Point Austin: Fed Up Yet?

What will the new Republican dispensation look like?

We got some strong early hints last weekend, as Gov. Rick Perry and house speaker wannabe Warren Chisum each fired shots across the bow of Medicaid, the joint federal-state program that – just for starters – provides health care to 3.6 million Texas children. On Saturday, Chisum bluntly told the Texas Tribune: "This system is bankrupting our state. We need to get out of it. And with the budget shortfall we're anticipating, we may have to act this year." The next morning, CNN's Candy Crowley cited Perry's new book, Fed Up!: Our Fight To Save America From Washington, in which he suggests dropping out of both Medicaid and the Child­ren's Health Insurance Program, and asked what would happen to those children. Perry answered, "We would create our own insurance program for them." An incredulous Crowley pointed out: "But the [federal] government gives you 60 percent of the money to fund this. How does that add up to help you?"

Perry blustered something about somehow getting the money anyway, and that ended the policy analysis. He was sharing the CNN limelight with Minnesota Gov. Tim "I-am-too-Presidential" Pawlenty and playing the sound-bite-based "Who can fearmonger 'Obamacare' more?" game. Pawlenty won on points, calling it "one of the worst pieces of legislation passed ... in modern history."

As for Perry and Chisum, with the legislative session still two months off, it's easy enough to wave this red meat and hope everybody forgets it by January. Apparently, a year ago – before the new federal health care law was even in final form – the Heritage Foundation issued a brief screed claiming Texas could "save" $60 billion by 2019 if it dropped out of Medicaid and CHIP (the Tribune repeated that nonsense without a trace of skepticism). When Her­it­age-hired wonks sneeze, GOP pols catch cold, so now some of the loopier members are sharpening their axes to cut $18 billion from the Texas budget (and economy). That's what Med­ic­aid spends here, with another billion or so for CHIP.

Indeed, currently 61% of that Texas Medicaid – or roughly $11 billion – is federal money. As my father-in-law likes to say, "Walk down the street and see who gives you $11 billion."

Throw Momma From the Home

Even setting aside the raw economics, the politics of walking out on Medicaid would be a real GOP buzzkill. I asked Anne Dunkelberg of the Center for Public Policy Priorities to consider the actual shape of what these bozos are contemplating. Before getting into specifics, she noted at the outset that it would take yet another massive revision in federal health care law even to enable such a withdrawal. Yet Medicaid is an easy target (unlike the politically popular Medicare), because it's wrongly imagined as only helping "poor people."

Dunkelberg countered with some imposing statistics: "Seven out of 10 nursing home residents in Texas are paid for by Medicaid. Virtually 100 percent of Texans who have serious disabilities ... if they're living in some kind of institutional setting ... that's being paid for by Texas Medicaid. About 55 percent of the babies born in Texas are paid for by Medicaid, and about a third of our children are covered, between Medicaid and CHIP." Start adding up those categories, and pretty soon you've got a constituency even the House Conser­vat­ive Caucus can't ignore.

Writing in Michael Tomasky's blog at the Guardian, University of Chicago health care expert Harold Pollack followed the money. "Almost 60% of Texas Medicaid dollars cover services to the elderly or the disabled," he wrote, so public reaction to any withdrawal might well include "surprising numbers of angry Good ol' Boys asking what the hell happened to the nursing homes and visiting nurse agencies that help their elderly parents, or why their cousin's autistic child suddenly can't get services through his local school."

Predictable Consequences

Perry and his allies like to pretend that the state can do what Medicaid does more cheaply, or that the entire system can be "privatized." Dunkelberg notes that thanks to Republican policymakers, Republican doctors complain that Medicaid payment schedules are already too low – "Medicaid pays providers the least," she said, "Medicare next, and then private insurance. ... The bottom line is, there's no easy way out of figuring out how to deal with people with the most serious disabilities, our oldest and frailest and poorest, our infants, and people over 65 who aren't able to pay for Medi­care." Not to worry – I'm sure those libertarian geniuses at the Heritage Foundation have that imaginary arithmetic all figured out.

The new federal health care law (if the GOP doesn't screw it up or defund it) will in fact bring more money to Texas, Pollack notes, precisely because Texas has so many uninsured poor people, for whom we're all now paying at emergency rooms. "The feds will pay virtually the entire tab for people made newly eligible for Medicaid through health care reform," fully covering people up to 130% of the poverty line. By contrast, a walkout would yank billions out of the Texas economy. Pollack again: "Perhaps the only predictable consequence would be to provoke a determined backlash from some of the most organized and well-funded constituencies in America: nursing home operators, advocacy groups for the physically and intellectually disabled, and many more. The macroeconomic consequences for Texas of rejecting more than $10 billion per year in federal aid would be significant, too."

Dunkelberg is a charitable person and suggested that these latest GOP proposals simply reflect a widespread political panic at exploding U.S. health care costs and the consequent longing for a "magic wand" that will somehow make medical care inexpensive. She also acknowledged that the headline feelers anticipate the kind of extreme views we're likely to see in the upcoming legislative session. "I think people need to understand," she said, "that this is as extreme a proposal as getting rid of Medicare."

I'm not so charitable, and I believe that the Republican politicians advocating this extrem­ism – Pawlenty, Perry, Chisum, and many others – are fully aware of the actual consequences and are simply pandering to the meanest possible impulses in the voting public, to the know-nothings who consider public health care insidious "socialism," and to those who believe that if there are many millions of people who can't pay for health care out of their own pockets, it's just too damn bad.

"If that is in fact your position, then you need to say it like that, out loud," said Dunk­el­berg. "If that is your feeling, if that is your belief how public policy should work, then what you are saying is, 'I really think it would be better if all poor people just didn't have access to health care.' That's the outcome."

Memo to Gov. Fed Up: Say it in plain Eng­lish, so everybody knows who you are.