Red tape: the next GOP plan for gutting health care

As January wraps up, it appears that Congress is still nowhere close to a deal on several major issues with significant implications for health policy. Four months into fiscal year 2018, Congress still can’t agree on FY 2018 funding levels or a budget deal to prevent sequestration—the deep, automatic, across-the-board cuts set to hit everything from the military to family planning and HIV/AIDS services to road and bridge safety. Hardline conservatives are happy to let sequestration hit non-defense priorities like health care, education, and infrastructure but are pushing for new spending for the Pentagon. Democrats have said that’s a non-starter.

Meanwhile, there’s little evidence that Congress is any closer to a DACA deal for Dreamers, and there are significant concerns that, even if the Senate can pass something, Republican leadership in the House won’t bring it to a vote unless moderate Republicans face more public pressure.

If there’s a silver lining to this madness it’s that the likelihood of a third round of reconciliation seems less and less likely the deeper we get into 2018 with so many must-pass items left undone. Reconciliation, recall, is the special process that allows GOP leaders to bypass a Democratic filibuster in the Senate and pass legislation with just 50 senators and the vice president. Last year, congressional Republicans tried and failed to kill the ACA and Medicaid using an FY 2017 reconciliation package, and then successfully used another reconciliation package for FY 2018 to enact deep tax cuts for themselves and their wealthy donors. Republicans had hoped to use a third reconciliation package for FY 2019 to launch another attack on health care and the social safety net.  But with their Senate majority reduced by one following the surprise special election of Democratic Senator Doug Jones (AL) and time running out on their long to-do list, it appears that reconciliation may no longer be a threat.

If that holds true, it’s great news for protecting the ACA and Medicaid, as well as Planned Parenthood and other abortion providers who were at risk of losing their ability to bill Medicaid for services in all of last year’s Trumpcare proposals. But that doesn’t mean we can breathe a sigh of relief quite yet.

Gutting Medicaid doesn't promote "dignity" and "independence"

 

House Speaker Paul Ryan (R-WI)—rumored to be retiring at the end of the year, with possible presidential ambitions—still wants to bolster his conservative legacy by forcing a vote on a stand-alone package of “reforms” that he hopes can win the support of vulnerable red-state Democratic senators. Using Orwellian phrases like “welfare,” “dignity,” “personal responsibility” and “promoting independence,” he wants to push forward radical changes to the Medicaid statute that would allow or require states to impose work requirements, drug testing, onerous new paperwork burdens, and more. Even couching the Medicaid program as “welfare” is a conscious attempt by conservatives to recast the critical health insurance program—which benefits the entire public health system—as a hand-out instead.

With the blessing of the Trump administration’s Center for Medicare and Medicaid Services (CMS), states are already attempting to ram through these changes under the guise of “demonstration projects.” But because the statute itself does not grant this leeway, these state waivers are subject to litigation. Former CMS official Eliot Fishman recently wrote about why:

[W]aivers must meet a legal requirement that they try to strengthen the Medicaid program: by expanding coverage, improving care delivery, or help safety net hospitals and other providers. But CMS’s recent announcement is directly opposed to the central Medicaid goal of covering low-income people. This is the first time in the 52-year history of the program that Medicaid waivers have been approved to reduce coverage instead of to expand it.

But if Republicans are successful in changing the underlying law itself, they will have achieved the very same coverage losses through the backdoor that they’d hope to achieve through block grants and other direct coverage cuts last summer. The danger is that, right now, few people understand what “work requirements” really mean—and what senator up for reelection wants to vote against getting people back to work?

In reality, there are very few Medicaid beneficiaries who could be working but aren’t. As the Center on Budget and Policy Priorities notes, the overwhelming majority of adults with Medicaid already work, are too sick to work, are going to school, are taking care of family members, or are already actively looking for work and can’t find it.

GOP 2018: Red tape is bad for white men in business suits, good for working mothers making minimum wage

Work requirements won’t change those circumstances, but the red tape associated with compliance will cause many of those people to lose coverage. As the New York Times recently reported, “a large body of social science suggests that the mere requirement of documenting work hours is likely to cause many eligible people to lose coverage, too.”

And that makes perfect sense, particularly for families already struggling simply to survive. As the article notes, “these [administrative hurdles] may be especially daunting for the poor, who tend to have less stable work schedules and less access to resources that can simplify compliance: reliable transportation, a bank account, internet access.”

From a public health perspective, it makes little sense to deny coverage that helps prevent the spread of disease, allows the mentally ill to access care, and ensures that family members are able to care for individuals who might otherwise require more costly services like nursing homes.

But as I noted in a 2016 research brief for Raising Women's Voices, the consequences for women and people of color would be particularly severe. While women and men have had roughly equivalent unemployment rates post-recession, women are far more likely to work part-time, making them vulnerable to the kinds of hourly requirements legislators have proposed. In 2014, for example, women accounted for 66% of the part-time work force and only 41% of the full-time workforce. Likewise, since the 1940s, the unemployment rate among African Americans has been consistently double that of white Americans.