Cuts to Medicaid? What do we need to understand before applauding or condemning?

At the time of this writing, many people are expressing outrage at the proposed cuts to Medicaid funding. Before taking constructive action, we need to know a whole lot more than that the Trump White House budget calls for “a large cut to Medicaid and Medicare funding.” This terse statement, which can be found in many news summaries, is utterly insufficient to deciding whether to be incensed or encouraged… or somewhere in between.

The proposed deep cuts to the Medicaid budget are bound to have a profound impact over the next decade... should nothing change to prevent what's proposed for 2020 and beyond. The proposed Trump budget calls for a 25% reduction in federal Medicaid expenditures by 2026, relative to what is currently estimated on the books. The proposal, which is based on the current House version of the AHCA, is not that easy to summarize in a single statement. What the Kaiser Family Foundation "opines" must be based on a lot of assumptions about how those reductions will impact various states and where individual states will choose to cut their Medicaid rolls. Are those in skilled nursing facilities likely to be "discharged" as the means of adjusting to the eventual 25% cut in federal Medicaid funding? There is no state that has made that kind of decision. Questions about how to adjust over the next decade have barely been asked and have definitely not been answered by each of the 50 states. Perhaps I'm missing something?

Because the Republican Congress follows confederate ideology, the solutions to this gradual, federal budget cut must come at the level of individual states. The federal government will provide less; states can decide whether to supplement with state funds or to cut the number/type of people who are eligible. In the current version, any state that has not already expanded eligibility would be forbidden from doing so. For example, some states, under the ACA, extended Medicaid eligibility to cover *anyone* living in poverty. Other (mostly Republican-dominated) states did not. The default is that the individual must meet more than the financial criteria (less than 133% of poverty level).

Across the United States, only 23% of non-elderly recipients of Medicaid are not employed. 63% have at least one family member who is employed full-time. [Henry J. Kaiser Foundation website, "Distribution of Nonelderly with Medicaid by Family Work Status"] Of those 23% who are not currently working and are *able* to work, what percentage of them would find employment that paid so much that they would no longer need Medicaid? I can't find anywhere that provides the data and an answer to this question.

The Congressional Budget Office estimate for this AHCA change in Medicaid coverage is that it represents an $800 billion total reduction in Medicaid costs between now and 2026. As a reference, for fiscal year 2016, total Medicaid spending was $574.2 billion. [Henry J. Kaiser Foundation website, "Total Medicaid Spending"]

Of course, I hope that the proposed changes at the federal level do not happen. We already have great disparity in Medicaid services between states. A gradual 25% cut at the federal level would undoubtedly exacerbate that disparity.

For now, I think we should all be planning ahead, to the extent we can put aside our own resources. With or without the AHCA, something has to change with Medicare and Medicaid. Either the withholdings for those programs have to increase or some other major change in healthcare for older adults and poor people has to happen. Insurance has to pay for itself. We will also need to pressure federal and state officials to develop plans that answer the question of what we do with the people who become ineligible for Medicaid and do not have the means to pay for essential care for themselves and their families. And the answers have to be viable; they cannot fly in the face of facts.

How can we determine President Trump’s actual agenda?

With the release of the first Trump White House budget, we know what some in the White House are trying to accomplish. There is, however, a great deal of discord within the White House staff and cabinet. It’s still not clear how many of the proposals come from Mr. Trump’s overarching objectives and how many are the work of members of his entourage, some of whom might be “fired” at any time. And, our Tweeter-in-Chief has been known to say two opposite things in the span of less than 24 hours. So in terms of specific ways that his nationalist and anti-regulations agenda will be carried out, this budget is our best indication of his agenda to date. It includes

• big increases in Dept. of Defense
• big increases in Dept. of Homeland Security
• big wall
• big decreases in health/medicine
• big decreases in science and technology
• big decreases in education
• big decreases in environmental protection
• big decreases in foreign aid

How do we translate these budget priorities into the Trump White House agenda? Fortunately, the budget document that was submitted to Congress explains the rationale pretty clearly. This gives us the assumptions they’re making and their “agenda.” Two examples give an idea of the agenda with respect to domestic policy.

Example #1: Trump put Scott Pruitt at the head of the EPA— a spokesperson for climate change deniers who sued the EPA about a dozen times, and Trump has now proposed an EPA budget cut of 31%. As outlined in the budget document, this guarantees there will be no further federal support for cleaning up toxic sites (like the Great Lakes, which hold 20% of the world’s fresh water). Pruitt’s EPA has already removed all the confirmed data on climate change (such as the relative contributions of natural meteorological variations on Earth, natural variations in solar energy release, and human use of fossil fuels) that was on the EPA website.

Pruitt and his advisors are “working on” a replacement for the 2016 EPA website. They say that the new website will focus on commerce (turning away from the EPA as our environment protector). Pruitt intends for the new site to explain how economic growth requires greater use fossil fuels, which will happen if businesses can pollute more (Some environmental regulations are already being repealed.) At the same time, the EPA has an updated section of the overall website that specifically addresses the importance of reducing pollution by U.S. businesses: https://www.epa.gov/p2/p2-resources-business [May 2017].

Pruitt recently claimed that carbon dioxide is not a “greenhouse gas.” (Pruitt has no background in chemistry, biology, or atmospheric sciences, so it is not surprising that he would make such a fundamental “misstatement.”) The EPA budget greatly decreases support for renewable energy options. The most recent headline regarding Trump’s position is that he is moving away from contending that the claims about climate change are part of an international hoax. This, after hearing from G17 leaders that he needs to adhere to the Paris Climate Agreement and why.

White House Assumptions & Rhetoric: If businesses can be free to pollute more, they will create more jobs and enjoy larger corporate profits. This is a specific instance of how trickle-down economics is purported to work. If toxic sites are going to be cleaned up, it’s on each state to find the budget to do so. If fossil fuel drilling and mining do not have to meet standards for toxic and polluting releases into the air, water, and land, then those in the fossil fuel industry will expand their drilling and mining (which feeds back into the first two assumptions).

Agenda:

#1-- Support the fossil fuel industry’s dominance as a provider of U.S. energy.

#2-- Convince working-class people that more manufacturing jobs will come their way as a result of significantly more jobs in the fossil fuel industry and, indirectly, more jobs in the business sectors that choose to increase the pollution they create.

(Republican caveat: There is also talk of Washington dictating to states that they cannot have more stringent laws regarding environmental protection, which flies in the face of Republicans’ strong push for states’ rights over federal rights.)

= = =

Example #2: Science, health, and technology are taking huge hits. Trump’s right-wing cronies are not fans of scientific research in many areas. The explanations for these reductions are mentioned in the budget proposal document. However, one recent White House comment is that these cuts are, in part, because scientists within the federal government have gone “too far” in their research on climate change. Here are a few of the agencies that are being cut to or through the bone.

National Science Foundation: 11% reduction in budget
This is how university innovation is funded: through NSF grants. Academic scientific research and early prototyping of applications are a major way that the United States develops advances in science, health, and technology. The majority of American businesses that used to have their own research labs have changed their innovation model so that they take the results of academic research (free and open to all because they’ve been federally funded) and develop their own products and services. (That is not to say that there is no research in these businesses, only that the investment is modest compared with what it used to be.) This new model substantially reduces the risk to businesses that used to have a one-in-ten internal research outcome that could be turned into profitable product lines and services.

Department of Health and Human Services: 16% reduction in budget
The stated intention is to cut Medicaid severely, to greatly reduce eligibility for children’s health insurance, and to eliminate the low-income energy assistance program. There is no acknowledgment that most Medicaid recipients have jobs, jobs that do not pay enough to be able to afford health insurance and co-pays for medical services. Instead, White House officials suggest that Medicaid can be cut significantly if recipients would “just get jobs.” According to the Congressional Budget Office, there will be about 23 million more people without health insurance. This, compliments of the House AHCA proposal. Trump has vacillated on his policy intentions regarding healthcare coverage for Americans. It appears that the vacillation may be due to gauging the reaction to his political base of supporters (who seem equate reduced coverage with reduced income taxes), but some of that vacillation appears to be due to learning-on-the-job about these federal services’ benefits to his base.

National Institutes of Health: 19% reduction in budget
These are the experts who regularly make breakthroughs in medicine and related health problems. It’s also the NIH that funds university research in important problems, from technology that will help elderly people live longer and more safely in their homes to prevention and cure of cancers. Notice how these would be ways to reduce the government’s costs for the AHCA, Medicare, and Medicaid.

Centers for Disease Control and Prevention: 17% reduction in budget from last year, bringing it to the lowest level in 20 years.
The cuts significantly reduce the ability of the CDC to discover new ways to effectively prevent diseases and to respond to emergent epidemics. The budget explanation states the intention to nearly eliminate all CDC aid to populations most at risk regarding health,  such as Native Americans living in tribal “reservations,” where poverty is endemic, and those in socioeconomically “disadvantaged” areas. “Disadvantaged” is a euphemism for disproportionate lack of economic opportunity and availability of services that would lead to improved opportunity and health outcomes.

White House Assumptions & Rhetoric: Federal funds have to come from somewhere to finance increased military costs, homeland security strength, and construction and maintenance of The Wall. It (apparently) isn’t important for the U.S. to be a leading contributor in advances in technology, science, and medicine. Science is highly over-rated as a source of facts. (I’m not sure where they think “facts” originate.)

Agenda:

#1— Fund nationalism (for example, increased investments in the DoD and DHS) through a significant reduction in support for Americans’ health.

#2— Put Americans at ease that science, technology, and health advances aren’t that important to their day-to-day lives.

Why do Progressives believe that Donald Trump will not help unify the country?

Neither Progressives nor Conservatives are hopeful that the United States (its citizens, voters, or elected officials) is about to unify anytime soon. Divisive thinking is now pervasive in the culture and has become systemic. Systemic conditions are extremely difficult to change.

As an example, a business culture can become so systemic that even getting rid of some of the people in the organization and replacing them with others rarely changes the entire business culture. Often, the new hires (at any level of the company) evolve to conform to the existing culture. Changing the CEO to someone with very different behaviors (a new role model) and a set of articulated, new expectations can help, to the extent that the CEO is strong-willed and aligned subordinates can weed out employees (starting with managers) who won’t or can’t conform to the imposed culture. If the company is sufficiently large, this change can take 5+ years to happen. Meanwhile, the company will be quite divided. Consider Carly Fiorina during her tenure at Hewlett-Packard (a name which she strategically referred to as “HP.”) She was strong-willed and discarded most of “The HP Way,” a statement of values advocated by the founders and embraced by many employees. With Fiorina’s imposition of a new culture, employees left in droves as they were committed to those long-time values—some resigning, others fired. But Donald Trump cannot fire members of Congress. He cannot fire Progressives. Governing the U.S. is not reality television and it is not corporation management. Progressive thinkers have a vote.

Progressives have been watching and listening to Donald Trump’s direct comments and behaviors for a long time. Many believe that the best predictor of the future is the past. In a few ways (not many), President-elect Trump is not as extreme a Conservative as those who are becoming the new establishment, that is, the alt-right and Tea Party Republicans. If congressional Republicans decide their best hope for keeping their jobs is to line up behind Trump, there will be only a very few points of political policy on which there’s a chance for Progressives and Conservatives to find common ground. Mostly, the distance between progressive thinking and conservative thinking is growing as the alt-right cements their power.

Why would even moderate conservative politicians line up behind President-elect Trump’s political positions? They might hope that lining up would reduce gridlock in Congress. Voters are tired of congressional gridlock… and might actually come to realize that if they keep voting for Republican incumbents, that gridlock is not going to go away.

Those who voted for Trump in the primaries were clearly not disturbed enough by his personality and open bigotry to vote for another Republican primary candidate. And 47% of those voting in the general election chose Trump. (Well, actually, it’s the Electoral College, since Secretary Clinton received almost 3,000,000 more popular votes than Trump. But the point remains that 47% of voters chose Mr. Trump.) The division is with the voters. There are people who will accept having a man committed to discrimination and there are people who won’t stand for that in any elected official, much less the president of the United States.

Five days after the election, President-elect Trump announced that he will not totally rescind the Affordable Care Act. I guess he still doesn’t understand separation of powers in the U.S. Constitution, as such changes are the responsibility of Congress. But if he pushes for the ACA to be improved and not discarded entirely, Conservatives in Congress can line up behind that. They don’t have to be 100% opposed to the entire ACA anymore because it can stop being called “Obamacare.” Their congressional home base will not desert them. It remains to be seen who has the most to gain with the modifications: healthcare providers, healthcare insurers, or the populace.

It is on social issues of equal rights, equal opportunities, and equal treatment that Progressives are certain there is no possibility of finding common ground. Progressives know that Trump is closer to progressive beliefs in only a very few of his political positions and that he has been quite the bigot in his own professional life. Many Progressives believe that Trump mostly played to his base of bigots and misogynists to gain prominence with large, admiring crowds and that Trump wants to keep those bigots’ support for another presidential election in 4 years. Appointing Stephen Bannon, well-known white nationalist and alt-right spokesperson, to the position of chief White House strategist and senior presidential advisor says volumes about where Trump is headed on civil rights. It is not toward anything that even moderate Conservatives could support, let alone Progressives.

Trump is not a deep thinker (he has volunteered that he prefers shallow thinking), but he has street smarts and instincts for how to be top dog. Progressives’ biggest concern is that civil and human rights will regress under President-elect Trump’s leadership. Already, we are seeing more hate crimes and hate speech from other bigot, xenophobes, and misogynists who feel they’ve been empowered by Trump. Appointing a white nationalist to a senior position states clearly that President-elect Trump could not care less about being a unifier.

People of color, women, people with disabilities, non-Christians, and people with non-straight gender identities can expect to experience day-to-day discrimination that is more open and more pervasive. Enforcement of existing civil rights legislation and of the U.S. Constitution’s provisions for equality with respect to race, national origin, religion, and gender is not going to become stronger under Donald Trump and his chosen administration.  Will Progressives embrace this? These attitudes and behaviors are repugnant and antithetical to Progressives’ beliefs.