HEALTH CARE/Joan Retsinas

Newspeak in Trumplandia: Block Grants

In Trumplandia our solons sprout Newspeak. Call it Trumpspeak. The president names a non-scientist to be chief scientist of the Department of Agriculture. (Sam Clovis, who recently withdrew.) The Civil War, long recognized as a battle over slavery, emerges as a dispute that wiser people might have settled via negotiations (John Kelly). Facts are “false news;” middling crowds are “record-breaking;” a man with a minimal understanding of American history counts himself “very intelligent.”

Trumpspeak dominates the healthcare lexicon. Consider Medicaid. It costs the federal government, as well as states, more than they want to spend. It covers the expenses of poor people, who might not be poor if they had the gumption of the First Family.

The goal is simple: cut expenditures. The vehicle: block grants.

The Trumpspeak connotations of Block Grants evoke benevolence. Think states’ power (not states’ rights – that is too loaded a phrase even in Trumplandia). Think states’ initiative. Think creativity. Think freedom from federal shackles. Remember Justice Brandeis’ vision of states as “laboratories of democracy.” “Block grants” emerge, in Trumpspeak, as the chimera only Democrats would be stupid enough to reject.

Outside Trumplandia, block grants emerge as less benevolent. The bottom line of block grants: less money to the states. The tradeoff for fewer dollars is the freedom to be creative.

But the path to cutting expenditures is well-trod.

First, cut the number of enrollees – a simple enough task when states are free to drop the extraneous enrollees shoved onto Medicaid rolls by a steamrolling Uncle Sam. Get rid of the Children’s Supplemental Health Insurance Program. It already is in legislative limbo. Although the federal government picks up most of the tab, states will still save by paring those rolls. Drop enrollees who earn above the legislatively-set ceiling – those working parents who don’t earn enough to buy health insurance on the open “individual” market, who can’t get insurance through their employers. The Affordable Care Act got more people onto insurance rolls by encouraging states to expand their definition of “eligible.” Let states go back to the good old days.

Next, pare the services. Do poor children need orthodontia? Does anybody need much mental health counseling, or counseling for addiction, or rehabilitation? How much is enough? Under the guise of managed care, states can close those doors enough to save money.

Reduce payments to “providers.” Physicians, nursing homes, home health aides, therapists – all can contribute to the genius of “block grant” savings. If stringent standards have made it hard for nursing homes to operate with fewer Medicaid dollars, lower those standards. Presto! Problem solved, money saved. The beauty of a block grant: it will let states showcase their ingenuity. Similarly, people who need custodial residential care, often adults with major disabilities, gobble up a major chunk of Medicaid dollars. Lower those standards.

Substitute lower-paid providers for higher-paid ones. For home health, we require trained nurses to give injections. Why not aides? Why not insist family members cooperate with “skilled care?”

On the revenue side, co-payments from recipients will help. (They might also lower demand – a double-headed savings.) On the banner of self-sufficiency, or work-is-good, make enrollees contribute to their care. Everybody else does; why not the poor?

One downside of the budget-savings is a higher census of the uninsured, but before the Affordable Care Act, 43 million Americans were uninsured; and a swathe of the electorate still screams “repeal,” eager for the good old days. Block grants will give them those good old days.

Another downside is an exodus of physicians willing to accept patients enrolled in Medicaid, but the longer wait-times for the physicians who still participate might yield greater savings.

Third, an outcry will follow the inevitable nursing home and residential treatment scandals. In the good old days before stringent regulations, we had a wealth of scandals. The media love them. But in a calculus worthy of Trumplandia, the number of patients hurt will be fewer than the number of voters thrilled at the savings.

Block grants in and of themselves can give states leeway to be creative, to craft better regulations, give providers more leeway. But this Administration has cloaked budget-cuts in the guise of “block grants.” “Cruel” emerges as “creative”. These “laboratories of democracy” resemble poorhouses. Trumpspeak at its best.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, December 15, 2017

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