The smart money in Washington is betting that Medicaid will suffer the deepest cuts when and if lawmakers strike a deal on deficit reduction. Why? Because it is assumed that Medicaid, which was designed to serve the poor, doesn't have powerful friends in the Capitol. That's just how politics works: The weak get shafted.
But maybe the smart money is wrong. Republicans who think that Medicaid is an easy target may be in for another hard lesson as seniors revolt against -- and Republicans back away from -- the GOP's plan to gut Medicare.
While the cuts to Medicare in Rep. Paul Ryan's budget have gotten the most attention, the plan -- approved by the House earlier this spring and rejected yesterday by the Senate -- would also have ended Medicaid as we know it, turning it into block grants to the states, repealing a provision of the Affordable Care Act that would have expanded coverage, and whacking $207 billion from the program over the next five years. Also, in contrast to how Ryan artfully delayed his radical Medicare changes until 2022, the huge cuts to Medicaid would have kicked in immediately.
That kind of draconian downsizing is not going to happen as long President Barack Obama wields a veto pen. But even a partial bid to enact Ryan's vision for Medicaid, whether as part of a debt-ceiling deal or a bigger deficit-reduction package, will reveal a surprising political truth: The program has more friends than people think.
Yes, Medicaid was designed for the poor during Lyndon Johnson's War on Poverty and still serves as a lifesaver -- literally -- for millions of low-income Americans. But it also benefits legions of seniors, primarily by covering nursing-home stays. And this group -- along with their kids -- will go on the warpath if Congress slashes Medicaid. Democrats foolish enough to sign on to big cuts -- say, out of desperation to keep the government from defaulting -- could find themselves in political trouble.
Lawmakers who have set Medicaid on the chopping block might want to bear in mind a few basic facts before they start swinging the ax.
First, the bulk of Medicaid benefits -- two-thirds -- go to the elderly and disabled. Drilling down further, a quarter of Medicaid spending helps seniors. So forget the idea that this is a program that mainly caters to poor adults and children.
In turn, many of Medicaid's benefits for seniors pay for nursing-home stays. Some 70 percent of America's 1.4 million nursing-home residents are on Medicaid, according to the Kaiser Family Foundation. And it's well known that plenty of middle-class and even upper-middle-class people turn to Medicaid for nursing-home coverage -- either after exhausting their savings or impoverishing themselves by transferring assets to others.
If Medicaid cuts mean less coverage for nursing-home stays, somebody else will have to pick up the tab or make other arrangements for care, and that somebody will be the kids or siblings of seniors. These people -- who generally aren't poor or politically marginalized -- will take out their wrath on the politicians responsible for this fallout.
It's also worth mentioning that Medicaid helps fill the gap in Medicare's prescription-drug coverage -- the infamous "donut hole" -- and any cuts that put that funding at risk won't go down very well.
A poll released earlier this week by the Kaiser Family Foundation found that just 13 percent of those surveyed supported major cuts to Medicaid as part of deficit reduction. A solid majority of 60 percent said they opposed turning the program into block grants and preferred keeping the program as is. The poll also found that Medicaid touches a great many lives: "Roughly one-half of Americans (51%) said they or a friend or family member has received Medicaid assistance at some point, with nearly that many (49%) saying Medicaid is 'very' or 'somewhat' important for them and their family."
To be sure, Medicaid is not as popular as Medicare, but it's almost as well liked and budget cutters will want to bear in mind that many Americans can't actually tell these two programs apart. They sound the same, and both do help seniors. Go after Medicaid, and voters may think you're gunning for Medicare, too.
A final point: A great many governors also aren't keen on cutting Medicaid, because they'll have to clean up the wreckage. Another recent study by Kaiser found that eight states -- including Florida -- would lose more than 40 percent of their federal funding for Medicaid over the next decade under the budget plan passed by House Republicans. That would spell fiscal disaster for those states.
Ideology matters in politics, but who gets what is ultimately more important, and some top state Republican leaders are sure to peel away from congressional Republicans as the Medicaid battle heats up.
None of this is to suggest that Medicaid isn't vulnerable. Certainly it's an easier target than Social Security, Medicare, and even defense spending. But in the coming months, Washington is likely to learn that Medicaid is no sitting duck.