Your Independent Journal from the Heartland
Donald Trump, mounting his Musk, is slaying Government — the beast that is ravaging our paychecks, supporting millions of sycophants and nincompoops feeding at our taxpayer trough. His MAGA fans are cheering.
At this stage, the cheers come easily. His MAGA base doesn’t care about AID — the money going to foreigners should stay here at home. The money to the Environmental Protection Agency feels like a waste: every time we clamp down on industries for polluting our air, water, or soil, we lose jobs. (The reality is different: Louisiana, with its lax oversight of pollution, teems with both dirt and poverty).
As for the Department of Education, in the MAGA grandparents’ time, education remained a state function, as it was at the start of this country. Has the Department of Education raised student performance? Even some Democrats who enroll their children in private schools will not raise the barricades to save that department.
On to Housing and Community Development. It subsidizes the housing of a lot of low-income tenants, while a lot of low-income MAGA enthusiasts get no subsidies. Of course, no thought for the giant mortgage-tax deduction that buoys the middle-class homeowners.
Finally, Trump-the-slayer has taken an axe to the National Institutes of Health, with its scientists poring over reams of data. A lot of Americans see no immediate value to their poring, and distrust some of the vaccines that come from all that spending.
Yet budget-wise, these are beasties, not the beast. AID, for instance, swallows 1.2% of the federal budget, a blip. The Department of Education, 4%, another blip. Erasing the Environmental Protection Agency (0.2% of the budget) will make us sicker, not wealthier. HUD gets 2.2%. When Trump-the-slayer takes an axe to these beasties, he gets publicity, no mega savings.
Soon the budget-slayer must face the budgetary Beasts: Social Security, Medicare and Medicaid. He won’t attack Medicare because his MAGA base, even if they don’t want to admit it, depend upon Social Security and Medicare. In fact, his bureaucratic minion, Dr. Oz, is profiting from his support of Medicare Advantage plans, which turn out to be a poor deal for sick people, a poor deal for the government-funder. The slayer will probably take a pass.
So it is on to Medicaid, a beast that gobbles $760 billion annually, or 9% of the federal budget,. States spend 26 to 30 percent of their budgets on this behemoth. Medicaid subsidizes healthcare for the poor, but also for the middle class, thanks largely to Democrats’ move to expand Medicaid to encompass more children and more mothers. President Barack Obama’s Affordable Care Act extended the budgetary carrot to states, encouraging them to expand the “eligibility” criteria to cover more people. (Ten states demurred: they elected to let those people find other insurance, or stay uninsured). And Medicaid is the last, often the first, funder of nursing home care. The track is familiar: a person enters as a private-paying patient, spends down assets (a savvy lawyer can protect some assets), and ends up on Medicaid, the federal/state dole, though the middle class residents hardly think of themselves on a dole.
Back to numbers: Medicaid subsidizes healthcare for 72 million Americans, for four in 10 children. It pays for 41% of all births. Two-thirds of adults have some family member who depends on Medicaid. A President who slays this Beast risks hurting his fans.
The mantra-to-pare zeroes in on “fraud and abuse.” Consider the zeal to require Medicaid recipients to work. Only Georgia has implemented that mandate. The first year, Georgia predicted 25,000 people would find work under that rule; after six months, 4,500 had enrolled. Crucially, the state spent more than $40 million to implement the program.
The Slayer has other tools to slay the beast: all will wreak havoc not just on the poor and the disabled, but on the Slayer’s populist base. Here are some plausible strategies.
• The federal government now pays a proportion of the cost, depending on the wealth of the state. In poorer states, Uncle Sam picks up more of the tab. Dropping the federal tab will save Uncle Sam millions, but it will force an added burden on the states.
• The federal government can drop reimbursements to providers. The upshot: depending on region, Medicaid recipients will have trouble finding physicians who will treat them.
• The government can drop reimbursements to nursing homes — already low. In fact, instead of urging higher staffing on nursing homes, the federal government can relax those standards, letting homes increase patient-to-staff ratios. The upshot: poorer care.
• This Administration can drop the Obama provision to let states expand coverage to more middle income, yet uninsured residents. The upshot: in 40 states, more people will lose their coverage. An additional upshot: hospitals and clinics will run deficits, or turn patients away.
• This Administration can renege on the payments to home and community based care. Initially Medicaid paid for institutional care. In 1981, the Omnibus and Reconciliation Act allowed states to cover this care. In 2005 it became a formal Medicaid option. This Administration is in a back-to-the-future mode. It can rush back a few decades and drop this program, which costs in total $116 billion (state and federal). If we axed it, the federal government would save $80 billion (2020 spending). That would leave approximately 4.2 million Americans adrift.
• The Administration could go the block-grant route. Instead of reimbursing states, the federal government could give each state a block grant, pushing states to weed out fraud-and-abuse, or, more realistically, cut reimbursement, cut the number of clients, increase the administrative processing time. Crucially, block grants do not automatically rise with inflation, leaving states with the authority to be “creative” with fewer dollars.
Will MAGA fans cheer when, to pare billions from the federal budget to continue his tax cuts, the Great Slayer takes an axe that hits them directly?
Joan Retsinas is a sociologist in Providence, R.I., who writes about health care. Email joan.retsinas@gmail.com.
