Since August, when Mitt Romney chose Paul Ryan as his running mate, the two campaigns have fought a fierce battle over who is the most stalwart protector of Medicare. In the first presidential debate, Romney assailed President Obama for his $716 billion in Medicare cuts, and Ryan did the same in last week’s vice presidential face-off. Likewise, the Obama campaign has hit Team Romney for the Ryan plan and its Medicare “premium support”—which, if implemented, would gradually replace traditional Medicare with subsidized, regulated private insurance.
The irony is that—in the short term, at least—Medicare will stay unchanged, regardless of who wins the election. Seniors are among the most mobilized voters in the electorate, and there’s too much political risk involved in making big, immediate changes to Medicare. For that reason, Medicare reform plans on both sides are backloaded and will take time to unfold.
The same isn’t true of Medicaid, the other major federal health-care program. The primary constituency for Medicaid—poor and working-class families—lacks the clout and influence of seniors. And while the Obama administration expanded the program in the Affordable Care Act, it has also made Medicaid a ripe target for conservative cuts to social insurance.
This means that, as Mother Jones’ Kevin Drum pointed out last week, Medicaid, not Medicare, is the actual flashpoint in this election. Romney has promised to “block grant” the program, giving states more flexibility in dealing with eligibility and benefits. Some states would use this as an opportunity to innovate. But as Drum notes, just as many would use it as an excuse to drop health coverage for poor people:
Lots of states, especially poor states in the South, don’t have much interest in experimenting. They just want to slash eligibility for Medicaid. Given the freedom to do it, they’d adopt what Ed Kilgore calls the “Mississippi model,” cutting off coverage for a family of three earning anything over $8,200. For all the talk of fresh thinking and new solutions, what they really want to do is simple: They want to stop providing medical care for poor people.
Admittedly, this is a little speculative. It’s possible—albeit, unlikely—that a future governor of South Carolina or Alabama might want to use the new flexibility to improve services for lower-income people. With that in mind, it’s also worth noting the extent to which Romney’s block-grant plan involves a massive cut to overall Medicaid spending. The Center on Budget and Policy Priorities finds that with a Paul Ryan-style block grant in place, overall Medicaid spending would decline by one-third over the next decade. When you put this in the context of Romney’s budget proposals—which include new defense spending and a promise to protect Medicare—and his promise to repeal the Affordable Care Act, the result is a $1.5 trillion reduction in Medicaid spending by 2022. These cuts would add an additional 14 to 19 million people to the ranks of the uninsured, on top of the 30 million people who would lose coverage as a result of full Obamacare repeal.
It’s his approach to Medicaid, more than anything else, that reveals Mitt Romney’s priorities—aid for the rich, paid for by taking relief from the poor.