The following originally appeared on The Upshot (copyright 2017, The New York Times Company).
There are only so many ways to cut Medicaid spending.
You can reduce the number of people covered. You can reduce the benefit coverage. You can also pay less for those benefits and get doctors and hospitals to accept less in reimbursement. Or you can ask beneficiaries to pay more.
None of those are attractive options, which is why Medicaid reform is so hard. Medicaid already reimburses providers at lower rates than other insurance programs. How do you reduce the number of beneficiaries when the vast majority of people covered are poor children, poor pregnant women, the disabled, and poor older people? Which of those would you cut?
Reducing benefit coverage has always been difficult because most of the spending has been on the disabled and poor older people, who need a lot of care. Beneficiaries don’t have much disposable income, so asking them to pick up more of the bill is almost impossible.
That doesn’t mean that states haven’t tried. As I’ve discussed in past columns, a number are attempting to increase cost sharing. But this isn’t really a solution because it doesn’t change overall spending much at all.
Part of the challenge lies in the way Medicaid was set up in the first place. The federal government picks up between 50 percent and 100 percent (depending on the population and the per-person income) of whatever it costs to provide health care to a state’s population. Many, if not most, Republican plans would like to change that.
They are pushing for what many refer to as a block grant program. The federal government would give a set amount of money to each state for Medicaid; it would be up to the states to spend it however they like. These block grants could be set based on overall past state needs or based on the number of beneficiaries in the state, referred to as a “per capita” block grant. Some per-capita block grants function more like “ceilings” than outright grants, allowing the state to be paid at normal Medicaid rates, but with a maximum each state could get based on the per-capita calculation.
The supporters of such plans have a point. Medicaid has all kinds of complicated rules, which can create perverse incentives throughout the system. It’s possible that the needs of one state are different from another, and that with more leeway in how Medicaid is administered on a local level, states could improve how they manage health care for the poor. It’s also true that the needs of the beneficiaries are widely different (children and the disabled, for example), and that treating them under one large program is inefficient.
The fiscal magic behind a block-grants approach is that the federal government can then set how quickly the amount they’re responsible for will increase over time, regardless of how quickly medical spending grows. If a gap develops between how much a state needs to spend, and how much the block grant provides, it’s up to the state to make up the difference. Those who support such a plan argue it gives states greater flexibility to make their own Medicaid programs work better.
A recent New England Journal of Medicine article provides some perspective on how this might work by looking at what happened before Medicaid was created in 1965. Care for the poor in the 1950s was done through direct reimbursements to providers. It was calculated on a per-capita basis — the average cash and medical needs of those the programs covered. Those amounts were capped, based on age and demographics. This is quite similar to how many Republican proposals might function.
When these capped amounts weren’t enough to pay for the programs, states had to make cuts. They began to restrict who would be covered, what would be covered and how much care beneficiaries could use. Some states refused to cover children at all. Others didn’t cover doctors’ visits or drugs.
In the early 1960s, the programs had only 3.4 million beneficiaries nationwide.
The 1965 Medicaid law removed these caps, and today Medicaid covers about 81 million people, or about one in four Americans. By 1980, spending in the program had grown by a factor of 10, and many politicians began to panic about the cost. This rise appears to have come not as much from a rise in benefits or payments as a huge increase in enrollees.
Andrew Goodman-Bacon, an economist at Vanderbilt University and one of the authors of the article, told me: “From the time Medicaid began until 1980, the amount spent per Medicaid recipient went up about 68 percent. The number of enrollees, however, went up almost 700 percent. Moreover, since 1980, the amount spent per Medicaid beneficiary has been almost flat, at just under about $5,800.”
Given that the growth in Medicaid spending seems mostly because of increases in the number of people benefiting from the program, it seems logical that one of the few ways to cut spending is by reducing that number.
The fact that so much of the discussion about Medicaid block grants centers on cuts points to most policy makers’ assumptions that cuts will need to be made. According to the Center on Budget and Policy Priorities, the House Republican budget plan for fiscal year 2017 (if it had passed) would have led to a reduction in Medicaid spending by $1 trillion over a decade. By 2026, federal funding for Medicaid would be one-third less than under current law.
From states’ point of view, whether they are reimbursed by a block grant or a percentage of coverage doesn’t really matter as long as the amount is enough. Almost no block grant plan allows for this, though. Planned cuts are how block grants make future federal budget projections look so good.
There’s no magic in how Congress reduces spending under a block grant mechanism. It just says it will do so, and leaves the hard decisions to others. It’s possible that some states will come up with solutions we haven’t been able to see before, and find a way to reduce spending without causing problems. If they can’t, though, they will have to make do with less, make the hard choices and face the brunt of the blame.