms of ex­pand­ing health in­sur­ance. It ex­pands Med­i­caid to help peo­ple who are slightly above poverty level, but it also cre­ates these ex­changes where peo­ple who are not at poverty level, and in fact are well above it, can also go and buy health in­sur­ance.

Q: What was the op­po­si­tion to the Af­ford­able Care Act’s ex­pan­sion of Med­i­caid? Be­cause as I re­call there was a lot of op­po­si­tion to it.

A: Ab­so­lutely. This was the gen­e­sis of the Tea Party move­ment in the sum­mer of 2009. But the op­po­si­tion was what Repub­li­can op­po­si­tion has been all along, which is these are hand­outs, these peo­ple are able-bod­ied. They can go out and get a job if they re­ally needed health in­sur­ance. Why are we sub­si­diz­ing these peo­ple? That op­po­si­tion … fu­eled the Tea Party and sort of stoked pop­ulism in this coun­try. And pop­ulism in this coun­try has al­ways been feel­ing like some­one above you is get­ting some­thing that you can’t have and some­one be­low you is get­ting some­thing that they don’t de­serve.

So maybe a lot of mid­dle-class or work­ing peo­ple look at the Med­i­caid ex­pan­sion and think, “Wait a minute, I

had to earn this,” or “My mother … paid down her lit­tle bitty sav­ings to get into that nurs­ing home on Med­i­caid. Why is that per­son just walk­ing in?” There are a lot of these peo­ple. And these peo­ple have come and got­ten Med­i­caid.

Q: And how many peo­ple have started to re­ceive their health care through Med­i­caid since Af­ford­able Care Act?

A: Eleven mil­lion.

Q: That’s a pretty big num­ber. Just since 2010?

A: Yes. I think it is al­ways eas­ier to say no to some­thing. The Tea Party was say­ing no, don’t do this. Now that it is in place, Med­i­caid has ac­tu­ally be­come kind of pop­u­lar. Op­posers will tell you that it’s al­ways been pop­u­lar, but I think the Med­i­caid ex­pan­sion has made it even more pop­u­lar.


Q: So the GOP bill that started in the House that passed it and now is com­pli­cat­edly mak­ing its way through the Se­nate, what would that do to the Med­i­caid ex­pan­sion un­der the Af­ford­able Care Act that has brought in­sur­ance to 11 mil­lion peo­ple?

A: In gen­eral, the bills would shrink the amount of money that the fed­eral gov­ern­ment is giv­ing to the states to pay for Med­i­caid. So with the Af­ford­able Care Act, the fed­eral gov­ern­ment started pay­ing 100 per­cent of these costs, then it went down to 95 per­cent. Now it’s at 90 per­cent and I think it is sup­posed to go down to 85 or 80 per­cent. But in­stead of hav­ing those per­cent­ages and say­ing to states, “How­ever many peo­ple come in and sign up for Med­i­caid, we are al­ways go­ing to pay this share of your costs,” it’s say­ing, “We are go­ing to put a per

capita cap on this Med­i­caid fund­ing.”

Q: So un­der the cur­rent Af­ford­able Care Act ex­pan­sion, it sounds like the fed­eral gov­ern­ment is on the hook for po­ten­tially huge amounts of money to pay the states to make sure that their Med­i­caid pop­u­la­tion is cared for.

A: Yes.

Q: Un­der the Repub­li­can Se­nate plan, there will be some form of a cap. It will say, “That’s it.”

A: Yes. There is no ques­tion that this is a huge out­lay of fed­eral money, right? Medi­care was at $581 bil­lion, Med­i­caid was at $553 bil­lion, and of that the fed­eral gov­ern­ment is pay­ing about $350 bil­lion. So there is no ques­tion—ev­ery time peo­ple have talked about deficit re­duc­tion, which has been talked about for decades—we are go­ing to cut rates, or we are go­ing to cut bu­reau­cracy, or we are go­ing to cut this. Re­ally, un­less you cut en­ti­tle­ments, you are not go­ing to cut the fed­eral deficit.

Q: Why is this such a par­ti­san is­sue if ev­ery­one agrees that Med­i­caid is re­ally ex­pen­sive and maybe too ex­pen­sive?

A: In some ways I think it has be­come less of a par­ti­san is­sue. It has be­come more of a po­lar­ized is­sue like ev­ery­thing else in this coun­try over the last 10 years, but I think what you are see­ing now is a bunch of Repub­li­can gov­er­nors stand­ing up and say­ing, “Don’t cut my Med­i­caid ex­pan­sion.”

You are see­ing Sen. Rob Port­man (R-Ohio) and Sen. Shel­ley Capito (RW. Va.) say­ing, “Don’t cut my Med­i­caid ex­pan­sion; it’s pay­ing for opi­oid treat­ment in my state, which has a huge ad­dic­tion.” So I think it is en­joy­ing more bi­par­ti­san sup­port. It’s just a lit­tle more dif­fi­cult for Repub­li­cans to jus­tify be­cause they are the party of small gov­ern­ment. They don’t like to think that this is the way that we pro­vide health care.

Capito is con­cerned about the Med­i­caid por­tion and what it would do to her state, which has the largest per capita pop­u­la­tion that’s in the Med­i­caid pro­gram … The bill is not that pop­u­lar among West Vir­gini­ans, and I think a lot of that is be­cause of the Med­i­caid ex­pan­sion and peo­ple have got­ten so used to Med­i­caid. It is so hard to take an en­ti­tle­ment away.

Q: How do we ex­plain a state like Ken­tucky, where a very large ex­pan­sion of Med­i­caid oc­curred and since the Af­ford­able Care Act was passed, there is a large per­cent­age of poverty, and there is a mas­sive prob­lem with opi­oids. And the man who cre­ated this Se­nate health-care bill that would roll back the ex­pan­sion of Med­i­caid un­der the Af­ford­able Care Act is Sen. Mitch McCon­nell, who rep­re­sents Ken­tucky.

A: I would ac­tu­ally ar­gue more cru­cially that is the other sen­a­tor from Ken­tucky is Rand Paul, who is a Repub­li­can or lib­er­tar­ian, who is pos­si­bly the big­gest sup­porter of the Tea Party way. Rand Paul is from a lib­er­tar­ian strain. He does not be­lieve we should be giv­ing these gov­ern­ment hand­outs to peo­ple. So in some ways, that part of the Repub­li­can party al­lowed Mitch McCon­nell’s rise, and Mitch McCon­nell knows he is be­holden to that point of view. Mitch McCon­nell is also a deal maker, right? And he is some­one who moves leg­is­la­tion through, and he has been say­ing for seven or eight years we are go­ing to take this away, we will rip this root and branch. So now he has got to do that.


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