Who Is Medicaid For?

There's a lot of Beltway chatter these days about block-granting Medicaid, a longtime Republican dream. In theory, block granting is simple: instead of covering a certain percentage of each state's Medicaid spending, states are all given a simple grant of money for Medicaid, which they can spend as they choose. They can add to it, they can redistribute it, they can create innovative programs, or do anything else they want. There are usually a few restrictions on where the money can go, but not too many.

Why are Republicans so gung-ho on block grants? The official answer is that they don't think Washington should be telling states how to spend their money. Instead, they want to let a thousand flowers bloom as our laboratories of democracy experiment with new and innovative ways of delivering health care more efficiently.

You will, of course, be unsurprised to learn that this isn't the real reason. The real reason is that, in practice, block grants will steadily reduce spending on Medicaid. There are two reasons for this, and both are simple. Currently, Medicaid reimburses doctors and hospitals for care at set rates. As health care costs rise, Medicaid spending automatically keeps up. Block grants, however, are usually set to increase at a specific rate, which is usually the overall inflation rate. This means that the block grants grow far more slowly than actual health care costs:

This chart shows what's happened over the past 16 years. If the same thing happens over the next 16, Medicaid spending would need to increase about 80 percent in order to provide the same level of services. Under a block grant keyed to overall inflation, however, it would increase only about 40 percent. In real terms, this means that projected Medicaid spending would be slashed by nearly a quarter. That's a nice, big chunk of money that can be put toward tax cuts for the rich.

The second reason that block grants reduce spending is even simpler. Under the current system, you qualify for Medicaid if you meet certain conditions. Income is part of it, and during recessions this means that Medicaid spending automatically goes up as more people qualify. With a block grant, this doesn't happen. It is what it is, regardless of how many people are in need. And since states are usually strapped during recessions and barred from deficit spending, this means that Medicaid spending stays constant or even goes down at the worst possible time.

Now, this doesn't have to happen. Block grants for Medicaid could be keyed to medical inflation, and the size of the grants could be keyed to a formula that accounts for the number of people who qualify for it. If Republicans did that, it would demonstrate good faith. It would show that instead of merely trying to free up money for tax cuts, they're truly interested in letting states experiment to see if they can provide better care with the same funding.

I guess we'll have to wait and see, but I wouldn't bet the ranch on seeing anything like that from Donald Trump and Paul Ryan. They just want to slash spending on the poor.

And that leads us to one final thing: who gets all this Medicaid money, anyway? The undeserving poor? Here's a breakdown from a very useful short Medicaid primer by CBPP:

Only about a third of Medicaid spending goes to poor adults. The vast majority goes to nursing care for the elderly; medical care for the blind and disabled; and medical care for children. Do you really want to see steadily reduced spending on grandma's nursing home—which will inevitably make long-term care even crappier than it is now? Do you really want to cut off the blind and disabled? Poor children? Even if you don't think that poor adults deserve decent medical care, are you really hellbent on taking it out on the elderly, the disabled, and poor kids?

We're going to find out.

The Oscar nominations are out today, and naturally the only question on everyone's mind is how many black nominees there are. Here's the answer, in an update of a chart from last year:

The acting categories took a sharp turn upward, largely thanks to three black actors who were nominated in the Best Supporting Actress category (Viola Davis, Naomie Harris, and Octavia Spencer). The songwriting category, by contrast, was unusually white this year.

But the best news comes from outside of the acting categories. The truth is that the Oscars for acting haven't been especially white in recent years. It's the Oscars for everything else that have been white. But this year, a record 9 percent of the nominees in the other categories were black. Some of this was due to the documentary category, which produced four films directed by African-Americans, but the rest of the list was blacker than usual too.

Any individual year is a crapshoot, of course, but this is a promising development. If you're truly interested in seeing more diversity in Hollywood, forget about acting. It's the "everything else" category to watch. That's the one that's been a white stronghold for 88 years and counting.

The Congressional Budget Office has published its latest forecast of deficits and debt over the next decade. Here it is:

As the CBO notes, this steady rise in the debt is pretty much inevitable given an aging population and a Republican Congress unwilling to properly fund our spending commitments. Still, I'm not a huge debt alarmist, and this projection doesn't bother me a lot. It would be nice to see the national debt decline during economic expansions like our current one, though. After all, economic expansions don't last forever, even with the galaxy's best businessman in charge of the country.

Still, it's worth putting this up as a baseline. This is the debt projection at the end of the Obama era. In 2020, after four years1 of total Republican rule, we can compare and see just what the projected debt looks like in the hands of folks who claim to be devoted to balanced budgets and low deficits. My guess is that it will be somewhere north of 120 percent of GDP.

Of course, I might be wrong. Maybe the economy will grow at 4 or 5 percent per year under GOP stewardship and the resulting boom will cause tax revenue to skyrocket and the debt to come down. Anything is possible, I suppose. But I wouldn't bet on it.

1Probably.

The New York Times has called one of President Trump's lies a lie. The word isn't used in the text of the story, but it is used in the headline:

In this case, Trump said that between three million and five million illegal immigrants voted for Hillary Clinton, and he would have won the popular vote if not for that. Why was that judged a lie? Presumably because Trump has said it before, and it's been widely exposed as flatly untrue. Trump surely knows this, which means he's telling a knowing falsehood, aka a lie.

This is a reasonable metric. The problem with branding something a lie is that you have to be sure the speaker knew it was wrong. Otherwise it's just ignorance or a mistake. But in Trump's case, it's often clear that he knows he's lying. When he says the crowd at his inauguration was over a million, it's clear that he has no basis for this. He's just making up a number. When he says millions of illegal immigrants voted, he knows it's false because a legion of reporters have told him it's false. When he says the unemployment rate is 42 percent, it might be a mistake the first time. But the tenth time? It's a deliberate lie.

Beyond this, I'll repeat a three-part test I offered a few years ago that I find useful for judging how deceptive a statement is:

  1. What was the speaker trying to imply? This is necessarily a judgment call, but it's what gets us away from a single-minded focus on "lying" and instead focuses our attention on how badly a speaker is trying to mislead us.
  2. What would it take to state things accurately? This is the most important part of the exercise. Without getting deep in the weeds (nobody expects politicians to speak in white paper-ese), what would it take to restate things reasonably accurately?
  3. How much would accuracy damage the speaker's point? Obviously, if accuracy dents the speaker's point only a bit, not much harm has been done. If it demolishes the speaker's point completely, it's as bad as an actual lie, even if you can somehow spin it as technically true.

In this case, Trump was (a) stating that millions of illegal immigrants voted, (b) the only way to restate this accurately is to say that only a tiny handful of illegal immigrants voted, and (c) this completely demolishes Trump's point. It's obviously a 10 out of 10, and since Trump is aware of this, that makes it an egregious lie.

Click the link to find out why I think this test is useful. The nickel version is that it's a check on my emotional response. When I go through these three steps, sometimes I find things worse than I thought and other times I find them more benign. Give it a try.

UPDATE: Here's an interesting little nugget about the evolution of the Times headline:

Julia Hahn is a 25-year-old Breitbart News reporter who has written several scorched-earth pieces about House Speaker Paul Ryan whenever he hasn't toed the Breitbart line to their liking. Naturally, that caught the approving eye of Steve Bannon, formerly the executive chair of Breitbart and now the Rasputin of the Trump administration. Robert Costa reports:

Hahn, 25, is expected to join the White House staff, serving as an aide to strategist Stephen K. Bannon....“She’ll be Bannon’s Bannon and make Bannon look moderate,” said William Kristol, the editor at large of the Weekly Standard, a conservative magazine. “Her tendency is to fight and fight, often to the extreme.”

....Her hiring alarmed and angered several allies of Ryan....Privately, a number of House Republicans told The Washington Post that Hahn’s involvement signaled Bannon’s plans to possibly put her to use against them, writing searing commentaries about elected Republican leaders to ram through Trump’s legislative priorities and agitate the party’s base if necessary.

“This is obviously a provocative act and clearly an intentional act,” said Peter Wehner, a longtime Ryan friend and former official in three Republican administrations....Wehner said that too many Republicans on Capitol Hill are “engaging in a fiction, a game, where Bannon and Trump aren’t taken seriously even though Bannon and Trump are operating in a serious way and bringing on people who are going to work for their cause, not for conservatives.”

Back during the primaries, Fox News thought they could take on Trump. Eventually they learned they couldn't, and abjectly caved in to him.

Trump's Republican opponents all underestimated him too. They figured he was bound to implode on his own, and they'd just as soon let someone else spend the money to attack him. By the time they all understood what was going on, it was too late.

The #NeverTrumpers did no better. Their campaign was almost embarrassingly ineffective.

Democrats did a bit better, largely because they had lots of polls to back up their confidence in victory. In the end, though, they underestimated Trump too. They underestimated the willingness of outsiders like James Comey and Vladimir Putin to help him, and they underestimated Trump's appeal to Midwestern working-class whites. Now he's president.

I fear that Paul Ryan is doing the same thing. He's hoping to chivvy Trump along for a while and get his pet bills passed: tax cuts, Obamacare repeal, corporate-friendly deregulation, block grants for Medicaid and other social welfare programs, etc. As Grover Norquist once said, all Ryan needs is a president with a few working fingers to sign the bills he sends him. If the price of this is ditching TPP and pretending to build a wall, no big deal.

Maybe it'll work. Maybe Ryan will get what he wants and then Trump will implode this time. But Ryan better be sure that he isn't the sucker in this relationship. Trump has a long memory for people like Ryan who failed to support him enthusiastically, as well as an army of supporters who will turn on Ryan instantly if Trump tells them to. If Ryan is sitting back and allowing Trump to amass power in the belief that he can cut Trump down to size later, he better think again. Too many people have made this mistake already.

A bunch of little things happened this afternoon. They're not really big enough for a full post each, so here's a brief roundup. First up, President Trump signed an order freezing the federal workforce. This is part of the standard conservative playbook, and I doubt it means much in the long run. However, press secretary Sean Spicer—who moments earlier had said he would never lie to us—explained that Trump's order "counters the dramatic expansion of the federal workforce in recent years." Just for the record, here's that dramatic expansion:

If you look closely, you can see the dramatic expansion at the far right of the beige line. Do you see it? No? Look harder. Use your browser to zoom in. See? There it is! The federal workforce increased from 2.09 million in 2014 to 2.12 million in 2015. And it probably went up to 2.14 million or so in 2016. That's less than it was at the end of the Reagan administration.

In other news, the Weekly Standard has this:

Republican leadership is rethinking its relationship with Democratic minority leader Chuck Schumer after Schumer betrayed a promise to allow a vote last Friday on President Donald Trump's pick for CIA director....Schumer agreed to a Friday Senate vote for the confirmation of Kansas representative Mike Pompeo in exchange for a Republican concession to delay Pompeo's hearing by one day, TWS reported Monday. The deal went awry when Oregon senator Ron Wyden and other Democrats objected to the Friday vote, pushing it to Monday, sources said.

Anybody who's been alive and sentient for the past eight years will just giggle at the supposed Republican outrage over a one-day delay. Democrats counted themselves lucky if they managed to get only a one-month delay for most of President Obama's appointees. Delays of a year were hardly uncommon, and some delays were explicitly forever.

But beyond partisan point scoring, there's an actual serious point to make about this. Although Republicans have said they don't plan to eliminate the filibuster, there's always been an unspoken caveat: if Democrats behave. But it's been obvious all along that it won't be long before they decide that Democrats have done something so outrageous that they're left with no choice but to blow things up. The Pompeo thing is the first shot in this war, and it's an indication of just how delicate Republicans will pretend to be over every tiny slight.

And speaking of Pompeo, check this out:

This sounds an awful lot like "Total Information Awareness," the Bush-era program that was canceled by Congress in 2003. Even two years after 9/11, it was too much for us to swallow. But I guess Pompeo wants to bring it back. After all, with a guy like Trump in the White House there's no real possibility that it will be misused. Right?

Finally, on a different subject entirely, do you remember that Aetna announced plans last year to pull back from the Obamacare exchanges? This was supposedly a purely business decision: they were losing too much money and couldn't sustain further losses. But then the Huffington Post unearthed a letter from Aetna's CEO to the Department of Justice that sounded an awful lot like a shakedown: if DOJ rejected Aetna's proposed merger with Humana, he said, "we will immediately take action to reduce our 2017 exchange footprint....instead of expanding to 20 states next year, we would reduce our presence to no more than 10 states."

Well, Aetna was losing money in a lot of places, but it also pulled back from 17 counties in Florida, Georgia, and Missouri, where it was profitable. Why? Because the Department of Justice specifically named those counties as places that would be harmed by a merger. Given all of this, a federal judge ruled today that Aetna's pullback wasn't entirely a business decision after all. Here's BuzzFeed:

Aetna was willing to offer to expand its participation in the exchanges if DOJ did not block the merger, or conversely, was willing to threaten to limit its participation in the exchanges if DOJ did,” Judge [John] Bates said Monday.

....Monday’s ruling cited internal documents showing Aetna was planning to withdraw from many health insurance exchanges for business reasons. But it said that on the day the Justice Department sued to block the merger, “Aetna employees were instructed to gather information regarding the 17 complaint counties.”...The emails specifically show Aetna executives confirming that Humana was present in those 17 counties, which, an executive said, “makes it easy we need to withdraw from those.”

....When Aetna said it was leaving the Florida counties, its own Florida exchange head said in an email, “I just can’t make sense out of the Florida decision....Never thought we would pull the plug all together. Based on the latest run rate data ... we are making money from the on-exchange business.” An Aetna executive responded by saying they should discuss it on the phone. The executive later testified in the trial, “these requests for phone calls were an attempt to avoid leaving a paper trail.”

Luckily, I'm sure Aetna has nothing to worry about. President Trump will negotiate a great deal with Aetna for whatever tremendously great health care plan he comes up with, and DOJ will then withdraw its complaint. Bygones, you know.

Sean Spicer is holding his first press conference today. The first three questions go to the New York Post, the Christian Broadcasting Network, and Fox News. They all ask softball questions.

How about those reports that US planes are attacking ISIS in collaboration with the Russians? Spicer refuses to deny it even though the Pentagon has already called the claim "rubbish."

Finally someone asks about Spicer's debacle on Saturday. It turns out that Spicer is upset about anyone questioning his integrity and claims that everything he said on Saturday was based on the best information at the time. Furthermore, he stands by his statement that Trump's inauguration was the most watched of all time. Sure, Reagan had 41 million viewers, but Reagan didn't have YouTube.1 Once you add in that, plus Facebook and smartphones and all that stuff, then Trump kicked Reagan's ass, amirite?

Then Spicer refuses to say what the unemployment rate is. There's a lot of different statistics out there, and anyway, Trump prefers to think of people, not faceless statistics. That's just the kind of guy he is.

What is Trump going to do about climate change? "He's going to meet with his team."

What are Trump's first three legislative priorities? Immigration, tax reform, regulatory reform. And that's not just the wall, either. We need a complete immigration overhaul.

Trump has no immediate plans to revoke DACA, the "mini-DREAM" act signed by President Obama. I wonder what the immigration hawks think of this?

What kind of relationship does Trump plan with China? "He understands what a big market that is." Okey doke.

Spicer is now denying that the cheers during Trump's CIA speech were mostly coming from folks that he brought along. "Just listen to the cheers. It was more than a few people."

I guess this could last forever, and I'm getting hungry. My professionalism has a limit, and it's now been reached. Spicer is droning on about the perfidy of the press and how Trump always outperforms people's expectations. Then we hear yet again about his outrage over the incorrect reporting regarding the MLK bust in the Oval Office. Spicer now claiming that Trump is treated way worse that any other president in history. Blah blah blah. That's it for me.

1This is pretty much a direct quote: "Reagan didn't have YouTube."

Houses in the Israeli settlement of Maale Adumim in the occupied West Bank, near Jerusalem. Members of the governing coalition are pressing for Israel to annex Maale Adumim.

It's full speed ahead for creating yet more facts on the ground in Israel. The LA Times reports:

The city of Jerusalem, emboldened by anticipated support from the Trump administration, on Sunday authorized the construction of some 560 new homes in areas of the city claimed by the Palestinians as a capital of their future state....A new era has begun,” Education Minister Naftali Bennett, the leader of the pro-settlement Jewish Home party, told Israeli reporters, calling on government ministers to support a decision to extend Israeli sovereignty to the West Bank.

....Members of Netanyahu’s coalition are pushing for a parliamentary bill to annex Maale Adumim, a sprawling settlement east of Jerusalem with a population of tens of thousands. Annexing it would nearly sever the West Bank between north and south.

“There is a giant change in the policy of the U.S., and we have to take that change into account — for our own benefit,” said Ofir Akunis, a lawmaker from Netanyahu’s Likud party, who said he would support annexation.

Considering that Barack Obama spent eight years trying to slow down Israeli settlements and it had no evident impact, we can only imagine what's going to happen now that Israelis have a US president who openly approves of annexing every square meter of land they can.

I just don't know how this all turns out. It's been obvious for a while that the two-state solution is dead. Prime Minister Netanyahu has obviously never supported it, and demographic changes have pushed Israeli politics to the point where Netanyahu is actually a bit dovish compared to the rest of his coalition. They're just going to keep building and building until something stops them—and at the moment, I'm not sure what something could be. If the entire rest of the world literally stopped trading with Israel, cut off diplomatic relations, and refused entry to all Israeli citizens—that might do it. But that's not going to happen, and I'm not sure that would be enough anyway as long as the US is still in Israel's corner.

I guess Jared Kushner will be tasked with "negotiating" something that will end up making all of this official policy. The rest of us are just going to have to figure out how to respond.

CBS News has confirmed what we all suspected about President Trump's visit to the CIA on Saturday:

An official said the visit “made relations with the intelligence community worse” and described the visit as “uncomfortable.”

Authorities are also pushing back against the perception that the CIA workforce was cheering for the president. They say the first three rows in front of the president were largely made up of supporters of Mr. Trump’s campaign.

An official with knowledge of the make-up of the crowd says that there were about 40 people who’d been invited by the Trump, Mike Pence and Rep. Mike Pompeo teams....There were about 400 members of the workforce who RSVP’d for the event out of thousands who received an invitation in their email late last week. Officials dismiss White House claims that there were people waiting to get into the event.

We now have a president who travels with his own private cheering section and allows the press to film his events only from approved angles that hide this fact. People keep comparing Trump to Mussolini, but I'm beginning to think this might be unfair to Il Duce.

I missed this when it came out a few days ago, but here's the latest Fox poll on what people want done with Obamacare:

Very few people want Obamacare repealed without something to replace it, and even fewer want it repealed without knowing exactly what kind of replacement Republicans have in mind. There's not a big partisan split on this, either. Among Republicans, 73 percent want Obamacare replaced with something new and 68 percent want to know what the replacement is before anything is repealed.

Here's another interesting tidbit:

Even among Republicans, hardly anyone really cares about the wall. This suggests that it will be pretty easy for the wall to get forgotten in the shuffle as Republicans in Congress go about the stuff they really care about: cutting taxes on the rich and cutting benefits for everyone else.