The Republican budget proposed by Rep. Paul Ryan (R-WI) would dramatically reduce access to care for millions of Americans by repealing the Affordable Care Act, turning Medicare into a “premium support” system that could make costs skyrocket, and switch the current Medicaid payment plan to a system of insufficient block grants. When it comes to Medicaid, however, not everyone is sure that budget goes far enough.

In an issue brief released last week, the conservative Heritage Foundation called for “transitioning” Americans out of Medicaid and “into more popular private health insurance options.” While the brief praised the block grant proposal from Ryan as an “important change,” it made clear that, in their view, even more action was needed:

The House Republican budget took important steps with regard to Medicaid by calling for the repeal of Obamacare and putting Medicaid on a budget. However, this is just a down payment on what needs to be done. The next—and equally as important—step is to put policies in place that restructure the Medicaid program so that low-income individuals and families are mainstreamed out of Medicaid and into the private health insurance market. In this way, Congress can expand the private insurance market, ensure more robust competition, and secure the kind of care that the vast majority of working Americans have today. At the same time, Congress needs to restore Medicaid to a true safety net program for the most vulnerable in society.

What Heritage did not say in their brief is that Medicaid actually costs less than private insurance. According to Families USA, it costs 20 percent less for Medicaid to cover lower-income Americans than private health insurance plans, which may not cover all the services those people need. And a study from the Kaiser Family Foundation released last week found that the rate of growth in Medicaid spending was actually lower than for private insurance plans.

Ryan’s block grant plan would cut federal spending on Medicaid by a third, dramatically reducing access to care and costing 14 million people access to care. If the Affordable Care Act was repealed, as Heritage and Paul Ryan both call for, the private insurers the brief suggests take over could also deny those people coverage because of a pre-existing condition. Under this plan, the “most vulnerable” Americans Heritage claims to be worried about would suffer.

-Zachary Bernstein

Mitt Romney’s proposal to transform Medicaid into a block grant program could reduce access to health care for lower income Americans and jeopardize the health care reform he signed into law as governor of Massachusetts, the Boston Globe reports. “As governor, Romney worked closely with the late Democratic Senator Edward M. Kennedy to secure hundreds of millions per year in federal aid to realize their shared goal of access to health care for all. Expanding Medicaid coverage – and the flow of federal money that came with it – was a key underpinning of the state’s 2006 law”:

“It would have been impossible for Massachusetts to do what it did without increased federal Medicaid support,’’ said John McDonough, a major architect of the state’s health care overhaul law and now director of Harvard University’s Center for Public Health Leadership.

“What he’s proposing is in direct opposition to what he did as governor,’’ said Amy Whitcomb Slemmer, executive director of Health Care for All in Massachusetts, citing the Bay State’s 98 percent coverage rate, the highest in the nation. “That kind of expansion would not have been possible under a block grant program,’’ as Romney has proposed.

Indeed, Romney funded his 2006 health care expansion by re-appropriating state funds and relying on additional federal Medicaid funding he secured from the Bush administration. As Romney himself explained to Bill O’Reilly in April of 2010, “[F]rom the beginning the plan was a 50/50 deal between the federal government and the state government. The Feds fund half of it, they have from the very beginning.” The Boston Globe notes that “approximately 56 percent of the gain in coverage was related to increased federal Medicaid support” in Massachusetts, and of the newly insured, “18 percent gained coverage through Medicaid, and another 38 percent gained coverage through Commonwealth Care, a program that federal Medicaid dollars pay half of.”

As a presidential candidate, however, the former governor has argued that he could lower federal spending on Medicaid by transferring control of the program to the states and transforming the current matching-rate funding structure into block grants that would pay states pre-determined funding amounts. The “blocks” would not increase with health costs or automatically rise during economic downturns.

According to a Congressional Budget Office (CBO) analysis of Rep. Paul Ryan’s (R-WI) Medicaid block grant proposal — which is very similar to Romney’s — federal expenditures on the program would be “49 percent lower in 2030 than current projected federal spending.” “[T]he magnitude of the reduction in spending relative to such spending in the other scenarios means that states would need to increase their spending on these programs, make considerable cutbacks in them, or both,” the Office concluded. “Cutbacks might involve reduced eligibility for Medicaid and CHIP, coverage of fewer services, lower payments to providers, or increased costsharing by beneficiaries—all of which would reduce access to care.”

Rep. Todd Rokita (R-IN)

Currently, the federal government matches state Medicaid spending on a per-claim basis and pays a fixed percentage of each state’s Medicaid costs so long as they adhere to certain federal guidelines. For instance, the Hyde Amendment already prevents states from spending any federal Medicaid funding on abortion services, with exceptions for rape and incest or when the life of the woman is threatened. Seventeen states have elected to provide more comprehensive abortion benefits, but pay for these procedures with state funding.

Rokita’s bill would dramatically change this. Like most Republican proposals, his legislation turns Medicaid into a block grant program that would give states a set amount from the federal government, letting them shape their own Medicaid programs with fewer federal standards and requirements. But states would be banned from covering abortion services, even with state funds, unless they buy separate health plans that include abortion insurance or only cover abortion care. As Mother Jones’ Nick Baumann explains, this would cost the 17 states that provide abortion coverage millions of dollars:

Those states do not generally purchase separate plans that cover abortion, several current state Medicaid officials and former state Medicaid directors told Mother Jones. Instead, they simply use state money to foot the abortion-related portion of the cost of the insurance. [...] Under the GOP proposal, that practice would be illegal.

Rokita’s bill “would be a significant change from how current law operates today,” adds Judy Waxman, the vice president for health and reproductive rights at the National Women’s Law Center. [...]

Requiring states to purchase separate abortion-only plans “would be a change and one that would be harmful to women in those states,” Waxman says, noting that the current structure has stood for decades without interference from Republican or Democratic administrations.

So far, 30 House Republicans have co-sponsored the bill, and the Republican Study Committee included the proposal in its official budget.

As part of the December deal to avoid a government shutdown, Congress banned funding for abortion services in D.C. The anti-abortion policy rider prohibited D.C. from even using local taxes to pay for abortion services, reinstating a 13-year ban on abortion funding in D.C. that President Obama overturned in 2009.

Rokita touted his plan as a way to get the federal government out of the way and to give states greater flexibility — so long as that flexibility does not include letting the states create their own policies on providing abortions for low-income women.

Last week, Republicans on the House Energy and Commerce Committee voted to slash $400 million from a program that would offer states performance bonuses if they enrolled more children in CHIP or Medicaid. Twenty-three states have already taken advantage of those bonuses, including 16 that increased their enrollment by more than 10 percent.

A new analysis released today looks at how those bonuses have increased enrollment nationwide. The study from the Georgetown University Center for Children and Families examined the 23 states that received performance bonuses for enrolling more children, and found that this program has already had better-than-expected effects:

Data on the bonuses show that in the 23 states that received bonuses in FY 2011, an additional 1.1 million kids were enrolled above expected levels. The most (123,000) can be found in the state of Ohio. While we can’t say that the bonuses fully explain this jump in enrollment, it would certainly be fair to say that they get some of the credit for supporting states in reaching these kids.

As we’ve seen over the years, Medicaid and CHIP have been responsible for driving the uninsured rate of children down to record lows. These bonuses have been an important incentive in making this progress and dismantling them threatens to undercut the great success we’ve seen in Medicaid and CHIP.

Over 12 million children were enrolled in the program in all 23 states combined. Altogether, those states boosted their enrollment numbers 10 percent higher than the expected level, and earned close to $300 million in bonus money for doing so. Thanks in large part to CHIP, the rate of uninsured children is at the lowest-recorded level ever.

As ThinkProgress reported yesterday, the cuts are not expected to pass the Senate this time around, but there is worry among children’s health advocates that they may be reintroduced at a later date. President Obama’s recent budget proposal did call for a change in the federal matching rates for CHIP beginning in 2017.

-Zachary Bernstein

Rep. Joe Barton (R-TX)

As part of an effort to reduce health spending by $115 billion, Republicans on the House Energy and Commerce Committee voted last week to cut $400 million from a program designed to make it easier for children in lower-income families to gain insurance through Medicaid or the Children’s Health Insurance Program (CHIP) and offer bonuses to states that see increases. According to Politico, 23 states have received bonus money for enrolling more children, with 16 of those boosting enrollment by more than 10 percent. While the proposal’s immediate future is dim, opponents say there is a chance it could resurface later on:

Although the Senate is unlikely to pick up this measure, [Executive Director of Families USA Ron] Pollack said he’s concerned it could reappear when Congress returns after the elections with a full plate of legislation in need of offsets.

“When you start with the House-passed budget and efforts like this, while it’s clear that they’re not going to become law, it’s just part of an opening bell about how the Republicans in the House want to handle a larger effort that will take place some time after the elections,” he said.

The lead sponsor of this bill, Rep. Joe Barton (R-TX), claimed weakening the eligibility requirements to boost coverage encouraged more people to try and game the system. But as Politico noted, the study he cited to back up his claim did not include any data specific to the bonus program Republicans are seeking to cut.

Here is what CHIP actually has done: It has helped cut the national rate of uninsured children to the lowest recorded level ever, keeping millions from losing all health coverage, and pushing long-term health costs lower. The program Republicans want to cut, meanwhile, paid out close to $300 million in bonuses last year alone and has already encouraged states to streamline their enrollment processes, eliminating bureaucratic waste.

The Republican budget presented by Rep. Paul Ryan (R-WI) would make dramatic cuts to child care funding and nutrition programs, and leave millions uninsured or underinsured.

-Zachary Bernstein

76 people, including actor Noah Wyle, were arrested yesterday during a protest in the Cannon House Office Building. The protest, organized by the group Americans with Disabilities for Attendant Programs Today (ADAPT), was focused on Rep. Paul Ryan’s budget, which makes deep cuts to federal Medicaid spending.

Ryan’s proposal would cut federal Medicaid funding by $810 billion, or 22 percent, over the next ten years, according to an analysis by the Center on Budget and Policy Priorities (CBPP). By 2022, states would be receiving an average of 34 percent less in federal Medicaid funding than they would under current law, a rate which would continue to rise alongside health care costs. As CBPP notes, the effects of this proposal could be devastating not just to state budgets, but also to millions of Americans who rely on the program:

States would have to offset these federal funding shortfalls by substantially boosting their own contributions to Medicaid or, as is more likely, using the greater flexibility that a block grant would provide to make deep cuts to eligibility, health and long-term care services, and/or provider reimbursement rates. Last year, when Chairman Ryan included a similar Medicaid block-grant proposal in his budget, the Urban Institute estimated it would lead states to drop between 14 million and 27 million people from Medicaid by 2021 (in addition to the 17 million people who would no longer gain coverage because of the repeal of the ACA’s Medicaid expansion).

States could respond to the funding dropoff by finding more revenue to pay for it themselves, through tax increases or spending cuts, or by cutting eligibility. As one protestor said of the cuts, “they’re gonna kill us first…If we can’t stay in our home, if we can’t get the things we need through Medicaid, we will die in the streets without that type of thing.”

– Zachary Bernstein