The Trump administration finds a new way to cut Medicaid spending Alex Wong/Getty Images The Trump administration is trying to cut Medicaid funding — again. A new plan would allow states to seek Medicaid block grants, which amount to spending caps on the enormously popular health care program. [Vox / Dylan Scott] Block grants — as opposed to the current open-ended matching federal funding for Medicaid that states receive — are a longtime conservative policy goal; however, it’s unclear whether the Trump administration can cap Medicaid spending without Congress. [Politico / Rachel Roubein and Dan Diamond] Advocates for the program say it would improve states’ flexibility and accountability in administering Medicaid; Democrats warn that block grants would instead imperil access to health care for the poorest and most vulnerable segments of the population. [NYT / Abby Goodnough] The reach of the block grant changes would be limited; according to federal officials, children, pregnant women, people with disabilities, and the elderly would not be affected. [WSJ / Stephanie Armour] This most recent rule change is just the latest instance of the Trump administration attempting to cut Medicaid. Previously, the administration has provided waivers so states can implement work requirements as a condition for Medicaid access. [NBC / Phil McCausland] The new changes are almost certain to be challenged in court; previous attempts to limit Medicaid through work requirements have been similarly challenged, and in many cases rejected by federal courts. [Washington Post / Amy Goldstein] Medicaid isn’t the only federal program in Trump’s sights; the administration’s proposed 2020 would cut both Medicare and Social Security, and the president indicated last week at the World Economic Forum in Davos that he would “take a look” at entitlement cuts. [CNN / Maegan Vazquez]

OBAMACARE ENROLLMENT NUMBERS ARE LOW, BUT LOOK CLOSELY

GREG SARGENT WASHINGTON POST

The enrollment numbers are in, and as expected, they are well short of projections. Around 106,000 enrolled in new plans during October — with approximately 27,000 coming from states where the federal government is running the exchange (with its extensive problems), and another 79,000 coming through the state exchanges. Republicans are gleefully pointing to the numbers as proof Obamacare needs to be scrapped entirely.
That confirms two things we’ve long known to be true: the website is a disaster, and short term enrollment figures are a serious political problem for the White House and Democrats. But to Larry Levitt, a vice president at the nonpartisan Kaiser Family Foundation, another very telling number is this one: over 975,000 have been determined eligible for a marketplace but haven’t yet chosen a plan.

“That’s one of the most telling numbers — a million people have been determined eligible,” Levitt tells me. “That means if the website had been working well, and a million people had gotten to the end of the process, we’d be looking at a very different trajectory now. We heard about the surge in traffic when HealthCare.gov went live. This suggests there is in fact a lot of interest.”
The thing is, though, that even this one-million number highlights both the perils and the potential upsides in not getting the damn website fixed. It shows us that if it isn’t fixed demand isn’t going to matter at all — enrollment will be very low, regardless of demand, putting Obamacare’s long term prospects in peril. But if it does get fixed, of course, you could see a real enrollment spike.

Meanwhile, the 100,000 number is getting a lot of attention, but the report also finds nearly 400,000 were determined eligible for Medicaid. “In total that’s over 500,000 people who signed up for insurance in the midst of a tumultuous launch,” Levitt says. “People make a distinction between the marketplace and Medicaid, but those are both elements of the Affordable Care Act — both are mechanisms to get people insured.”

Republicans will argue that as it stands now, many more people are feeling an adverse effect from Obamacare — by losing coverage or seeing higher premiums. That is a very valid point. But the crux of the issue is that the question of how many will benefit, and how many will be adversely impacted, is far from settled. We don’t know how many people will sign up, and we don’t know how many people will really be adversely impacted, since many may find plans on the exchanges they like better – many may find those plans provide a better deal in the long run or that subsidies keep their prices low.
Indeed, if it’s true that today’s numbers show demand is high — and if the website does get fixed – GOP smugness about the collapse of Obamacare may look awfully shortsighted in a few months. As bad as today’s numbers may have been — and allowing that the law’s success over time is anything but assured — Obamacare is moving forward, and we have a glimpse of what that really looks like.

A WAR ON THE POOR

Gov. John R. Kasich of Ohio said of fellow Republicans in Washington, "I’m concerned about the fact there seems to be a war on the poor."


PAUL KRUGMAN N.Y. TIMES

John Kasich, the Republican governor of Ohio, has done some surprising things lately. First, he did an end run around his state’s Legislature — controlled by his own party — to proceed with the federally funded expansion of Medicaid that is an important piece of Obamacare. Then, defending his action, he let loose on his political allies, declaring, “I’m concerned about the fact there seems to be a war on the poor. That, if you’re poor, somehow you’re shiftless and lazy.”

Obviously Mr. Kasich isn’t the first to make this observation. But the fact that it’s coming from a Republican in good standing (although maybe not anymore), indeed someone who used to be known as a conservative firebrand, is telling. Republican hostility toward the poor and unfortunate has now reached such a fever pitch that the party doesn’t really stand for anything else — and only willfully blind observers can fail to see that reality.

The big question is why. But, first, let’s talk a bit more about what’s eating the right.

still sometimes see pundits claiming that the Tea Party movement is basically driven by concerns about budget deficits. That’s delusional. Read the founding rant by Rick Santelli of CNBC: There’s nary a mention of deficits. Instead, it’s a tirade against the possibility that the government might help “losers” avoid foreclosure. Or read transcripts from Rush Limbaugh or other right-wing talk radio hosts. There’s not much about fiscal responsibility, but there’s a lot about how the government is rewarding the lazy and undeserving.

Republicans in leadership positions try to modulate their language a bit, but it’s a matter more of tone than substance. They’re still clearly passionate about making sure that the poor and unlucky get as little help as possible, that — as Representative Paul Ryan, the chairman of the House Budget Committee, put it — the safety net is becoming “a hammock that lulls able-bodied people to lives of dependency and complacency.” And Mr. Ryan’s budget proposals involve savage cuts in safety-net programs such as food stamps and Medicaid.

 

Rep. Paul Ryan said he doesn't "want to turn the safety net into a hammock that lulls able-bodied people to lives of dependency and complacency."

 

 

All of this hostility to the poor has culminated in the truly astonishing refusal of many states to participate in the Medicaid expansion. Bear in mind that the federal government would pay for this expansion, and that the money thus spent would benefit hospitals and the local economy as well as the direct recipients. But a majority of Republican-controlled state governments are, it turns out, willing to pay a large economic and fiscal price in order to ensure that aid doesn’t reach the poor.

The thing is, it wasn’t always this way. Go back for a moment to 1936, when Alf Landon received the Republican nomination for president. In many ways, Landon’s acceptance speech previewed themes taken up by modern conservatives. He lamented the incompleteness of economic recovery and the persistence of high unemployment, and he attributed the economy’s lingering weakness to excessive government intervention and the uncertainty he claimed it created.

But he also said this: “Out of this Depression has come, not only the problem of recovery but also the equally grave problem of caring for the unemployed until recovery is attained. Their relief at all times is a matter of plain duty. We of our Party pledge that this obligation will never be neglected.”

 

Can you imagine a modern Republican nominee saying such a thing? Not in a party committed to the view that unemployed workers have it too easy, that they’re so coddled by unemployment insurance and food stamps that they have no incentive to go out there and get a job.

 

      

So what’s this all about? One reason, the sociologist Daniel Little suggested in a recent essay, is market ideology: If the market is always right, then people who end up poor must deserve to be poor. I’d add that some leading Republicans are, in their minds, acting out adolescent libertarian fantasies. “It’s as if we’re living in an Ayn Rand novel right now,” declared Paul Ryan in 2009.

But there’s also, as Mr. Little says, the stain that won’t go away: race.

In a much-cited recent memo, Democracy Corps, a Democratic-leaning public opinion research organization, reported on the results of focus groups held with members of various Republican factions. They found the Republican base “very conscious of being white in a country that is increasingly minority” — and seeing the social safety net both as something that helps Those People, not people like themselves, and binds the rising nonwhite population to the Democratic Party. And, yes, the Medicaid expansion many states are rejecting would disproportionately have helped poor blacks.

So there is indeed a war on the poor, coinciding with and deepening the pain from a troubled economy. And that war is now the central, defining issue of American politics.

AFFORDABLE CARE AND MEDICAID

PAUL KRUGMAN N.Y. TIMES

For now, the big news about Obamacare is the debacle of HealthCare.gov, the Web portal through which Americans are supposed to buy insurance on the new health care exchanges. For now, at least, HealthCare.gov isn’t working for many users.

It’s important to realize, however, that this botch has nothing to do with the law’s substance, and will get fixed. After all, a number of states have successfully opened their own exchanges, doing for their residents exactly what the federal system is supposed to do everywhere else. Connecticut’s exchange is working fine, as is Kentucky’s. New York, after some early problems, seems to be getting there. So, a bit more slowly, does California.

In other words, the technical problems, while infuriating — heads should roll — will not, in the end, be the big story. The real threat remains the effort of conservative groups to sabotage reform, especially by blocking the expansion of Medicaid. This effort relies heavily on lobbying, lavishly bankrolled by the usual suspects, including the omnipresent Koch brothers. But it’s not just money: the right has also rolled out some really lousy arguments.

And I don’t just mean lousy as in “bad”; I also mean it in the original sense, “infested with lice.”

 

Before I get there, a word about something that, as far as we can tell, isn’t happening. Remember “rate shock”? A few months ago it was all the rage in right-wing circles, with supposed experts claiming that Americans were about to face huge premium increases.

It quickly became clear, however, that what these alleged experts were doing was comparing apples and oranges — and as Ezra Klein of The Washington Post pointed out, oranges that, in many cases, you can’t even buy. Specifically, they were comparing the premiums young, healthy men were paying before reform with the premiums everyone — including those who previously couldn’t get insurance because of pre-existing conditions — will pay under the new system. Oh, and they also weren’t taking into account the subsidies many Americans will receive, reducing their costs.

 

Now people are signing up for policies on state exchanges and, to a limited extent, on the federal exchange. Where are the cries of rate shock? Anecdotal evidence, which is all we have so far, says that people are by and large happily surprised by the low cost of their insurance. It was telling that when Fox News eagerly interviewed some middle-class Americans who said they had been hurt by the Affordable Care Act, it turned out that none of their guests had actually checked out their new options — they just knew health reform was terrible because Fox News told them so.

 

      

Now, about those lousy Medicaid arguments: Last year’s Supreme Court decision upholding the Affordable Care Act did strike down one provision, the one that would have forced all states to accept an expansion of Medicaid, the already-existing program of health insurance for the poor. States are now free to reject that expansion. Yet how can states justify turning down a federal offer to insure thousands of their citizens, one that would cost them nothing in the first year and only trivial amounts later? Sheer spite — the desire to sabotage anything with President Obama’s name on it — is the real reason, but doesn’t sound too good. So they need intellectual cover.

 

Enter the same experts, more or less, who warned about rate shock, to declare that Medicaid actually hurts its recipients. Their evidence? Medicaid patients tend to be sicker than the uninsured, and slower to recover from surgery.

O.K., you know what to do: Google “spurious correlation health.” You are immediately led to the tale of certain Pacific Islanders who long believed that having lice made you healthy, because they observed that people with lice were, typically, healthier than those without. They were, of course, mixing up cause and effect: lice tend to infest the healthy, so they were a consequence, not a cause, of good health.

The application to Medicaid should be obvious. Sick people are likely to have low incomes; more generally, low-income Americans who qualify for Medicaid just tend in general to have poor health. So pointing to a correlation between Medicaid and poor health as evidence that Medicaid actually hurts its recipients is as foolish as claiming that lice make you healthy. It is, as I said, a lousy argument.

 

And the reliance on such arguments is itself deeply revealing, because it illustrates the right’s intellectual decline. I mean, this is the best argument their so-called experts can come up with for their policy priorities?

Meanwhile, many states are still planning to reject the Medicaid expansion, denying essential health care to millions of needy Americans. And they have no good excuse for this act of cruelty.

A Federal Budget Crisis Months in the Planning

Michael Stravato for The New York Times

"You are here because now is the single best time we have to defund Obamacare. This is a fight we can win." SENATOR TED CRUZ, speaking in August to a Heritage Action gathering in Dallas

N.Y. TIMES SHERYL GAY STOLBERG and MIKE McINTIRE

 Shortly after President Obama started his second term, a loose-knit coalition of conservative activists led by former Attorney General Edwin Meese III gathered in the capital to plot strategy. Their push to repeal Mr. Obama’s health care law was going nowhere, and they desperately needed a new plan.

Out of that session, held one morning in a location the members insist on keeping secret, came a little-noticed “blueprint to defunding Obamacare,” signed by Mr. Meese and leaders of more than three dozen conservative groups.

It articulated a take-no-prisoners legislative strategy that had long percolated in conservative circles: that Republicans could derail the health care overhaul if conservative lawmakers were willing to push fellow Republicans — including their cautious leaders — into cutting off financing for the entire federal government.

 

We felt very strongly at the start of this year that the House needed to use the power of the purse,” said one coalition member, Michael A. Needham, who runs Heritage Action for America, the political arm of the Heritage Foundation....Last week the country witnessed the fallout from that strategy: a standoff that has shuttered much of the federal bureaucracy and unsettled the nation.

To many Americans, the shutdown came out of nowhere. But interviews with a wide array of conservatives show that the confrontation that precipitated the crisis was the outgrowth of a long-running effort to undo the law, the Affordable Care Act, since its passage in 2010 — waged by a galaxy of conservative groups with more money, organized tactics and interconnections than is commonly known.

 

 

David Koch of Americans for Prosperity, Michael A. Needham of Heritage Action and former Attorney General Edwin Meese III played roles in the health law fight.

 

 

With polls showing Americans deeply divided over the law, conservatives believe that the public is behind them. Although the law’s opponents say that shutting down the government was not their objective, the activists anticipated that a shutdown could occur — and worked with members of the Tea Party caucus in Congress who were excited about drawing a red line against a law they despise.

A defunding “tool kit” created in early September included talking points for the question, “What happens when you shut down the government and you are blamed for it?” The suggested answer was the one House Republicans give today: “We are simply calling to fund the entire government except for the Affordable Care Act/Obamacare.”

The current budget brinkmanship is just the latest development in a well-financed, broad-based assault on the health law, Mr. Obama’s signature legislative initiative. Groups like Tea Party Patriots, Americans for Prosperity and FreedomWorks are all immersed in the fight, as is Club for Growth, a business-backed nonprofit organization. Some, like Generation Opportunity and Young Americans for Liberty, both aimed at young adults, are upstarts. Heritage Action is new, too, founded in 2010 to advance the policy prescriptions of its sister group, the Heritage Foundation.

 

The billionaire Koch brothers, Charles and David, have been deeply involved with financing the overall effort. A group linked to the Kochs, Freedom Partners Chamber of Commerce, disbursed more than $200 million last year to nonprofit organizations involved in the fight.....

 

 

The groups have also sought to pressure vulnerable Republican members of Congress with scorecards keeping track of their health care votes; have burned faux “Obamacare cards” on college campuses; and have distributed scripts for phone calls to Congressional offices, sample letters to editors and Twitter and Facebook offerings for followers to present as their own.

One sample Twitter offering — “Obamacare is a train wreck” — is a common refrain for Speaker John A. Boehner.

As the defunding movement picked up steam among outside advocates, Republicans who sounded tepid became targets. The Senate Conservatives Fund, a political action committee dedicated to “electing true conservatives,” ran radio advertisements against three Republican incumbents.

Heritage Action ran critical Internet advertisements in the districts of 100 Republican lawmakers who had failed to sign a letter by a North Carolina freshman, Representative Mark Meadows, urging Mr. Boehner to take up the defunding cause. “They’ve been hugely influential,” said David Wasserman, who tracks House races for the nonpartisan Cook Political Report.

 

On Capitol Hill, the advocates found willing partners in Tea Party conservatives, who have repeatedly threatened to shut down the government if they do not get their way on spending issues. This time they said they were so alarmed by the health law that they were willing to risk a shutdown over it. (“This is exactly what the public wants,” Representative Michele Bachmann of Minnesota, founder of the House Tea Party Caucus, said on the eve of the shutdown.)

 

Despite Mrs. Bachmann’s comments, not all of the groups have been on board with the defunding campaign. Some, like the Koch-financed Americans for Prosperity, which spent $5.5 million on health care television advertisements over the past three months, are more focused on sowing public doubts about the law. But all have a common goal, which is to cripple a measure that Senator Ted Cruz, a Texas Republican and leader of the defunding effort, has likened to a horror movie.

 

 

We view this as a long-term effort,” said Tim Phillips, the president of Americans for Prosperity. He said his group expected to spend “tens of millions” of dollars on a “multifront effort” that includes working to prevent states from expanding Medicaid under the law. The group’s goal is not to defund the law.

“We want to see this law repealed,” Mr. Phillips said

------

..... In the three years since Mr. Obama signed the health measure, Tea Party-inspired groups have mobilized, aided by a financing network that continues to grow, both in its complexity and the sheer amount of money that flows through it.

A review of tax records, campaign finance reports and corporate filings shows that hundreds of millions of dollars have been raised and spent since 2012 by organizations, many of them loosely connected, leading opposition to the measure.

One of the biggest sources of conservative money is Freedom Partners, a tax-exempt “business league” that claims more than 200 members, each of whom pays at least $100,000 in dues. The group’s board is headed by a longtime executive of Koch Industries, the conglomerate run by the Koch brothers, who were among the original financiers of the Tea Party movement. The Kochs declined to comment.

------

In the fight to shape public opinion, conservatives face well-organized liberal foes. Enroll America, a nonprofit group allied with the Obama White House, is waging a campaign to persuade millions of the uninsured to buy coverage. The law’s supporters are also getting huge assistance from the insurance industry, which is expected to spend $1 billion on advertising to help sell its plans on the exchanges.

 

“It is David versus Goliath,” said Mr. Phillips of Americans for Prosperity.

-----

“I think people realized that with the imminent beginning of Obamacare, that this was a critical time to make every effort to stop something,” Mr. Meese said in an interview. (He has since stepped down as the coalition’s chairman and has been succeeded by David McIntosh, a former congressman from Indiana.)

The defunding idea, Mr. Meese said, was “a logical strategy.” The idea drew broad support. Fiscal conservatives like Chris Chocola, the president of the Club for Growth, signed on to the blueprint. So did social and religious conservatives, like the Rev. Lou Sheldon of the Traditional Values Coalition.

The document set a target date: March 27, when a continuing resolution allowing the government to function was to expire. Its message was direct: “Conservatives should not approve a C.R. unless it defunds Obamacare.”

But the March date came and went without a defunding struggle. In the Senate, Mr. Cruz and Senator Mike Lee, a Utah Republican, talked up the defunding idea, but it went nowhere in the Democratic-controlled chamber. In the House, Mr. Boehner wanted to concentrate instead on locking in the across-the-board budget cuts known as sequestration, and Tea Party lawmakers followed his lead. Outside advocates were unhappy but held their fire.

“We didn’t cause any trouble,” Mr. Chocola said.

Yet by summer, with an August recess looming and another temporary spending bill expiring at the end of September, the groups were done waiting.

-----

When Senator Richard M. Burr, a North Carolina Republican, told a reporter that defunding the law was “the dumbest idea I’ve ever heard,” the fund bought a radio ad to attack him. Two other Republican senators up for re-election in 2014, Lamar Alexander of Tennessee and Lindsey Graham of South Carolina, were also targeted. Both face Tea Party challengers.

Millions of Poor Are Left Uncovered by Health Law

Claretha Briscoe, left, of Hollandale, Miss., with family. She earns too much to qualify for Medicaid but not enough to get subsidies on the new health exchange.


N.Y. TIMES

A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.

Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.

People shopping for insurance on the health exchanges are already discovering this bitter twist.

 

Gladys Arbila of Houston with her son, Christian Vera. Texas chose not to expand the Medicaid program, so Ms. Arbila does not qualify for it or for new federal insurance subsidies.
----
The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.
-----
The disproportionate impact on poor blacks introduces the prickly issue of race into the already politically charged atmosphere around the health care law. Race was rarely, if ever, mentioned in the state-level debates about the Medicaid expansion. But the issue courses just below the surface, civil rights leaders say, pointing to the pattern of exclusion.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion. Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.

In Mississippi, Republican leaders note that a large share of people in the state are on Medicaid already, and that, with an expansion, about a third of the state would have been insured through the program. Even supporters of the health law say that eventually covering 10 percent of that cost would have been onerous for a predominantly rural state with a modest tax base.

“Any additional cost in Medicaid is going to be too much,” said State Senator Chris McDaniel, a Republican, who opposes expansion.

The law was written to require all Americans to have health coverage. For lower and middle-income earners, there are subsidies on the new health exchanges to help them afford insurance. An expanded Medicaid program was intended to cover the poorest. In all, about 30 million uninsured Americans were to have become eligible for financial help.
------
Poor people excluded from the Medicaid expansion will not be subject to fines for lacking coverage. In all, about 14 million eligible Americans are uninsured and living in poverty, the Times analysis found.       

The federal government provided the tally of how many states were not expanding Medicaid for the first time on Tuesday. It included states like New Hampshire, Ohio, Pennsylvania and Tennessee that might still decide to expand Medicaid before coverage takes effect in January. If those states go forward, the number would change, but the trends that emerged in the analysis would be similar.

 

Mississippi has the largest percentage of poor and uninsured people in the country — 13 percent. Willie Charles Carter, an unemployed 53-year-old whose most recent job was as a maintenance worker at a public school, has had problems with his leg since surgery last year.

His income is below Mississippi’s ceiling for Medicaid — which is about $3,000 a year — but he has no dependent children, so he does not qualify. And his income is too low to make him eligible for subsidies on the federal health exchange.

“You got to be almost dead before you can get Medicaid in Mississippi,” he said.

He does not know what he will do when the clinic where he goes for medical care, the Good Samaritan Health Center in Greenville, closes next month because of lack of funding.

-----

Blacks are disproportionately affected, largely because more of them are poor and living in Southern states. In all, 6 out of 10 blacks live in the states not expanding Medicaid. In Mississippi, 56 percent of all poor and uninsured adults are black, though they account for just 38 percent of the population.

Dr. Aaron Shirley, a physician who has worked for better health care for blacks in Mississippi, said that the history of segregation and violence against blacks still informs the way people see one another, particularly in the South, making some whites reluctant to support programs that they believe benefit blacks.

 

Dr. Shirley said: “If you look at the history of Mississippi, politicians have used race to oppose minimum wage, Head Start, all these social programs. It’s a tactic that appeals to people who would rather suffer themselves than see a black person benefit.”

 

Where Poor and Uninsured Americans Live

The 26 Republican-dominated states not participating in an expansion of Medicaid are home to a disproportionate share of the nation’s poorest uninsured residents. Eight million will be stranded without insurance.  

 

LEECHING MEDICAID

NY TIMES

The White House is encouraging skeptical state officials to expand Medicaid by subsidizing the purchase of private insurance for low-income people, even though that approach might be somewhat more expensive, federal and state officials say.

Ohio and Arkansas are negotiating with the Obama administration over plans to use federal Medicaid money to pay premiums for commercial insurance that will be sold to the public in regulated markets known as insurance exchanges.

Republicans in other states, including Florida, Louisiana, Pennsylvania and Texas, have expressed interest in the option since Gov. Mike Beebe of Arkansas, a Democrat, received a green light from Kathleen Sebelius, the federal secretary of health and human services.

Valerie Jarrett, a top White House aide, has been a catalyst in talks with Ohio and other states.

The idea of using “premium assistance” to buy private insurance for new Medicaid beneficiaries is a sharp departure from the 2010 health care law, in which Congress expanded Medicaid to cover the poorest Americans and assumed that people with higher incomes would obtain private coverage through the exchanges.

In many states, Republicans are trying to create a hybrid of the two alternatives, taking federal money for the expansion of Medicaid but using it to help people buy commercial insurance instead.

State Senator Jonathan Dismang, a Republican from central Arkansas, said the idea appealed to him because it would “use the markets to provide better health care and to increase competition in the health insurance industry,” which could drive down costs.

[ Esco: The above news report is in today's paper. This is a case tho, where to learn the truth, you do want yesterday's paper. Or, to be exact, the paper of March 3, 2013 (below):

KRUGMAN NY TIMES

Conservatives like to say that their position is all about economic freedom, and hence making government’s role in general, and government spending in particular, as small as possible. And no doubt there are individual conservatives who really have such idealistic motives.

When it comes to conservatives with actual power, however, there’s an alternative, more cynical view of their motivations — namely, that it’s all about comforting the comfortable and afflicting the afflicted, about giving more to those who already have a lot. And if you want a strong piece of evidence in favor of that cynical view, look at the current state of play over Medicaid.

Some background: Medicaid, which provides health insurance to lower-income Americans, is a highly successful program that’s about to get bigger, because an expansion of Medicaid is one key piece of the Affordable Care Act, a k a Obamacare.

 

There is, however, a catch. Last year’s Supreme Court decision upholding Obamacare also opened a loophole that lets states turn down the Medicaid expansion if they choose. And there has been a lot of tough talk from Republican governors about standing firm against the terrible, tyrannical notion of helping the uninsured.

Now, in the end most states will probably go along with the expansion because of the huge financial incentives: the federal government will pay the full cost of the expansion for the first three years, and the additional spending will benefit hospitals and doctors as well as patients. Still, some of the states grudgingly allowing the federal government to help their neediest citizens are placing a condition on this aid, insisting that it must be run through private insurance companies. And that tells you a lot about what conservative politicians really want.

Consider the case of Florida, whose governor, Rick Scott, made his personal fortune in the health industry. At one point, by the way, the company he built pleaded guilty to criminal charges, and paid $1.7 billion in fines related to Medicare fraud. Anyway, Mr. Scott got elected as a fierce opponent of Obamacare, and Florida participated in the suit asking the Supreme Court to declare the whole plan unconstitutional. Nonetheless, Mr. Scott recently shocked Tea Party activists by announcing his support for the Medicaid expansion.

But his support came with a condition: he was willing to cover more of the uninsured only after receiving a waiver that would let him run Medicaid through private insurance companies. Now, why would he want to do that?

Don’t tell me about free markets. This is all about spending taxpayer money, and the question is whether that money should be spent directly to help people or run through a set of private middlemen.

And despite some feeble claims to the contrary, privatizing Medicaid will end up requiring more, not less, government spending, because there’s overwhelming evidence that Medicaid is much cheaper than private insurance. Partly this reflects lower administrative costs, because Medicaid neither advertises nor spends money trying to avoid covering people. But a lot of it reflects the government’s bargaining power, its ability to prevent price gouging by hospitals, drug companies and other parts of the medical-industrial complex.

For there is a lot of price-gouging in health care — a fact long known to health care economists but documented especially graphically in a recent article in Time magazine. As Steven Brill, the article’s author, points out, individuals seeking health care can face incredible costs, and even large private insurance companies have limited ability to control profiteering by providers. Medicare does much better, and although Mr. Brill doesn’t point this out, Medicaid — which has greater ability to say no — seems to do better still.

You might ask why, in that case, much of Obamacare will run through private insurers. The answer is, raw political power. Letting the medical-industrial complex continue to get away with a lot of overcharging was, in effect, a price President Obama had to pay to get health reform passed. And since the reward was that tens of millions more Americans would gain insurance, it was a price worth paying.

 

But why would you insist on privatizing a health program that is already public, and that does a much better job than the private sector of controlling costs? The answer is pretty obvious: the flip side of higher taxpayer costs is higher medical-industry profits.

So ignore all the talk about too much government spending and too much aid to moochers who don’t deserve it. As long as the spending ends up lining the right pockets, and the undeserving beneficiaries of public largess are politically connected corporations, conservatives with actual power seem to like Big Government just fine.