The GOP’s “menu” of reconciliation pay-fors (via Politico) makes it clear that cost-savings aren’t possible without deep cuts to Medicaid — these big-ticket proposals will both hurt beneficiaries *and* piss off governors.
www.politico.com/f/?id=000001…
— Adrianna McIntyre (@adrianna.bsky.social) January 10, 2025 at 1:47 PM
Dr. McIntyre is mostly focusing on Medicaid.
The GOP proposals can be summarized as Screw The Blue States.
Per-Capita caps will bite more in areas that have higher Medicaid per capita spending. Equalize Medicaid Payments for Able Bodied Adults means rolling back the 90% federal match rate for ACA Medicaid Expansion to the standard Medicaid federal payment rate. This would trigger a half dozen or more states to automatically cancel Medicaid expansion (including North Carolina). The states that have not expanded Medicaid are one swing state (Wisconsin) that already has Medicaid-ish expansion to 100% FPL via Badgercare at regular reimbursement, one swingy state (Georgia) and a bunch of red states.
Lowering the FMAP floor sounds technical. The FMAP is the Federal Matching Assistance Percentage or the federal share of Medicaid payments. Poorer states get more federal money than richer states. The formula is determined by per capita income in a state relative to the national average. It is updated annually. There is a floor, where the federal government pays at least 50% of Medicaid costs. The 10 states that have the floor apply to them are all Blue States. Lowering the FMAP floor makes these ten states pay a lot more for Medicaid out of the state budget than the federal budget. This is very similar structurally to the SALT cuts in the 2017 tax cuts.
On the ACA side, the state by state distributional impact is messier as CSR enrollment is overwhelmingly in the Medicaid non-expansion states. Recapturing Excess Premium Tax Credits means going after people who estimate that their income will be 105% Federal Poverty Level ahead of time but whose actual income was 95% Federal Poverty Level when they file their taxes. Limiting Health Program Eligibility is not a big saver — immigrants who are timed barred from collecting Medicaid are eligible for ACA tax credits — but I think it is part and parcel of the Public Charge Rule to reduce immigration by making health insurance unaffordable for most immigrants who are not working for a Fortune 500 company.
Remember, the House is where there is leverage
Let’s Be Smarter – Act I
Professor Bigfoot
I’m having a tough time right now with all of this— Mrs. B has been through breast cancer treatments for the last year; she’s now on meds costing ridiculous amounts of money.
These sonsabitches have me grinding my teeth.
And when I think about the Americans* who voted for that rat bastard… it’s kinda hard not to hate.
Steve LaBonne
@Professor Bigfoot: I don’t try very hard.
David Anderson
@Professor Bigfoot: I feel ya — and I hope that Mrs. Bigfoot is doing well.
Starfish (she/her)
@Professor Bigfoot: My sister has been on meds that cost $18,000 a month for several years due to cancer. They have some terrible side effects.
different-church-lady
Giving billionaires our money was pretty much the only plank in the GOP platform until Trump came along.
Now there’s two: hurt people deliberately while giving billionaires our money.
different-church-lady
@Professor Bigfoot:
GOP MAKES HEALTH CARE COSTS SKYROCKET EVEN MORE, CARE GOES AWAY:
Those Demonrats caused it all! We gotta vote MAGA even harder!"Baud
@Professor Bigfoot:
Good luck to her in her treatment.
They deserve the hate, but the problem is hate’s self corrosive nature.
Professor Bigfoot
@Baud: Brother, that’s the only reason to resist it.
But it’s hard, yo.
Downpuppy
The federal Medicaid expense for 2024 was $607B, so I’m guessing that the savings chart is 10 year. Over half of that was to elderly and disabled. Per capita caps to save $918,000,000,000 are going to require a lot of ice floes.
Professor Bigfoot
@Starfish (she/her): Mrs. B’s on one of those now.
In the middle of chemo and radiation, her “medicare advantage” insurer decided that they would no longer cover her hospital.
Just (pouf!) and we hadda find another one that DID cover her hospital… but higher out of pockets, et cetera.
I’m SO DAMNED LUCKY so far, my only meds are cheap generics. SO FAR.
They say anger is fear’s bodyguard.
Parfigliano
Looks like an excellent plan to create Luigi’s on a national scale.
Sure Lurkalot
Comrade Scott calls every billionaire a policy failure and yes, that’s true, BUT ALSO, people who crave an inordinate level of wealth for its own sake and having achieved that, require more and more, immune to the extent of harm to people and planet…well, let’s just say even sociopath and psychopath don’t quite cut it. We need new words.
Once again, a good illustration of “inordinate level of wealth”: https://mkorostoff.github.io/1-pixel-wealth/
Percysowner
@Professor Bigfoot: When I got old enough for Medicare I went with traditional. I was lucky, my state retirement system allows me to buy dental and vision at a group rate, so I didn’t need the “extras” advantage gives you. Plus I have enough to pay for a Medigap plan.
When I had cancer, I didn’t pay anything. Luckily all of my drugs have been generics, so I’ve lucked out there, although I had to switch prescription plans this year, my old one went away.
They are going to ruin Medicare, but I’m hoping to hold onto traditional as long as possible.
Archon
The one thing that could genuinely lead to the dissolution of the United States in the medium to long term is the MAGA Republican strategy of defunding programs in blue states while also not giving emergency funding to blue states when disasters happen (which seems like the plan). All that while blue states pay most of the taxes.
That type of party politics is a completely unsustainable way for the United States to function as a union.
Steve LaBonne
@Percysowner: Individual dental and vision are not that expensive either. And the “free” coverage with many “Advantage” plans is paid for out of the excess payments the government makes to the insurance companies, by one estimate 22% more per capita than for traditional Medicare enrollees. That is unlikely to last forever. The first thing I say to anyone approaching 65 is stay far away from “Advantage”. I forlornly hope they won’t succeed in forcing us all into it.
Another Scott
Agreed that the leverage is in the House. Fritschner highlighted that the GQP’s blueprint for the reconciliation bill was going to be ready in early January, then early February, then late February – the timing changing in less than a week. They don’t have all their cats herded yet (and if past is prologue, they may not be able to).
Thanks.
Best wishes,
Scott.
Steve LaBonne
@Another Scott: I hope Jeffries can find ways to keep the pressure, and the spotlight, on vulnerable Republicans.
Harrison Wesley
I was fortunate that when I needed major surgery ten years ago, my employer gave us a great healthcare plan. Now that I’m retired and have doodlysquat I’m on an Advantage plan. I really, really don’t want to push it and am trying to get into all that healthy living stuff I should have been doing for the last sixty years or so.
TBone
@Steve LaBonne: I bought an individual dental plan until I realized that the low premium was still higher than any benefit they’d ever pay. Unrelated, when dentist said I needed a biopsy, I found out that I’d be much better off at an ear, nose & throat doctor than at any oral surgeon because of billing codes.
TBone
@Steve LaBonne: I share that forlorn hope.
TBone
@Sure Lurkalot: they are cave dragons sitting on their hoards of gold and rubies.
Steve LaBonne
@TBone: As far as I can tell all dental insurance is of limited value, including what I got back in the day with my gold-plated insurance from the county I worked for. I have a bridge because that plan wouldn’t pay anything at all for an implant.
TBone
@Parfigliano: did you see the new UHC authorization processs? One phone call, and only one, and if the doctor is mid-surgery, it’s surgery interruptus. I posted the story earlier (breast cancer surgeon blew the whistle on the new auth scam procedure).
Steve LaBonne
@TBone: One, two, many Luigis.
TBone
@Steve LaBonne: yup, hard agree. I don’t trust the hygiene issues posed by implants that go into the jawbone. Seems like a great way for additional access of pathogens and harmful bacteria. Come right on in!
TBone
@Steve LaBonne: I was so pissed when I read that story. Should I repost here, I wonder …
Ohio Mom
Okay, I read this post twice, breathing deeply and trying to stay calm. Because as I sometimes tire of saying, Medicaid allows people with disability to live. As in, Food, Clothing and Shelter (yes, there’s SNAP for good but it isn’t sufficient). Also, aides, transportation, day programs and job coaching, and over that all, case management.Oh yes, and medical coverage and the equipment people with mobility challenges need to function.
As I’ve said many time before, Medicaid is Ohio Son’s lifeline, along with Social Security (which needless to say, is also in the crosshairs).
I can’t tell where disabled people fit I this scheme. It sounds mainly like a sideways attack on the ACA but disabled people could end up as collateral damage.
I also want to underline the part of this post where David points out that the funding mechanism for Medicaid is the state puts up half and the Feds match that amount, 1:1, except for Red taker-states where the Feds put in more than half. This is one of the places Blue states are bailing out Red states.
TONYG
@Professor Bigfoot: Most of the assholes who voted for Trump in November will be harmed by these policies. They are too fucking stupid to realize that.
Steve LaBonne
@Ohio Mom:
They don’t. Your son is a sacrifice Republicans are willing to make. They are pure evil.
Steve LaBonne
@TONYG: Dying of Whiteness is teaching me that many of them do realize it, but are willing to sacrifice their very lives for their twisted white supremacist ideology.
TBone
ICYMI
https://people.com/fred-trump-iii-interview-son-william-disability-advocacy-8706139
eclare
@TBone:
I’ve had an implant for about fifteen years. Love it. Will definitely do it again if I need to.
TBone
@eclare: good to know, thanks!
Miss Bianca
@eclare: I’ve had mine for over 30. Since I lost seven teeth – among other things – in a bike accident, it seemed like the way to go.
But, oh my lord – was it a fight to get it! Back then, shall we say, the insurance companies *weren’t* so eager to pay for them. Had to get the head of student health at my university to go to bat with the insurance company.
p.a.
Turned 65 in June, already retired, employer funded MedAd (United😱) $0 premium, if the doc/institution takes classic Medicare, so far I’m covered wherever. Before next choice period I’m going to do the research, maybe go traditional with the fill-ins I need.
eclare
@Miss Bianca:
Oh ouch! I think my insurance paid for some, but not much. It was just one, and I honestly can’t remember.
Glory b
@Steve LaBonne: Im happy to see that I’m not the only one who’s read it.
Too many people say “We have to show them that they are voting against their own interests!”
They aren’t. Their interests aren’t what YOU think they are.
Steve LaBonne
@p.a.: Unless you live in one of the three states (IIRC) that forbid insurers from medically underwriting Medigap policies after the initial enrollment period, you may find that you can’t get one- either prohibitive premium or flat rejection. A lot of people find this out the hard way, alas. “Advantage” is set up to be a roach motel- you can check in but you can’t check out.
lynno
How many jobs did Obama care create? Or are we to look forward to a reduction in the patient doctor ratio?
BellaPea
I haven’t posted recently, as I’ve been in my Mom’s home town to finish cleaning out her house and to get it ready to be sold. I can’t believe I finally sold the thing, and in two months no less! We were lucky as her assisted living expenses are between $4,500 and $5,000 per month. She had LTC insurance, and after a bunch of back-and-forths those payments kick in next month. Insurance companies are a device from the devil. Hopefully, now that we’ve sold the house, we can take care of her from now on as she has Alzheimer’s and is gradually getting worse. This country does absolutely nothing to assist with elder care. I don’t know how lower income people manage.
Another Scott
Meanwhile, relatedly, … GovExec.com:
Gerry knows how to do this politics stuff. It’s worth keeping an eye on him.
More at the link.
Best wishes,
Scott.
CliosFanboy
@Glory b:
it’s against their rational logical interests, but not their perceived, emotional ones.
Steve LaBonne
@CliosFanboy: They have a rational, logical interest in keeping white Christian men at the top of the pyramid. Without that they’re just poor schmucks, no better than the people they despise.
gene108
@Another Scott:
Connolly thinks Musk or Ramaswamy will listen, relative to them, a broke ass Congressman who’s fighting cancer and may not have long to live?
What a naive summer child Connolly is.
Geminid
@BellaPea: That must be a relief. Glad you’re back.
Glory b
@CliosFanboy: Exactly.
Gvg
@TBone: I have had my first for about 12 years, no problems. The hygiene should be about the same as a root canal if done by a true expert. I have read that implants are becoming so popular and such moneymakers that unqualified people are doing them and there are problems naturally with that. My first 2 were done by a guy with decades of experience, then last summer after a year of several infected teeth and root canals/ crowns the first crown was infected again so the tooth had to be removed by an the surgeon. My dentist wanted to do an implant himself which he had always ent me elsewhere for previously, and the price was really high. So I thought about it, and went to the surgeon who had done me before for a second opinion and quote. He was cheaper but he thought he saw more cavities that my dentist had not spotted. So I went to my parents dentist for a full exam only a month after my previous one and found about 7 or 8 cavities. I have a new dentist, and I am getting several implants. Not cheap, but not at the rates the previous guy was quoting. He charged more for other things too.
Most dentists around here won’t take most dental insurance. There is one that just Reimburses up to a limit that most of them take.
Glory b
@gene108: I think that statement was for the media, not that he believes it.
Elon strikes me as someone with a short enough attention span that he could be easily played. He’s never really had any pushback in his life, similar to Trump.
Steve LaBonne
@gene108: Really? Taking an opportunity to publicly explain that Muskaswamy don’t know their ass from a hole in the ground seems like good politics to me.
Ksmiami
@Archon: Blue states need to stop funding the feds. Immediately. Dissolve the country
RevRick
@lynno: This is an important aspect to highlight in the GOP’s insane agenda. Slashing $5.3+trillion sounds great to a lot of people, because it’s just a number. But from a macroeconomic standpoint it’s the dumbest idea imaginable.
Why?
Because all that federal spending is somebody else’s income, or in the case of Medicare and Medicaid, some hospital, nursing home or rehab center’s income, and thus the employees of said institution’s income. Most of those on the receiving end of this spending are people in the bottom 80%, who will turn around and buy stuff from other Americans.
Meanwhile, the other side of this agenda is to shovel a ton of money into the laps of those who already have a ton of money and will just use it to buy stocks or crypto or a mansion they visit on occasion.
In other words, it will flush the economy down the toilet.
Steve LaBonne
@RevRick: Which will totally be Joe Biden’s fault. What a mess he left for Trump to clean up! Living in the post-truth era is maddening.
Glory b
@Steve LaBonne: Yeah, isn’t that the kind of thing people WANT Dems to do?
Again, whatever we do, we aren’t doing it right, it seems.
catclub
No one understands what the axes are in a learning curve plot. X axis is time ( or experience), Y-axis is how much you have learned. A steep learning curve would suggest rapidly learning a lot. Not what he means.
catclub
Except for Medicaid paying for nursing home care for everyone impoverished by their previous care ( or having strategically gotten rid of all assets the government can see). Medicaid is the biggest payor of those nursing homes.
Kind of a what have the Romans done for us, lately, thing.
Another Scott
@catclub: Yeah, I noticed that too.
I think most people think of it as an effort curve, not a proficiency curve. Climbing El Capitan vs walking to school (even up hill both ways).
He probably would have lost his audience of normies if he had used it “correctly”. ;-)
Best wishes,
Scott.
Glory b
@catclub: Hmm, I always thought it meant a lot to learn (more than the learner thought) and a short time to do it in.
billcoop4
It’d like “I coudn’t care less” when you mean “I could care less”. The Colloquialism will always win even if it’s not correct.
BC
Bill Arnold
@Parfigliano:
Among the millions of people who would lose health care, there would be at least 10s of thousands with e.g. respectable long-range rifle skills. Some of them would be on beta blockers, which are forbidden as performance enhancers in competitive shooting.
catclub
@Another Scott:
So an effort curve would be a derivative of a learning curve. Now it is even MORE non-intuitive.
BillCoop is probably correct. Just don’t think about it.
Miss Bianca
@billcoop4:
Umm…don’t you mean the other way ’round?
Gretchen
The first new idea for eldercare in years came from Harris: paying for in-home care for all the people who don’t want to get sent to a Medicaid nursing home, which incidentally is far more expensive that staying home. All the old red-hats just noped out of that and went for the guy who doesn’t care if they starve in an alley.
We opted for Medicare Advantage because the monthly premium was a LOT less than the supplemental. It was fine when we were younger and healthier, and then we hit the point where they didn’t want to pay for something necessary. Fortunately that advantage plan pulled out of our area, which is the only circumstance where you can switch to supplemental without underwriting. Phew!
I had no idea how complicated the whole Medicare thing was until we had to choose among the many choices and multiple parts. I still don’t understand it – we needed a navigator. If you need a navigator to make it through signup, it’s too complicated. I suspect it’s too complicated so people don’t realize what’s not covered.
Downpuppy
@catclub: I read that as a learning curve too steep to think there’s a chance in hell these clowns will ever climb it.
Ohio Mom
@p.a.: I’ll warn you that it can be hard to switch from Medicare Advantage to Traditional MedIcare because Gap plans may hold pre-existing conditions against you, and you definitely need a Gap plan. They can’t hold pre-existing conditions against you when you first turn 65 but after that…
I’m trying to make this a short comment but Medicare is so complicated! Good Luck!
Glory b
@Downpuppy: Yeah, that’s what I thought.
Glory b
@Ohio Mom: I understand that the rule of thumb is just say no to Medicare Advantage.
Geminid
@gene108: I think you’ve got it wrong about Connolly, but this is not a point worth arguing in prospect. We’ll see how Connolly does leading the Democratic side of the Oversight Committee soon enough.
Ohio Mom
@Glory b: Yes, Traditional Medicare is the superior pathway. But to people who have very limited retirement incomes, Medicare Advantage looks much more affordable. Which it is, until it isn’t.
Then you pay with poorer health care, including denied claims and being limited to a set of doctors who might not be the best for your particular medical condition.
Steve LaBonne
@Glory b: It seems like a great deal when you’re relatively young and healthy. But the “healthy” part can change in a minute and then you’re totally at the “mercy” of UHC et al. I hate to see people learning that lesson too late because they didn’t understand the full reality. People approaching 65 should either be prepared to put in a lot of research or else find a trustworthy advisor who isn’t being spiffed by insurance companies.
Steve LaBonne
@Ohio Mom: It is scandalous that traditional Medicare costs more in absolutely Indispensable supplement premiums than many low income seniors can afford. But there’s very little about our health “care” “system” that isn’t scandalous.