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Jay Rockefeller
Sen. Jay Rockefeller (Reuters)

Sen. Jay Rockefeller (D-WV) is worried about Medicaid, and with good reason. He explained last week to Ezra Klein.
"The safer Medicare is, the more endangered Medicaid is," sighs Sen. Jay Rockefeller. "Reading the tea leaves and being in a lot of meetings over the last couple of days, I worry that people are saying, ‘great, now we can really cut into Medicaid.' "

That shouldn't be the case. Medicaid is a bigger program than Medicare, serving more than 50 million people, to Medicare's 48 million. Nor does it poll substantially worse. A recent Kaiser tracking poll found that 88 percent of Americans wanted either no reduction or small reductions in Medicare funding. At 83 percent, Medicaid was close on its heels. And given those poll numbers, both programs should be bulletproof....

So Rockefeller, the chairman of the Senate Finance Committee's Subcommittee on Health Care, is trying to make some noise. Earlier today, he sent the administration a letter signed by 37 Democrats opposing the Republican budget's changes to the program. Four other Democrats sent their own letter. That makes 41—a filibuster-proof block. "That'll surprise people," he says. "Now, signing a letter is easier than casting a vote. But in government, if you float something out there and people don't say much, people mistake that for acquiescence. I think this is getting to be the time where people are going to start fighting back."

He's got reason to be concerned about Medicaid, even within his own caucus, despite the fact that 41 of his colleagues signed onto that letter to the White House. While he has, for now, enough to block cuts, that support could have some weaknesses.

They may have reason to worry. Some of the Democrats who didn't sign a letter aren't exactly voicing rock-solid opposition to Medicaid block grants, and at least one—Joe Manchin of West Virginia—is suggesting he could support them.

"The good news is that there are 41 people" who signed the letters, one Medicaid advocate told POLITICO. "The bad news is it took them a long time to get there, and it took a lot of effort to get them there."


The filibuster-proof 41 signatures prove that a large-scale Medicaid overhaul is not likely to pass. But a close look at the letters shows the program is vulnerable to other changes.

The letter doesn't mention Republican attempts to repeal Medicaid's maintenance of effort provisions, which bar states from paring back Medicaid eligibility standards. If such a vote were to come up in the Senate—or in budget talks—it may be a difficult proposal for some moderate Democrats from budget-strapped states who are up for reelection in 2012.

"It's definitely noteworthy," the Medicaid advocate said. "MOE is a little more controversial.… I think they didn't put it on there for a reason. It would have been harder to get 41 signatures."


The absence of 11 Senate Democrats and Connecticut independent Joe Lieberman from the letters is another noteworthy omission.

The list of Democratic senators who didn't sign onto the Medicaid letters includes a few heavyweights, such as Majority Leader Harry Reid, Senate Finance Committee Chairman Max Baucus of Montana and Budget Committee Chairman Kent Conrad of North Dakota. Spokesmen for their offices did not return requests for comment, but advocates believe the top senators stayed out of the Medicaid fray because of their involvement with budget negotiations.

The White House has strongly defended Medicaid against the Republicans' block grant program included in their budget, but this less-than-absolute support for not making other cuts to the program could make it easier for the Biden negotiations to slide on it.

Which would be counterproductive, from a budget perspective. Medicaid is an extremely efficient and cheap (for healthcare delivery) system. Eroding it will not only potentially hurt the million of participants in the program, but undercut implementation of the Affordable Care Act.

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Comment Preferences

  •  The healthcare system in this country is crazy (17+ / 0-)

    Low income/kids = Medicaid
    Not low income/kid/65 = Private health insurance
    65+ = Medicare

    Just expand medicare to every person in the country. This expansion would absorb medicaid and wipe out most of the private health insurance with their 20-30% overhead.

  •  Oh yes. Medicaid is definitely going on (10+ / 0-)

    the chopping block, for sure. Who is going to defend it?

    Medicare will come out unscathed from these negotiations, but you can put down pretty sure money that Medicaid is headed for the grim reaper. Right in the middle of a vicious recession. Right when people need it most.

    Hooray for negotiations.

    •  And the DC Dems will be the ones to offer it up (1+ / 0-)

      per he budget cuts "negotiations."

      Step One:  Rs demand fundamentally altering/eviscerating Medicare and SS.  

      Step Two:  Dems offer up radical changes to Medicare to keep Rs quiet.

      Step Three:  Rs say nothing.

      Step Four:  Dems offer up more cuts to ensure continued silence, thinking, "Wow!  We won!  This process really works!!  And we're really good at it!"

      LaFeminista's Overton diary is timely, apt, and should be required reading by Dems.  (Rs already have it down.)

      "Dega dega dega dega. Break up the concrete..." The Pretenders

      by Terra Mystica on Tue Jun 14, 2011 at 02:31:09 PM PDT

      [ Parent ]

    •  Elderly Facing Nursing Home Need (2+ / 0-)
      Recommended by:
      CherryTheTart, NCPSSM

      and their families.

      Same folks who put Medicare out of harm's way.  They may not be there now,  but I guarantee they know someone who has.  

      Over 40% of people over 65 will end up needing nursing home care sometime during their lifetime even more will need some kind of long term care (including home and community based services like assisted living facility or home health nursing).  

      The elderly in raw numbers make up only 10% of Medicaid reciplients  but account for 25% of the costs.

      The disabled make up only 15% of recipients but account for 42% of the cost.

      Low income adults below 65 make up 25% by the numbers but only 12% of the cost.

      A small group, 5% of recipients, account for over 50% of the costs.

      Medicaid pays for 7 out of 10 nursing home residents and 43% of all long term care including home and community based alternatives.  

      Private insurance pays less than 1% of nursing home care.

      Some studies estimate that cash out of pocket (ie uninsured and not yet poor enough to qualify for Medicaid) already pays for up to 37% of nursing home costs.  

      Since the recession, over 7 million more people have enrolled in Medicaid.  The recession and collapse in value of many retirement accounts and house values has and will disproportionatly impact the elderly who were on the cusp of selling their home and moving into a long term care facility (voluntarily or driven by need.)

      State flexibility is another term for ability to use federal Medicaid dollars to subisdize their state's general fund and avoid the need to live within their own state's means.  

      The federal financing of this program already pays a greater share (Federal Financial Participation) in states with lower average incomes.  It varies from a minimum of 50% up to 75%.  

      The 2009 Stimulus (ARRA) bailed out States by picking up a greater share of that financing on the condition that States not take the money and run by taking the money but cutting back on services ("maintenance of effort" requirements.)  That's now gone or going away.  

      The 2014 expansion of Medicaid, making the poverty level from well below the national poverty threshold and increasing the coverage to those 1/3 above that income threshold was also conditioned on that same prudent principle.  (Much of the cost of that expansion is picked up by the federal financing.)

      If the FFP match was included as part of the Block Grant program, States with FFP of 66% (Hi There Red States) and higher would lose $2 in federal money for every $1 cut in State spending.  Block grants would likely allow them to cut state spending without experiencing that leveraging affect.

      If we, all of us, as federal tax payers are going to help fund this program, we have a right to know it is meeting basic standards in quality, coverage and integrity.  

      If, by removing these safeguards as part of a magic "Block Grant" approach, the GOP predicts massive savings, where are those savings coming from?  

      Ingenuity and flexibility are not the magic wands the GOP would like to pretend.  

      The 'savings' will come not from fat but from meat and bone as both coverage and quality are cut to squeeze within the available money.

      Are we going to allow States to keep additional Federal money while cutting back on the programs they offered to be eligible for that level of Block Grant?

      If a State had included all available options under Medicaid services in 2007, takes all the enhance revenue from the Federal government but cuts back its services covered to the bare mininimum currently covered or some even more austere level allowed under the Republican proposal, how is that fair?

      Can states cut back their services but still get the same level of federal money, shifting the money to cover other budget needs not within the Medicaid program?   By doing so, will we be cross-subsidizing their other state expenditures and allowing them to avoid the "evil" of tax increases on their state citizens?  

      Given the Republican aversion to "entitlement" programs, will the States be able to cap the number of days (or $) that any nursing home resident is allowed under Medicaid? Will nursing home residents face eviction (discharge) once they've hit their State Limit Of Care?  (Or as implied in Ryan's version of The Road, be encouraged to get out of their welfare hammock and get a job?)

      If you're confident that State's would handle this new freedom and "flexibility" in a prudent and compassionate manner, you've been absent from this past year's budget hearings in state capitals around the Country.  

      As a Federal Taxpayer, I have no interest in funding the "no new taxes pledges" of red states already getting a disproportionate share of the federal funding under this program because of their lower average income per capita.  

      The Kaiser Foundation has some excellent resources on this issue (and many others) here:

      House Republican Budget Plan: State-By-State Impact of Changes in Medicaid Financing  (Includes a State-by-State comparison of current law including ObamaCare (ACA) vs the Ryan/GOP Budget plan and current law with ObamaCare (ACA) repealed. - Table 1 - Pg 14/20)

      Top 5 Things To Know About Medicaid


      Implications Of A Federal Block Grant Program For Medicaid

      Medicaid and Block Grant Financing Compared - Issue Brief - 2004

      Federal Dollars and State Flexibility: The Debate Over Medicaid's Future - 1995

      Here's a quick primer for those still trying to figure out which is MediCARE and which is MediCAID.

      Medicare and Long-Term Care:
      While there are a variety of ways to pay for long-term care, it is important to think ahead about how you will fund the care you get. Generally, Medicare doesn’t pay for long-term care. Medicare pays only for medically necessary skilled nursing facility or home health care. However, you must meet certain conditions for Medicare to pay for these types of care. Most long-term care is to assist people with support services such as activities of daily living like dressing, bathing, and using the bathroom. Medicare doesn’t pay for this type of care called "custodial care". Custodial care (non-skilled care) is care that helps you with activities of daily living. It may also include care that most people do for themselves, for example, diabetes monitoring. Some Medicare Advantage Plans (formerly Medicare + Choice) may offer limited skilled nursing facility and home care (skilled care) coverage if the care is medically necessary. You may have to pay some of the costs. For more information about Medicare Advantage Plans, look at the Medicare Personal Plan Finder.

      Medicaid and Long-Term Care:
      Medicaid is a State and Federal Government program that pays for certain health services and nursing home care for older people with low incomes and limited assets. In most states, Medicaid also pays for some long-term care services at home and in the community. Who is eligible and what services are covered vary from state to state. Most often, eligibility is based on your income and personal resources.

      We'd rather dream the American Dream than fight to live it or to give it to our kids. What a shame. What an awful, awful shame.

      by Into The Woods on Tue Jun 14, 2011 at 04:53:25 PM PDT

      [ Parent ]

  •  Joe Manchin? (8+ / 0-)

    He's a died in the wool corporate tool.  Don't every expect anything from him....and you won't be disappointed.  

  •  What isn't in danger (13+ / 0-)

    with "moderate" Democrats?  Let's face it. The corporatists have 1.5 parties, the American people something less than half a party...

    The ability to face this truth is a critical dividing line among Democrats and progressives.

    Whom do you blame more? The rattlesnake, or the bipartisan guy who put it in your sleeping bag?

    by chuckvw on Tue Jun 14, 2011 at 02:01:43 PM PDT

  •  Ugh (13+ / 0-)

    Medicaid is already too close to apartheid medicine in most states.  Payment rates are very low, so many providers don't come near it.  A lot of states, like mine, have outsourced their Medicaid programs to companies that operate it at a profit, further reducing available money.  And trying to take care of Medicaid patients is very frustrating in a private practice because of all the restrictions and exclusions that apply.  It makes private insurance almost look sane.

    And I've practiced in states with relatively good Medicaid programs.  In other states it's almost impossible to get and the next worst thing to worthless.  Medicaid is in tough shape already, and if it's cut further it'll only get worse.   We need an universal health care program, not a patchwork of smaller programs that can be pecked to death by the corporatists.  When, oh when, will politicians find the spine to reopen that debate?

    DC politicians don't realize they're corrupt for the same reason fish don't realize they're wet.

    by Dallasdoc on Tue Jun 14, 2011 at 02:02:56 PM PDT

    •  Our Governor Skeletor here in FL, and the evil (2+ / 0-)
      Recommended by:
      Dallasdoc, CherryTheTart

      WRONG shits that dominate our legislature with a nearly totally silent Dem minority, are pushing to have all Medicaid stuck into the already demonstrably failed form of "HMOs." Which of course will include Solantic, the Skeletor's Palace Fizzicians, and as far as I can tell the evil little shit has not even done what he said he was going to do, divest himself and his lovely wife of that massive conflict of interest/latest ripoff of public funds, so that state employees are forced to undergo random drug testing and all "welfare recipients," that lovely code phrase, will have to pay for drug testing out of their own pockets.

      It's almost getting too much to bear -- Too bad Canadians are happy to come to FL and thaw out, but they don't want 'Muricans going in the other direction unless they bring lots of money and special skills. Sort of sounds like Arizona, which of course has none of the other "socialist detractions."

      "Is that all there is?" Peggy Lee.

      by jm214 on Tue Jun 14, 2011 at 04:18:17 PM PDT

      [ Parent ]

  •  millionaires in Congress should not get to vote (5+ / 0-)

    if they have no idea how hard it is to be poor why should millionaires in Congress get to vote on cutting benefits to the poor?

  •  I used to have trouble remembering the names (10+ / 0-)

    of the programs:  which was Medicaid and which was Medicare.     My sweetie gave me a mnemonic:  MedicAID is for poor people who are unpopular because theye need AID.  MediCARE is for old people and we CARE about old people because they vote.

    "The extinction of the human race will come from its inability to EMOTIONALLY comprehend the exponential function." -- Edward Teller

    by lgmcp on Tue Jun 14, 2011 at 02:21:37 PM PDT

  •  OFFS, all this noise about poor people (2+ / 0-)
    Recommended by:
    evangeline135, jm214

    C'mon now, really, who gives a damn about poor people? I mean, they're such a drag on the tax base.

    Only 41 Democratic signees.

  •  if the block grant thing (2+ / 0-)

    becomes a real possibility, the medical industry is going to revolt against it big time.  medicaid is the only way thay get reimbursed at the hospital for a large number of their patients.

  •  So send Rockefeller a message (2+ / 0-)
    Recommended by:
    jm214, CherryTheTart

     Tell him that you will help.  If we only talk to ourselves in an echo chamber, we will only have ourselves to blame.

      History shows that GOP have always attacked on the fringes and Medicaid recipients won't know they are being attacked until it is too late.  

  •  Anybody know where the letter is? (0+ / 0-)

    I'd like to call my senators and thank them if they signed (I'm sure Al Franken did) and berate them if they didn't (I wouldn't be surprised if Amy Klobuchar didn't - because somebody somewhere might get a little bit upset about it).  

    •  Found it (0+ / 0-)

      Main Letter

      And yep, Al signed it, and nope, Amy didn't.  My God, she's a worthless sack of crap.

      Even Tester signed it.  

      •  She Sent Her Own Letter. (1+ / 0-)
        Recommended by:
        Senators co-signing the Rockefeller letter were Patrick Leahy, Kirsten E. Gillibrand, John F. Kerry, Daniel K. Inouye, Daniel K. Akaka, Barbara A. Mikulski, Benjamin L. Cardin, Barbara Boxer, Jeff Bingaman, Al Franken, Mary L. Landrieu, Sherrod Brown, Jeff Merkley, Robert Menendez, Frank R. Lautenberg, Charles E. Schumer, Debbie Stabenow, Sheldon Whitehouse, Robert P. Casey, Jr., Jack Reed, Maria Cantwell, Patty Murray, Tim Johnson, Richard Blumenthal, Ron Wyden, Bernard Sanders, Bill Nelson, Mark Begich, Christopher A. Coons, Richard J. Durbin, Jeanne Shaheen, Tom Harkin, Jon Tester, Herb Kohl, Carl Levin and Tom Udall.

        Sens. Dianne Feinstein, Mark Udall, Michael Bennet, and Amy Klobuchar sent separate letters.

        I cannot find the text of that letter and would certainly like to see what it says.

        We'd rather dream the American Dream than fight to live it or to give it to our kids. What a shame. What an awful, awful shame.

        by Into The Woods on Tue Jun 14, 2011 at 05:12:22 PM PDT

        [ Parent ]

  •  This is potentially bigger for (2+ / 0-)
    Recommended by:
    millwood, Into The Woods

    middle income voters than Medicare. Nursing home care for elderly parents ends up being financed by Medicaid once private funds run out.  I doubt if people are going to want to provide home care for their relatives.  Also, the nursing home lobby is likely to do some major squawking over anything that threatens their reinbursement.

    "Forever is composed of nows." Emily Dickinson

    by Leftovers on Tue Jun 14, 2011 at 04:08:50 PM PDT

  •  Democrats have cut $500B. Plan to cut $200B more. (0+ / 0-)

    For Rockefeller, Reid, Obama to pretend they are not leading the charge to cut Medicare/Medicaid is simply a lie.

    CBO Cost Estimate of HR4872, Reconcilation Act of 2010 (Final Health Care Legislation).  Table 2. Shows cuts to Medicare/Medicaid of $455B over 10 years.

    CBO's estimate for Obama current 2012 budget is another $210B in reductions on Medicare/Medicaid spending.

    These cuts from Obama, Rockefeller and Reid are on top of decades of Reagan, Bush and Bush cuts the point that Medicare coverage (or lack of it) is leading cause of bankruptcy in elderly.  Medicare requires payments by elderly plus 20% of all bills which quickly depletes assets, if any.  With home prices tanking, the leading investment for older American's is gone.

    What US needs is a $1T spending increases for Medicare/Medicaid and cancellation of Obamacare which will cut $500B over next 10 years.  Medicare needs to cover 100% of of 65 health care costs. And this needs to be done at the Federal level to take the cost burden off of states which are bankrupt from Wall St fraud on investments and real estate.

  •  Poor people's lives - worthless to DC (0+ / 0-)

    The elite in DC don't consider poor people human and deserving of health care.

    "It's better to die on your feet then live on your knees" E. Zapata

    by Blutodog on Tue Jun 14, 2011 at 07:14:51 PM PDT

  •  The political class (0+ / 0-)

    in America could give a rat's ass about people who need help. And yes that includes a nice chunk of Democrats. If it weren't for republicans ... Oh what the hell I'm disgusted with them all.

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