What to Ask About New Safety Net Work Requirements

March 6, 2017

As I said last week, we’ve reasons to expect that more work requirements imposed on “work-able” adults who have — or need to have — safety net benefits. So it’s worth considering how we might assess what state governors and legislatures propose.

We have two major models for work requirements — Temporary Assistance for Needy Families and SNAP (the food stamp program), as applicable to able-bodied adults without dependents.

Both permit not only work for pay, but participation in a program that prepares for such work. Participation counts only if for a minimum numbers of hours. generally averaged over some period of time.

Assuming, as I think one can, that proposed new work requirements will include a broader range of permissible activities than work for pay, we thus have some experience to assess them. Some questions then.

Will the state ensure that all unemployed or under-employed adults who are otherwise eligible for the safety net program can get a slot in a job training program for the requisite number of hours?

Very few states do for the ABAWDs, the Center on Budget and Policy Priorities reports. The federal government provides states with some funds expressly for SNAP-related employment and training. But most states use most of those funds to move adults with children into the workforce.

Experience with TANF also makes this a relevant question. I haven’t seen a comprehensive account of slot shortages. This much we know. States spend, on average, 7% of their federal funds, plus those they must spend to get them on work activities.

The District of Columbia’s TANF program reflected a similar priority in the not-too-distant past. In 2014, parents waited up to 11 months for access to a job training program. And the clock kept ticking, so to speak, toward the date when they and their children could never have TANF benefits again.

Will the state provide the other resources many of the adults will need to work or participate in a job training program for the required number of hours?

The adults, by definition, have little, if any income. And such as they have, must often pay for rent, food (even with SNAP benefits) and other basic needs, e.g., supplies and handfuls of coins for laundry, telecommunications of some sort.

Will the state provide transportation and/or a transportation subsidy, e.g., an auto fuel allowance for those with a car, a bus pass and/or subway fare card for those on a public transit route?

And what about the adults with children not old enough to be in school during all the hours they’re supposed to work or prepare for same? They’ll need free or nearly-free child care. And it’s unrealistic, as well as potentially unsafe for the kids to expect parents to count on friends or relatives.

The affordable childcare record generally indicates a gap to fill. Last year, for example, 20 states had waiting lists for childcare assistance or had closed them, the National Women’s Law Center reports.

Virtually all states require parents to chip in some money of their own, as a co-pay. It’s generally small as a percent of income for those below the poverty line.

But in at least four states, it’s at least 10% — $250 a month for a single parent with just one child. (Some exceptions here that wouldn’t apply to every parent subject to a new work requirement.)

How will state identify adults who aren’t work-able?

SNAP rules exclude from the ABAWD requirement adults who are medically certified as unemployable due to a mental or physical condition, pregnant or otherwise already exempt, presumably because they’ve qualified for SSDI (Social Security Disability Income) or SSI (Supplemental Security Income).

The bar here is very high. Someone, for example, may be employable, i.e., able to work and get a job, but not for an average of 20 hours a week or for months at a time. One or both are common enough for people with certain chronic conditions.

So what standard will the state set? Will it ensure that all adults potentially unable to work can have the requisite medical review — and, if necessary, the legal help to surmount to notorious barriers to gaining federal disability benefits?

Consider too that adults who’ve no disabilities may have compelling, related reasons not to work — a child with severe disabilities who needs constant care, for example, or a frail, aged parent.

Most states and the District exempt TANF parents with such responsibilities from work requirements. Will states do the same if they opt for new work requirements?

Will participating adults be able to find jobs — and keep them?

No job training program lasts indefinitely. And it’s very doubtful that a state would allow a work-able adult to move from one to the next and then the next until s/he could find a job.

Yet some safety net participants have what are commonly called barriers to work, e.g. mental or physical disabilities that don’t rise to the SSI/SSDI level, functional illiteracy. Just plain long-term unemployment is a barrier too, as are common consequences—credit checks, for example.

On the other hand, many adults who rely, at least for awhile on safety net benefits had jobs no longer available in the area they live in — or elsewhere.

The jobless former factory workers and coal miners that Trump appealed to would seem to need retraining tailored to employers’ needs in their area — and others projected nationally.

Will the state do the necessary market and personal assessments? How will it provide these and other services to poor people in small rural communities, if it has them?

Where will the money come from?

Well, the state shouldn’t look to the federal government for more funds — not at least for the foreseeable.

Recall that the flexibility states would gain to impose work requirements on Medicaid beneficiaries would also shift costs to them, increasingly over time — currently estimated at $560 billion over the next 10 years.

Experience with not only TANF, but SNAP E&T offers further cautions. Congress, as you probably know, has never increased funding for the former. The latest Farm Bill restored the latter to the same maximum it had in 2004 — in real dollars, about 44% less.

And the budget Trump is trumpeting would reduce total federal spending for non-defense discretionary programs by $54 billion — not a happy prospect for the grants states receive for job training, placement help and the like.

These aren’t the only questions I’d want to ask. But they must suffice for now, lest this post swell entirely out of compass. Would any of you like to add others?


Those Who Do Not Work Will Not Eat… or Have Other Basic Needs Met

March 2, 2017

Conservatives have long liked the notion of conditioning safety net benefits on work or a near equivalent, e.g., participation in a job training or education program, unpaid community service.

Work requirements are in the forefront now, due mainly. not only to what Congressional Republicans are reportedly mulling over for their Medicaid “modernization.”

Work requirements aren’t new, of course. They’re a key feature of Temporary Assistance for Needy Families.

And the law that created it also denied ongoing SNAP (food stamp) benefits to able-bodied adults without dependents who don’t work or participate in a job training program at least half-time.

So we’ve some experience with work requirements. And, as the old saying goes, “What you see depends on where you stand.” But not altogether. That experience can give us filters to assess proposals to build work requirements into more federally-funded programs.

I’m going to confine this post to the political landscape and how influential conservatives justify work requirements. Will follow up with a post on those filters.

Republican Leanings Toward More Work Requirements

The House Republicans evolving Medicaid overhaul doesn’t impose work requirements. Instead, it grants states vastly greater latitude to set eligibility standards.

We can foresee some results, including work requirements because a handful of Republican governors have jumped ahead, asking the federal administrative agency for permission to impose them.

The Obama administration’s Medicaid administrators rejected most requests. But it’s a brand new day in the executive branch. And Trump’s lead decision-maker helped develop the Kentucky governor’s still-pending request.

In short, the waiver petitions show the way the wind is blowing in some Red States — and what more states may do when granted the flexibility the House bill drafters have in mind.

Many poor and near-poor people may have to meet work requirements in other programs intended to keep them healthy and safe — or suffer the consequences.

House Speaker Paul Ryan’s blueprint for his party’s poverty agenda includes, as a principle, “Expect work-capable adults to work or prepare for work in exchange for welfare benefits.” Those benefits serve a wide range of low-income people’s basic needs, e.g., health care, food, housing, help with home heating bills.

The Heritage Foundation, which now seems to have a virtual seat at the White House policymaking table, has called for an across-the-board work requirement for able-bodied SNAP recipients.

The new Secretary for Housing and Urban Development has hinted at potential work requirements for people who live in subsidized housing. For example, he told the Senate committee vetting him that he wanted HUD’s programs to “be a Band Aid and a springboard to a better life.”

The Chairman of the House committee that oversees HUD has been more forthcoming. “We will reform our housing programs for the poor to reflect the value of work,” he said at a forum on the issues.

How Supporters Justify Work Requirements … and Grains of Salt

We find several sorts of justifications for work requirements. Ryan and numerous other conservatives cite what happened in the first few years after parents (mostly single mothers) had to comply with work requirements to receive time-limited cash assistance for their families.

A large number did, in fact, move from welfare to work, though not only because of the new requirements. Most importantly perhaps, the labor market was very tight then. Employers sorely needed more low-skill workers.

Looking past those years, we see that single mothers have fared badly in the labor market, as have TANF families generally. But lead Republicans still cite TANF as the model safety net program.

We’re all familiar by now, I suppose, with allusions to safety net benefits as a hammock. Seems that poor people prefer lolling comfortably, at taxpayers expense, to even trying to get a job.

They must be dumped out of their hammocks, if not immediately than with imminent prospects that they will be — as indeed, TANF parents (and their children) generally are.

On a less pejorative note, we hear that work is the best way out of poverty. That’s true enough enough, if one can find a job paying more than a poverty-level wage. (The same folks who invoke this remedy generally don’t support minimum wage increases.)

“Work confers dignity …responsibility,” says Arkansas’ governor, who’d sought permission to impose a work requirement for Medicaid. One might wonder what the stay-at-home spouses of like-minded proponents think.

Snark aside, it defies common knowledge to argue that only people who work for pay feel as sense of personal responsibility.

Consider, for example, a poor mother with children, scrambling to put food on the table, find some place for the family to spend the night — even donating her plasma until she’s in danger of anemia in order to get some cash.

I’m not sure what dignity means in this context — perhaps the respect of others, though the link to responsibility suggests it’s supposed to mean respect for one’s self. Whether working bolsters self-respect would seem to depend on a number of factors, including how attuned one is to our society’s work ethic.

On the flip side, many of us know, I think, how demoralizing it is to look for a job and net nothing, month after month. Demoralizing also to settle for a job that calls for far less than what one’s qualified to do — and pays far less as well.

That’s a likely result for many work-able adults in safety net programs if they’re subject to work requirements that are either time-limited or conditioned on participating in programs geared to push them into (or back into) the workforce as quickly as possible, like the “work first” approach once common in TANF and still favored in some quarters. .

Top-flight progressive advocates adamantly oppose any further work requirements. They cite, for example, the percent of safety net beneficiaries who already work or live with some who does.–or on the other hand, the very high percent who can’t be expected to.

All this said, new work requirements seem a not unlikely result of the Republican majorities in Congress now having a like-minded executive branch — and the very high portion of states where Republicans set the agenda.

So, as promised, I’ll suggest some questions we might ask if — or should I say as — more work requirements surface.


House Republicans Unveil Reverse Robin Hood Healthcare Plan

February 27, 2017

House Speaker Paul Ryan and his lead colleagues have generated even more news about the Republicans’ plans to repeal the Affordable Care Act.

Still no legislation. Still spare details. And still, it seems, no genuine consensus, though a large majority now understand that simply repealing the ACA would be a disaster politically, as well as for the 20 million or so Americans who’ve gained health insurance coverage since the law kicked in.

Ryan, however, has released a policy brief that purports to set out the major elements of the House Republicans’ repeal-replace plan.

Needless to say, it aims to radically cut federal spending on health care. Beyond that, a New York Times headline captures the major thrust: “Republican Health Care Proposal Would Redirect Money From Poor to Rich.”

Here briefly are the major changes and how they’d make the shift. Long post, but on one of the biggest immediate threats to the well-being of low and moderate-income people in this country and our common — though obviously not universal — concept of equity.

End of Medicaid As We Know It

Many concerned parties, including yours truly, have animadverted before about Ryan’s plans to convert Medicaid to a block grant.

Basically, states would no longer receive partial reimbursements for the costs they incur in providing health care to the poor and near-poor people they’ve enrolled. They’d instead receive a fixed sum of money, coupled with even fewer requirements and restrictions on what they can do.

We can predict from the fate of other block grants that the fixed sum will either remain the same, regardless of increases in the number of very low-income people in need — or grow somewhat, but not enough to not enough to benefit everyone eligible or who would have been had the block grant not been created.

Ryan’s new plan includes this option, but leans toward a variation — per capita grants. These too use a formula to set states’ funding, but it’s based on the regular federal match that each received in a base year for people in specific categories, e.g., children, people with disabilities.

The grants would increase, based on the inflation rate. But the rate, as commonly measured, reflects the prices of goods and services consumers commonly pay for, e.g., food, fuel, housing, with medical expenses merely folded in.

As we all know, health care costs rise more. And they’re projected to rise considerably higher, boosted by aging baby boomers, new, high-priced drugs and other drivers.

In short, same basic result, achieved by something with less tarnished name — and with a further, predicable cost-shift to all the states and the District of Columbia that have expanded their Medicaid programs.

Specifically, the plan would fold in repeal of the higher federal government match for newly-eligible people enrolled in Medicaid programs. States would continue to have the it for some unspecified time so as “not to pull the rug out from” them or beneficiaries.

The rug would, however, be immediately pulled out from under adults deemed able to work, regardless of whether they do, but at a very low wage — or have any reasonable prospects of landing a non-poverty wage job.

Redirected Tax Credits

Under the current law, people who buy health insurance on an exchange get a tax credit that serves as a subsidy if their annual income is less than 400% of the federal poverty line — currently $97,400 for a four-person family. The subsidy goes directly to the company that provides the insurance the beneficiary chooses.

It’s greatest for those in the lowest income bracket and diminishes till it reaches the highest. So it ensures that very low-income people can afford comprehensive health insurance, while not spending federal money on people in upper-income brackets.

The Ryan plan would instead award tax credits directly to people who have no employer-sponsored health insurance or coverage under a government program.

They’d would be based only on age, with larger (unspecified) credits to older people. As the Times column suggests, this would seem to make some sense, since older people tend to need more medical care.

But it means is that some very wealthy people would get a larger benefit than many of the very poor, who not only need more help in affording health insurance, but often have more health care problems.

Expanded Health Savings Accounts

Our current system already offers people opportunities to sock money away tax-free for specific medical and dental needs by putting it into a Health Savings Account.

As with the better-known Individual Retirement Accounts, you can save only up to a maximum in any given year, but the cap is based on age, when you become eligible and the type of insurance you have (see below), rather than age and taxable earnings.

You’re not required to withdraw any money during a given year. So what you’ve invested continues to grow, assuming it’s invested well and that administrative costs don’t offset real-dollar gains.

And you don’t have to pay income taxes when you withdraw, if you spend the money for approved healthcare purposes — another difference from an IRA.

The biggest difference, however, is that you have to expose yourself and your family to budget and/or health risks because you can’t have an HSA unless your insurance plan is a high deductible, i.e., covers only what are sometimes referred to as catastrophic costs.

Current federal rules, for example, allow insurance companies to require high-deductible customers to pay as much as $7,850 for an individual or $15,700 for a family before they start covering costs.

HSAs are thus obviously beneficial to some people who can afford what they and any dependent family members need and still have money left over because they’ll owe less at tax time. But only those who can stash enough to cover thousands of dollars of healthcare costs.

The Ryan plan would allow people to contribute their maximum out-of-pockets to their HSAs. Another provision would allow spouses to contribute all or part of so-called catch-up contributions, i.e. those made in a given year to compensate for lower than maximum contributions previously.

Conservatives, including lead Congressional Republicans have long argued that healthcare costs would drop if people had “more skin in the game,” i.e., more to save or lose depending on whether they choose to seek health care and, if so, what sort and from whom.

This, as I think everybody knows, is profoundly unrealistic. We’ve neither the knowledge nor, in many cases, the time to choose healthcare services the way we choose, for example, large-screen TVs.

It’s nevertheless the theory underpinning the HSA expansion, with its inherent push toward high-deductible plans. And again, it’s effectively spending more on well-off people — in this case, by forfeiting tax revenues.

Undermining the ACA Before Full Repeal

Long as this post is, I haven’t covered all parts of the plan — most notably, the full repeal part.

Sufficeth it to say that it would roil the insurance market — by immediately eliminating the penalty for having no insurance, for example, and the penalty imposed on larger employers that don’t cover most of their full-time workers.

So if Obamacare isn’t failing now — as the policy brief misleadingly says it is — it surely would during the transition period the brief promises.

NOTE: Last Friday, two insider news sources posted a leaked draft of the House Republicans’ legislation. It generally tracks the measures I’ve summarized.


Let’s Not Forget Affordable Dental Care

January 23, 2017

A comment posted some time ago raised an issue about Medicaid that seems even more timely now because it opens to the door to larger current and prospective issues.

Seems the commenter had to have some teeth pulled. Her dentist told she would have to wait for dentures until her mouth heals instead of getting a temporary set. She felt that she and others covered by Medicaid were “treated differently from other people,” who aren’t doomed to toothlessness. Would I look into this?

And I did, learning more in the process about not only the source of her problem, bur dental care in our health insurance system — today and prospectively. Results, as follows.

The commenter is actually quite fortunate. States don’t have to include dental services in their Medicaid programs, except when they administer the Children’s Health Insurance Program by expanding them.

For adults, dental care is an optional benefit, both for those whom states covered before the Affordable Care Act and those who became newly eligible when states opted for expansion. Those states must provide “essential health benefits” for the latter, but dental care isn’t one of them.

Virtually all states and the District of Columbia do cover some dental services, but only fifteen cover a comprehensive mix, the Kaiser Family Foundation reports.

Many cap per person spending or the number of services covered. And thirteen cover only emergency treatment. Even coverage doesn’t ensure affordability because beneficiaries may face high out-of-pocket costs.

Not all states that cover dental services cover dentures. And even fewer cover dentures for all beneficiaries as often as they might need them. They’re responding here to limits the federal government sets on reimbursements.

But low-income adults aren’t treated all that differently from their better-off peers. Traditional Medicare provides no coverage for dental services, except in certain limited cases when the beneficiary is in a hospital.

We who’ve had employer-sponsored health insurance also know that incomplete—or no—coverage for dental services is more common than the commenter apparently assumed.

But better-off people can shell out for dental care or supplementary insurance. Not so for low-income working age adults. Only 19% of those who were officially poor went to a dentist in 2013. And 44% had had untreated cavities in the prior two-year period.

Nearly a third of those with incomes low enough to qualify for an expanded Medicaid program reported an unmet need for dental care last year.

Without it, they may not only lose teeth and have to live with gaps in their mouths. Untreated oral diseases, including cavities can cause or worsen a range of other health problems.

Lack of sufficient coverage is obviously a major barrier, but it’s not the only one. In some places, e.g. rural areas, inner cities, there simply aren’t enough dentists. That’s partly due to an unwillingness on their part to treat low-income patients, especially those covered by Medicaid.

Dentists object to the paperwork and lost income because Medicaid patients—at least, by reputation—often don’t show up for appointments. But dentists also cite low reimbursement rates—sometimes so low as to not even cover costs.

Now, we know that states often cut provider reimbursement rates when economic downturns drive up their Medicaid costs because that’s more politically palatable than tightening up on eligibility or coverage.

And we know they’d face budget crunches—and not only during recessions—if Republicans in Congress convert Medicaid to a block grant and the President agrees.

Not much of an “if” here. The Trump’s campaign’s policy positions included a block grant. And Congressman Tom Price, his choice for Secretary of Health and Human Services, folded a block grant into the House budget plan when he chaired the responsible committee.

Looking at how states now use their flexibility to limit dental care coverage, we could reasonably expect them to make further cuts there.

They might instead (or also) cut dentists’ reimbursement rates. More than half the states did that in the aftermath of the Great Recession. So Medicaid beneficiaries who still had dental coverage may have had more problems finding someone to treat them, as certainly seems the case in Washington and in Florida.

Some states might instead join those that provide no coverage whatever.

The block grant is only one of the clear and present dangers to the health of poor and near-poor people, including the health of their teeth, gums and everything else in and around their mouths.

The impending repeal of the Affordable Care Act would immediately deny higher federal reimbursement rates to the 31 states and the District of Columbia that have expanded their Medicaid programs.

The repeal, in and of itself, would free them to shrink or eliminate dental health benefits for the newly-eligible children they enrolled because they’d no longer have to provide the essential health benefits the ACA specified.

This would also be true for most other insurance plans, unless state regulations required them because the same EHB requirements apply. And if, as predicted, premiums soar, one could expect plans to drop dental care or, at least, radically cut back coverage.

Some of you may recall the boy who died from a brain infection because his mother couldn’t find a dentist to treat him in time—this for wont of Medicaid. We might have more such cases, with or without it.

We’d almost surely have more low-income adults toothless (and not only temporarily) and more dead too because they couldn’t afford dental care—or related medications.

I know this seems a worst case scenario and perhaps an unwarranted leap from a singular problem to a vast array. But when we think about what will happen in the aftermath of health care “reforms,” we need get beyond the numbers, as important as they are.

Price objects to our government programs because they get between doctors and their patients. But, in fact, people who should be patients won’t be.

And when we think of them, we shouldn’t forgot those who need dental care because, as one dentist said, “the mouth and the head are connected to the rest of the body.”


Devastating Effects of Affordable Care Act Repeal

January 5, 2017

The Urban Institute puts some hard numbers on what will happen if the Republicans in Congress dismantle the Affordable Care Act. They’re shocking.

An estimated 53.5 million people would have no health insurance in 2021. That’s more than double the number who’d have no coverage if the ACA were intact.

Coverage would shrink most for low-income people enrolled in Medicaid, presumably because states would no longer receive funds to cover most of the costs of people who became eligible when they expanded their programs.

They’d be hard put to make up the loss and so would probably set lower limits on income eligibility, cut back on services covered and/or further reduce their reimbursements to healthcare providers.

Looking only at the first of these cost-savers, the Institute estimates that 14.5 million fewer children and working-age adults would have coverage under Medicaid.

The Institute’s estimates do not include the results of converting Medicaid to a block grant, as lead Congressional Republicans—and our incoming President—favor.

His choice for Secretary of Health of Human Services included one in the budget plan he produced while Chairman of the House Budget Committee. It would have cut federal Medicaid spending by a whopping $1 trillion over the next 10 years.

No way that state and local governments could compensate for losses so great. The crunch, however, could well be larger.

An economic downturn (likely) would cause job losses and so make more people income-eligible, even with lower thresholds. The federal government would no longer pick up its share, as it does under the current system.

The Center on Budget and Policy Priorities used the Institute’s data to estimate state-level losses. Here’s what we learn about the District of Columbia.

In 2019, 32,000 fewer residents would have health insurance if Congress repeals the ACA. This, like the nationwide total, is more than double the number who’d otherwise no coverage.

Nearly 23,500 more residents have gained affordable health insurance through Medicaid since 2013. Many would lose this coverage unless the District used its own funds to make up for the federal funds that would no longer pay most of the costs for the newly eligible. That would require a total of $1.7 billion between 2019 and 2028.

The District would also lose $85 million in funding for its health insurance marketplace. And residents who now have insurance through the marketplace would immediately lose the tax credits that subsidize their costs.

The Center doesn’t estimate how much more they’d have to pay to retain the coverage they have now. It does, however, say that the credits cover 73% of monthly premiums nationwide. Faced with that much more out of pocket, many lower-income residents would presumably forgo insurance.

In short, repeal of the ACA will have devastating effects on low and moderate-income District residents, as it will on virtually everyone but the very well-off nationwide.

Millionaires would, in fact, get tax cuts bigger than the total average income of families in the bottom two-fifths of the income scale. The very wealthiest would get cuts averaging $260,630.

We’re given to understand that the Republican leadership has put repeal at the top of its agenda. It probably won’t, however, impose an immediate death sentence on every provision, what with not having the promised replace.

It does, however, have a bill that Republican majorities have already passed. It would eliminate the two provisions I’ve focused on here—the additional funding for states that have expanded Medicaid and the tax credits that low and moderate-income people get to subsidize the costs of plans they buy on exchanges.

Republicans also, as I’ve mentioned, have the basis for converting Medicaid into a block grant. So they could make a costly down payment on a major campaign promise.

Hard to find a hopeful note to end on. So I’ll borrow from Ron Pollack, the long-time Executive Director of Families USA, a leading advocacy organization for Americans’ healthcare needs.

“One should never underestimate the extraordinary backlash that occurs when people have something they value that’s taken away,” he says.

What remains to be seen is whether they’ll lash back forcefully enough before the affordable healthcare protections the ACA provides are taken away.


Broken Bone, But Not Broke, Thanks to Medicare

December 1, 2016

A week before Thanksgiving, I got up on the right side of bed, but from closer to the edge than I realized. Landed flat on my back and lay there in excruciating pain. But I managed to get dressed, make sure essentials were in my purse, call 911 and hobble downstairs to open the door.

Folks in the ER took X rays and a CAT scan. Determined I’d fractured a pelvic bone, but probably wouldn’t need surgery. So they sent me to a hospital, where the tests were repeated and the same diagnosis made.

Then on to a rehabilitation center, where I got both physical and occupational therapy to ready me for living at home alone and as much painkiller they’d allow. I’m still in pain, but otherwise in pretty good shape—and home again neither permanently disabled nor bankrupt..

I’m told that the transport, medical and therapy services and the rooms, food and the like in the hospital and rehab center will cost me nothing. The painkillers require copay, but it’s small. And my Medicare Advantage plan sets a low cap on all my out-of-pockets for the year.

I shudder to think of the bills I’d face if not enrolled in Medicare — or more precisely, the Advantage plan I chose. And I says to myself, what if I were twenty or so years younger now and I’d had the same accident when I was sixty-five?

You know, I’m sure, that this isn’t a hypothetical question. House Speaker Paul Ryan apparently plans to link his pet Medicare “reforms” to whatever the Republican majority does to dismantle the Affordable Care Act,

“Medicare has got some serious problems because of Obamacare,” he recently told Fox News, claiming, as he has in the past, that the program “is going broke.” This is wrong on both counts, as the Washington Post’s fact checker explains. And Ryan probably knows it.

But he also knows he’s got an opportunity he didn’t before. He’s produced multiple versions of his so-called Medicare reform plan. The latest, in his Better Way healthcare policy paper, is a dense, blame-heavy thing. This much, however, I think, we can gather in answer to my what-if question.

I wouldn’t have health insurance through any form of Medicare. Ryan would link the minimum eligibility age to the age former workers become eligible for full Social Security retirement benefits. That would be sixty-seven under current law. But Ryan, among others, has wanted to raise it further.

The rationale for withholding both sorts of benefits from people who’ve reached what we ordinarily think of as retirement age is that Americans are living longer. This, Ryan says, is because we’re healthier—thus, inferentially, not in need of Medicare until we’re significantly older.

Set aside the over-simple reading of the rising longevity figure, we’re not living longer because we’re healthier. It’s rather because medical science has gotten better at keeping sick people alive and because we’re spending more on healthcare—this according to the National Bureau of Economic Research.

The constantly evolving treatments of various sorts will mean nothing, of course, if people who need them don’t have insurance to cover most, if not all of the costs.

And what about a case like mine? My life expectancy had nothing whatever to do with my falling, though my age may have had something to do with the fact that a bone cracked.

Say, however, I’d reached the ripe old age for Medicare. It wouldn’t come close to covering my healthcare costs. I’d get a subsidy of some sort to help me pay premiums for either a non-government insurance plan, misleadingly termed an Advantage Plan, or traditional Medicare, also misleadingly termed.

Ryan misleads because neither of the choices we’d have would offer as much care for as relatively little. Our premium support would do more for the poor than the well-off. But it wouldn’t rise to keep pace with rising healthcare costs.

This is a main feature, not a bug. Ryan’s fundamental aim isn’t to save Medicare, as he claims, but to cut federal spending. So the subsidy—not, he protests, a voucher—would cover less and less over time.

But we’d get more bang for the buck, he says, because insurers would reduce costs and improve quality of care so we’d choose their program over competitors’. Medicare would then have a built-in cost containment mechanism, as it doesn’t now.

It already has various price controls, however, though Republicans would blow some away in repealing the ACA.

The bigger deal, however, is that private insurers can’t keep premium costs and out-of-pockets low enough for most of us to afford them. Nor can what’s now traditional Medicare, which would be in even worse shape than its alternatives.

And the bigger deal yet is that the soon-to-be Secretary of Health and Human Services has long objected to Medicare and enthusiastically supported Ryan’s privatization plan.

Shortly before his nomination, he said he expected Congress to move forward with a Medicare replacement plan in six to eight months—as soon as it’s dispatched with the ACA.

Republicans can tackle both without any Senate Democrats voting in favor, through a somewhat arcane process known as budget reconciliation. So unless more than two Republicans heed the vast majority of Americans, who oppose any spending cuts to Medicare, future seniors won’t have affordable health care.

This tally assumes that Trump will ignore his promise to leave Medicare alone. We still don’t have a clear read on that. But I’m even less confident now than I was a couple of weeks ago. One need only look at the healthcare reform page on his new website—and, of course, his choice for HHS.

The fact that I personally got—and will continue to get—the healthcare services I need at a price I can afford doesn’t make what seems to be coming down the pike irrelevant to me, though that’s clearly what the Medicare reform crew intends.

Nor do I rest easy, knowing that ending Medicare as we know it is only one piece of the attack on our affordable healthcare system.

We know, for example, that block granting Medicaid appeals to Trump—and that he’ll almost surely have a chance to sign a bill that denies low-income people, seniors among them, the affordable healthcare services they can count on now.

This wouldn’t directly affect me. But if I had less money, it would because Medicaid would help pay for my Medicare out-of-pockets—and, in at least some states, the costs of a home health aide. Anyone hobbling around the way I am needs someone to help with basic tasks.

But how many states would still provide it as healthcare costs rise and federal funding doesn’t?


What’s New (and Not) in the House Budget Committee Plan

March 24, 2016

I feel sorry for progressive analysts and advocates whose main business is the federal budget and related issues because they again have to swat down pernicious proposals and misleading justifications.

I myself am tired of blogging on the retreads we see in the proposed House budget resolution — the immediate occasion of my pity and exasperation that I suspect is shared.

So what’s new? A few things that would devastate programs for low-income people, as well as some not new.

Vast Spending Cuts

The Washington Post has repeatedly reported that the House budget plan would cut spending by $30 billion over two years to offset what last year’s budget deal allows above the caps originally set for the upcoming fiscal year.

This is doubly misleading, though not, I think, intentionally. First off, the deal has already offset that $30 billion, though the savings reach the total over a longer period of time. Second, the plan would actually cut spending by $6.5 trillion during the next 10 years, the usual window for budget-related estimates.

The massive cut isn’t new. Nor the justification for it. The plan, like its recent predecessors aims to balance the federal budget, without raising more revenues.

It would, in fact, raise less than likely now because it would eliminate taxes on all profits corporations claim to earn overseas and the Alternative Minimum Tax collected from well-off individual filers who benefit from the lower capital gains tax rate, plus diverse deductions and credits.

Where the “Savings” Would Come From

The House Budget Committee finds roughly a sixth of its savings in discretionary programs, i.e., those that depend on annual appropriations. Most are subject to the caps, while only a few others are.

The plan provides for spending up to the somewhat higher caps agreed to for the upcoming fiscal year. But it doubles down in the years following, while boosting spending on defense even more than the budget tables show.

Spending on non-defense discretionary programs would fall by about $1 trillion below the current caps, according to a Center on Budget and Policy Priorities estimate.

These programs include a wide variety that serve low-income people’s immediate needs, e.g., affordable housing and child care, help with home heating bills. Others offer them or their children opportunities to improve their earnings prospects, e.g., job training, work-study for college students.

Most have already lost real-dollar value since the year before Congress passed the law that imposed the caps, as the Coalition on Human Needs shows.

A much bigger chunk of the savings would come from changes in mandatory programs, i.e., those the federal government must spend enough on to provide full benefits authorized by laws other than a budget.

What’s not new is a sketch of sorts for partially privatizing Medicare. Likewise proposals to convert Medicaid and SNAP (the food stamp program) to block grants.

The former would reduce federal spending by more than $1 trillion, the latter by $125 billion — nearly a third during the block grant’s first four years. Another $25 billion or so saved by not-new proposals House Republicans tried to get into the latest version of the Farm Bill.

The block-granting impacts are self-evident, as they’ve always been. Either states would have to use significantly more of their own funds to sustain the same benefits to the same groups now eligible or they’d have to cut benefits, deny them to some or a combination of both.

What’s sort of new is the re-branding. The undermined programs wouldn’t be block grants, but rather state flexibility funds, the more palatable term the House Budget Committee adopted last year.

I’ll have more to say about the Committee’s plans for healthcare programs because the not-new proposal to repeal the Affordable Care Act and a separate effort to undermine it pose broader threats than the block grant in and of itself.

I’ll just cut to the chase here in hopes of answering a question I’m guessing is on the minds of those of you still reading what seems the same old, same old with new numbers.

Why Worth a Worry

The House Budget Committee’s plan won’t develop into next year’s budget — or the many legislative changes needed to gut the mandatory programs. It may not even pass in the House because some of the Tea Partiers feel it doesn’t cut spending enough.

If it does pass, it won’t in the Senate, even if all Republicans there vote for it because they’d need at least six Democrats to join them. Lotsa luck there.

Yet I think the analysts and advocates I pity are right to not just shrug off the plan as a waste of their energies and time. Set aside, if we can, the upcoming elections.

When state flexibility funds, attacks on the ACA and other radical spending cuts resurface year after year, they become familiar in a way that doesn’t breed contempt. They gain a sort of tolerance — as negotiable perhaps or at least due the deference we generally accord debatable propositions.

Not saying all is right with all the programs the federal government funds. But the notion that it should leave the well-being of low-income and other disadvantaged Americans to the states they live in — and whatever those states can and choose to spend — seems to me fundamentally wrong.

This is not a notion that should cease to shock just because it’s teed up year after year, with new wrinkles and rhetorical flourishes.

All told, the House budget plan would cut spending on programs for low-income people by $3.5 trillion over the next 10 years — about 40% of what’s spent now or nearly one and a half times their share of non-defense spending.

And that should shock as much as the House Republican majority’s first budget plan — the ironically entitled Path to Prosperity — did.