Dollars, Cents and Republican Sadism

Posted January 11, 2018 9:37 p.m. EST

Democrats want to strengthen the social safety net; Republicans want to weaken it. But why?

GOP opposition to programs helping the less fortunate, from food stamps to Medicaid, is usually framed in monetary terms. For example, Sen. Orrin Hatch, challenged about Congress’ failure to take action on the Children’s Health Insurance Program, a part of Medicaid that covers nearly 9 million children — and whose federal funding expired back in September — declared that “the reason CHIP’s having trouble is that we don’t have money anymore.”

But is it really about the money? No, it’s about the cruelty. Over the past few years it has become increasingly clear that the suffering imposed by Republican opposition to safety-net programs isn’t a bug, it’s a feature. Inflicting pain is the point.

To see what I mean, consider three stories about health care policies.

First, there’s the saga of Medicaid expansion under the Affordable Care Act. The Supreme Court allowed states to opt out of this expansion. But accepting expansion should have been a no-brainer for every state: The federal government would initially pay the full cost, and even in the long run it would pay 90 percent, meanwhile bringing money and jobs into state economies.

Yet 18 states — all of them with Republican-controlled legislatures, governors or both — still haven’t expanded Medicaid. Why?

For a while you could argue that it was about cynical political strategy: Medicaid expansion was a policy of Barack Obama, and Republicans didn’t want to give a Democratic president any policy successes. But that story can’t explain states’ continuing resistance to the idea of providing health coverage to thousands of their own citizens at minimal cost.

No, at this point it’s clear that GOP politicians simply don’t want lower-income families to have access to health care and are actually willing to hurt their own states’ economies to deny them that access.

Second, there’s the issue of work requirements for Medicaid. Some states have been petitioning for years for the right to force Medicaid recipients to take jobs, and this week the Trump administration declared that it would allow them to do so. But what was driving this demand?

The reality is that a vast majority of adult Medicaid recipients are in families where at least one adult is working. And a vast majority of those who aren’t working have very good reasons for not being in the labor force: They’re disabled, they’re caregivers to other family members or they’re students. The population of Medicaid recipients who “ought” to be working but aren’t is very small, and the money that states could save by denying them coverage is trivial.

Oh, and of the 10 states reportedly seeking to impose work requirements, six have accepted the ACA Medicaid expansion, which means that most of the money they could save by kicking people off would be federal, not state, dollars. So what’s this about?

The answer, surely, is that it isn’t about saving money, it’s about stigmatizing those who receive government aid, forcing them to jump through hoops to prove their neediness. Again, the pain is the point.

Finally, there’s the case of children’s health insurance. Again, federal funding expired back in September, and millions of children will lose coverage soon if that funding isn’t restored. So what will it cost the Treasury if Congress does what it should have done months ago, and restores funding? The answer, according to the Congressional Budget Office, is — nothing. Or actually less than nothing. In fact, a 10-year extension of CHIP funding would save the government $6 billion.

How is this possible, given the roughly $14 billion a year CHIP currently spends on health? The key point, laid out in a budget office analysis a few months ago, is that many (but not all) families whose children are currently covered by CHIP could alternatively be covered by subsidized private insurance through the Obamacare exchanges.

Private insurance is, however, considerably more expensive than Medicaid, which uses its bargaining power to hold down costs. (The cost of private insurance has gone up even further now that Republicans have repealed the individual mandate, worsening the risk pool.) As a result, subsidies for private insurance would end up costing more than the direct coverage children currently get through CHIP.

And don’t imagine that, because many children thrown off CHIP would find alternative sources of coverage, the kids would be alright. For one thing, a significant number wouldn’t get covered: The number of uninsured kids would rise substantially. Furthermore, private insurance, which often involves large out-of-pocket expenses, is much worse than CHIP for lower-income families.

So Republican foot-dragging on CHIP, like opposition to Medicaid expansion and the demand for work requirements, isn’t about the money, it’s about the cruelty. Making lower-income Americans worse off has become a goal in itself for the modern GOP, a goal the party is actually willing to spend money and increase deficits to achieve.

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