House Republicans make it official: Gutting the ACA is back on the table again (Part 2)

See Part 1 Here

Again, here's the Republican Study Committee (RSC, aka House Republicans) 2025 Budget Proposal. The ACA-related section begins on page 86:

Under the RSC Health Care Task Force plan, protections pertaining to guaranteed issue and the prohibition on coverage exclusions would be retailored to reward continuous coverage and promote portability in the individual marketplace.

"RETAILORED." DANGER WILL ROBINSON.

Scratch Guaranteed Issue.

Additionally, to provide Americans with options that fit their individualized needs, each state would again be allowed to determine the minimum attributes and cost-sharing parameters of plans to best meet the needs of their own citizens. In no case, however, would carriers be able to rescind, increase rates, or refuse to renew one’s health insurance simply because a person developed a condition after enrollment.

Scratch Essential Health Benefits, Minimum Actuarial Value, Maximum Out of Pocket Costs and No-Cost Preventative Services, and welcome back to Annual & Lifetime Benefit Caps.

This RSC budget would also encourage insurers participating in the individual market to offer discounted premiums to younger, healthier enrollees by allowing medical underwriting. These plans would be the same as other ACA plans offered by the same insurers but would offer lower premiums with guaranteed lifetime renewability in exchange for a one-time underwriting.

(And yes..."discounted premiums" for healthy enrollees is another way of saying "higher premiums" for unhealthy enrollees.)

Separately, states—and not the federal government—would be empowered under the RSC plan to establish restraints on the extent to which carriers could incorporate the health risks of individuals into premiums.

Yep...scratch Community Rating.

So what happens to high risk people (ie, those with expensive/chronic medical conditions)?

WAIT FOR IT...YOU KNOW IT'S COMING...

Individuals with high-risk medical conditions would have affordable access to state-run Guaranteed Coverage Pools under which their health care costs would be subsidized with federal grants and further contained by any state-enacted premium-setting restrictions.

HIGH RISK POOLS! DRINK!!

I can't believe I'm linking to this piece again, but here we are.

...In addition, the RSC Budget would fully repeal Obamacare’s destructive tax increases.

BOOM. THAT'S the real reason why the GOP is still so hell-bent on repealing the ACA even now, seven years after President Obama left office: The fairly modest  tax increases on the wealthy:

High-income taxpayers also help pay for Obamacare. The health law requires workers to pay a tax equal to 0.9% of their wages over $200,000 if single or $250,000 if married filing jointly to finance Medicare’s hospital insurance. It also imposes a 3.8% surtax on various forms of investment income for taxpayers whose modified adjusted gross income is over $200,000 if single or $250,000 if married filing jointly. Those provisions will account for $346 billion in revenues by 2025, according to the CBO.

In any event...

A number of states have used Section 1332 waivers in a way reflective of this approach. Under Section 1332, States can receive federal subsidies that originally would have gone to insurers through the ACA marketplace and, using state-matching funds, to implement innovative models free of top-down Obamacare mandates. States can only receive these waivers if they show that their plan will ensure access to high-quality care for all citizens (regardless of health-status) and reduce premiums. The use of 1332 waivers has been immensely successful. States with 1332 waivers saw premium reductions of 7.48% from 2018-2019.319 Premiums in non-waiver states increased by 3.1%.320 The RSC plan would empower all states to implement these innovative models to lower costs and ensure guaranteed access to affordable coverage for all Americans regardless of health status.

Annnnnnd there it is: They plan on perverting the ACA's Section 1332 Waiver provision to basically allow states to do whatever the hell they want. This is pretty much what Trump's CMS Administrator Seema Verma attempted to do a few years back:

State Innovation Waivers allow states to implement innovative ways to provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver, provides coverage to a comparable number of residents of the state as would be provided coverage absent a waiver, and does not increase the federal deficit.

State Innovation Waivers are available beginning January 1, 2017. State Innovation Waivers are approved for five-year periods, and can be renewed. Waivers must not increase the Federal deficit.

...The downside of 1332 waivers, of course, is that defining what counts as being "at least as good" is highly subjective...and much of this depends on the judgment of whoever is running things at HHS and/or CMS. Which, at the moment, happens to be Trump appointees Alex Azar and Seema Verma respectively.

Again, at the time it was just a draft version of the new proposed rules. Today, CMS has posted the rules themselves...and they should set off klaxon alarms at every level (via Amy Goldstein of the Washington Post):

The Trump administration is urging states to tear down pillars of the Affordable Care Act, demolishing a basic rule that federal insurance subsidies can be used only for people buying health plans in marketplaces created under the law.

According to issued Thursday by federal health officials, states would be free to redefine the use of those subsidies, which have since 2014 provided the first help the government ever has offered consumers to afford monthly insurance premiums.

States could allow the subsidies to be used for health plans the administration has been promoting outside the ACA marketplaces that are less expensive because they provide skimpier benefits and fewer consumer protections. Even more dramatically, states could let residents with employer-based coverage set up accounts in which they mingle the federal subsidies with health-care funds from their job or personal tax-deferred savings funds to use for premiums or other medical expenses.

...The new advice, called “waiver concepts” because they are ideas for how states could get federal permission to deviate from the law’s basic rules, stray from both of those goals. And it would allow states to set difference income limits for the subsidies — higher or lower than the federal one.

...And so on and so forth.

From the House GOP plan:

One of President Trump’s greatest accomplishments as president was to institute a number of flexibilities into the health care system to make it work for Americans. These include the repeal of the individual mandate, repeal of Independent Payment Advisory Board (IPAB), ending unconstitutional Cost Sharing Reduction (CSR) payments, expanding 1332 waivers (as mentioned above), protecting and increasing the availability of short-term limited-duration plans, and expanding access to health reimbursement arrangements (HRAs), among others. Nearly all of these reforms are or will be under attack by the Biden Administration. The RSC Budget opposes all efforts to undermine these critical reforms.

Believe it or not, I'm not going to completely trash all six of these. Zeroing out the individual mandate penalty (technically it was never actually repealed, just changed from $695 to $0 or from 2.5% of income to 0.0%) did indeed cause average premiums to jump an average of around $580 per enrollee...but, to be fair, the federal penalty was never high enough to be fully effective, and the Subsidy Cliff did put millions of middle-class enrollees in a bit of a bind. It shouldn't have been repealed but with the original subsidy formula being as weak as it was I can't completely condemn it.

As for elimination of CSR payments, I've written enough about that to publish a novel or two. The bottom line is that one of Trump's attempts to sabotage the ACA actually ended up kind of/sort of improving it (depending on the state/insurance carrier you're talking about), completely by accident on his part.

By "on his part" this I mean that while there were a number of people at CMS and insurance carriers who understood how to turn lemons into lemonade via Silver Loading, I guarantee you that Trump himself (who openly boasted about how pulling the plug on CSR reimbursement payments would supposedly destroy the exchanges) was utterly clueless about how doing so would actually play out.

As for the rest of the list, according to the CBO, repealing the IPAB:

H.R. 849 would repeal provisions in the ACA that authorized the establishment of IPAB. According to CBO, repealing IPAB would increase spending by $17.5 billion between 2018 and 2027, because in CBO’s assessment, the Board will be required to generate Medicare savings of that amount over the 10-year period. The House legislation does not include offsets to cover the cost of repealing IPAB. Repealing IPAB could affect Part B premiums paid by beneficiaries and the financial outlook of the Medicare Hospital Insurance (Part A) trust fund.

I have no idea if that's how things are actually playing out, but there it is.

As for Short-Term Limited Duration (STLD) plans, aka ShortAssPlans, expanding those isn't something to brag about:

...short-term policies:

• are often medically underwritten – applicants with health conditions can be turned down or charged higher premiums, without limit, based on health status, gender, age, and other factors;

• exclude coverage for pre-existing conditions – policyholders who get sick may be investigated by the insurer to determine whether the newly-diagnosed condition could be considered pre-existing and so excluded from coverage;

• do not have to cover essential health benefits – typical short-term policies do not cover maternity care, prescription drugs, mental health care, preventive care, and other essential benefits, and may limit coverage in other ways;

• can impose lifetime and annual limits – for example, many policies cap covered benefits at $2 million or less;

• are not subject to cost sharing limits – some short term policies, for example, may require cost sharing in excess of $20,000 per person per policy period, compared to the ACA-required annual cap on cost sharing of $7,350 in 2018;

• are not subject to other ACA market requirements – such as rate review or minimum medical loss ratios; for example, while ACA-compliant non-group policies are required to pay out at least 80% of premium revenue for claims and related expenses, the average loss ratio for individual market short-term medical policies in 2016 was 67%; while for the top two insurers, who together sold 80% of all short-term policies in this market, the average loss ratio was 50%.

So, what's next on the House GOP's wish list?

Interstate Health Insurance Plans - In order to increase choice among insurance plans and increase access to more affordable options, the RSC Budget would ensure consumers are able to purchase health insurance across state lines. This would drive down costs by encouraging plans to compete to provide access to high-quality care.

"BUY ACROSS STATE LINES" DRINK!!

(sigh) As I noted back in 2019:

I can't believe that they're still trying to dredge this back up again.

For years...decades, really...Republicans have been trying to claim that "Buy Insurance Across State Lines!" would be a panacea for all of our health insurance expense woes. Every time there's a debate about how to lower health insurance costs, BASL is the stock answer they give (it's right up there with "Tort Reform" on the Republican Healthcare Bingo board).

The idea behind BASL is that if health insurance in your state is too expensive, you can simply enroll in a less-expensive policy available in a different state. Presto, problem solved!

Once again, there are several major problems with this logic. First of all, it completely tramples on states rights...something which Republicans used to supposedly care about...regarding setting their own minimum threshold of insurance regulation. This is also a massive threat to the stability of risk pool in the first state, since siphoning off healthier, lower-cost enrollees into out of state plans would leave the rest of the risk pool that much sicker and more expensive to treat, leading to even higher premiums.

Setting that aside, however, the next issue pretty much stops things in their tracks: The Affordable Care Act ALREADY ALLOWS insurance carriers to do exactly this:

Buying health insurance across state lines has been proposed as an alternative to the Affordable Care Act – but it’s already in the law.

The Republican presidential front-runners, along with their trailing competitors, are all big fans of allowing Americans to buy health insurance across state lines, arguing that doing so would boost competition, resulting in lower costs and greater choice for consumers. Often, conservatives have framed such a plan as part of a replacement package for Obamacare.

The thing is, such permission is already part of President Barack Obama's health care law.

The little-known provision, found in section 1333 of the roughly 1,000-page Affordable Care Act, allows for states to create "health care choice compacts" permitting insurers to sell policies to consumers in any state participating in the compact, as long as they follow specific rules.

In fact, guess what?

Five states – Georgia, Kentucky, Maine, Rhode Island and Wyoming – already have enacted interstate compact statutes, according to the National Conference of State Legislatures.

Note that the article above by Kimberly Leonard is from 2016...and in fact the compact provision has been part of the ACA since it was signed into law in 2010.

OK, what else? Well, another slight bump in the BASL road is that even with five states enacting these compacts, not a single insurance carrier has expressed any interest in utilizing them, with very good reason: A Michigan resident enrolling in a healthcare policy sold out of Alabama isn't going to find it particularly useful unless they plan on making a 15-hour drive every time they have to visit the doctor or pick up a prescription.

In order for an insurance carrier to set up shop in a state, they have to establish a network of doctors, hospitals, clinics and other participating healthcare providers. Furthermore, those providers are subject to the home state's regulatory structure, not those of the state the carrier is based in. That takes an awful lot of time, money and resources to do, and can get confusing when the carrier is trying to intermingle the rules of one state with another in their internal operations. It's simply more trouble than it's worth.

As a result, if a carrier really wants to expand into a different state, all they have to do is establish a subsidiary corporation in that state with its own legal entity status, staff, policy offerings and so forth...which is exactly what some carriers have done. In case you haven't noticed, health insurance conglomerates like UnitedHealthcare, Aetna, Molina and so on do offer plans in more than one state...some are available in dozens, in fact.

As Sabrina Corlette of Georgetown University's Center on Health Insurance Reforms just noted:

Finding #7: Aside from conservative think tank types, across-state lines laws lack a champion. Neither insurers nor the consumers the laws were designed to benefit lobbied for these laws. Nor did they advocate for their implementation.

— Sabrina Corlette (@SabrinaCorlette) March 7, 2019

Ah, but you see, House Republicans have a solution to the problem of state-controlled health insurance regulation: 

McCarron-Ferguson Repeal - The RSC Budget support Rep. Paul Gosar’s (R-AZ) Competitive Health Insurance Reform Act, which reforms the McCarran-Ferguson Act to restore the application of federal antitrust laws to the business of health insurance to provide for competition and protect consumers.

What does the McCarron-Ferguson Act do? 

The McCarran–Ferguson Act, 15 U.S.C. §§ 1011-1015, is a United States federal law that exempts the business of insurance from most federal regulation, including federal antitrust laws to a limited extent. The 79th Congress passed the McCarran–Ferguson Act in 1945 after the Supreme Court ruled in United States v. South-Eastern Underwriters Association that the federal government could regulate insurance companies under the authority of the Commerce Clause in the U.S. Constitution and that the federal antitrust laws applied to the insurance industry.

You may be surprised to hear Republicans wanting to remove states rights, especially when it comes to regulating private industry...but if the goal is for federal regulations to be stripped to the bone, it makes sense to give the feds the final say in just how junky that junk insurance is allowed to be.

Legalize Association Health Plans – The RSC Budget would codify President Trump’s Association Health Plans rule, which was designed to allow small businesses to pool together to leverage lower cost health insurance on behalf of their employees. By allowing multiple small businesses to band together to form a larger insurance pool, Association Health Plans make health insurance more affordable and accessible. Expanding access to Association Health Plans would reduce premiums by as much as $4,100 in the small group market and $10,800 in the individual market. Unfortunately, President Trump’s rule has been mired in legal proceedings and the Biden Administration has already taken steps to rescind it. To protect President Trump’s rule, the House passed RSC Chairman Kevin Hern’s (R-OK) CHOICE Arrangement Act, which would codify Association Health Plans in addition to several other types of health purchasing arrangements.

Yeah, about Association Plans...

AHPs don’t have to provide the ACA’s “essential health benefits.” While some AHP entities have chosen to offer plans that include a traditional set of benefits — such as hospital and outpatient care, prescription drugs, and mental health services — this is not a requirement.

...AHPs can set premiums for small groups and individual self-employed people in ways that are not permitted in the ACA’s small-group and individual markets. They can set premiums based on gender, occupation, and other factors that insurers can’t consider when setting premiums for individual and small-group plans. They can charge small businesses with older workers far more compared to those with younger workers than ACA plans allow, and AHPs have more ability to vary rates based on geography.

...Some AHPs can directly set higher premiums for small groups whose workers have pre-existing conditions or offer firms with healthier workers a premium reduction. Some AHPs can consider the pre-existing conditions and the past medical claims of small business workers when setting premiums (known as “medical underwriting”).

...AHPs are not subject to the ACA’s “single risk pool” requirement. This means the companies that offer them do not have to pool together all their enrollees in the small-group or individual market (respectively) when setting premiums. This gives entities offering AHPs greater ability to set premiums in ways that reflect the health status of AHP enrollees only, separate from the broader market.

AHPs don’t participate in risk adjustment, which helps protect against risk segmentation. Risk adjustment, which the ACA applied to plans in the individual and small-group markets, transfers revenues from insurers that enroll a healthier-than-average group of consumers to those that enroll a sicker-than-average group, compensating the latter for the extra health care costs they incur. It helps reduce the financial incentives for insurers to try to avoid enrollees (such as those with medical conditions) who cost more to cover, but it doesn’t apply to AHPs.

...In addition, AHPs have a history of financial instability and fraud. By weakening limits on AHPs, recent federal rule changes (and changes that some states are contemplating as well) could make it easier for unscrupulous or poorly managed AHPs to set up shop. If an AHP goes insolvent, as has happened in the past, it could leave people with unpaid medical claims and state regulators trying to clean up the mess. The AHPs currently getting the most attention are operated by prominent trade organizations and large, established insurers. These entities may be able to avoid some of the worst AHP pitfalls of the past. But weaker rules also help open the door to less well-known entities, and encouraging more AHPs to form makes state and federal enforcement more challenging.

Back to the House GOP proposal...

Oppose Inflation Reduction Act Price Controls – The RSC Budget opposes the price controls enacted by the Inflation Reduction Act. Rather than enact reforms to lower costs through increased competition in the pharmaceutical industry, President Biden and Congressional Democrats have embraced socialist price controls that will limit access to life-saving drugs for those who desperately need them.

Ah, yes: "Socialist Price Controls," otherwise known as "Letting Medicare Negotiate over Prescription Drug Pricing," something which is so absurdly rational that even 76% of REPUBLICANS support it.

Later on they go after Medicaid and CHIP, proposing to "streamline" both programs:

As a quasi-voluntary, state-federal partnership, Medicaid traditionally subsidized health care services for the most vulnerable Americans, including individuals with disabilities, low-income children, low income seniors, and pregnant women. Medicaid is the largest federal means-tested welfare program and accounts for the majority of federal means-tested spending. Federal funding is estimated to be $551 billion in 2024 and grow to a projected $898 billion in 2034. Despite spending that continues to climb at an unsustainable rate, Medicaid continues to fail beneficiaries.

Research has shown patients covered by Medicaid are, in some cases, more likely than the uninsured to have poor health outcomes, such as an increased instance of death after a major surgery. A landmark randomized controlled trial in Oregon compared similar populations of low-income, able-bodied Medicaid enrollees with non-enrollees. The study found, “Medicaid increased health care utilization, reduced financial strain and reduced depression, but produced no statistically significant effects on physical health or labor market outcomes.”

Ugh. Here we go again. This single study out of a single state with 1.3% of the U.S. population from 16 years ago has been cited over and over again by Republicans and conservatives to supposedly "prove" how terrible Medicaid is. Once again, my colleague Louise Norris has the receipts:

Fact #1: The study did not compare the health outcomes of Medicaid beneficiaries with uninsured individuals.

This study compared the health outcomes of lottery winners, who were given a chance to apply for Medicaid, with lottery losers, who were not given that opportunity. However, only 30% of the lottery winners successfully enrolled in Medicaid. Moreover, both categories included individuals who had private insurance as well as people who obtained Medicaid through other means.

Ultimately, the winning group had only an 11 percentage point increase in insurance coverage compared to the losing group. In sum, the study measured the impact of that modest increase in health coverage—not a simple sorting between all-Medicaid, on the one hand, and all-uninsured, on the other.

Fact #2: The study found a statistically significant relationship between Medicaid coverage and improvements in depression, access to care, financial security, and self-reported health status.

For an outcome to be statistically significant, scientific convention holds that there must be at least a 95% likelihood that it resulted from the identified cause rather than chance. The larger the sample size and the more prevalent the studied condition within the sample, the easier it is for the study to detect a statistically significant effect. The study found that increased coverage due to the lottery resulted in statistically significant improvements in depression, access to care, financial security, and self-reported health status—in other words, improvements that almost certainly were caused by the receipt of health coverage, rather than chance.

Fact #3: The study sample size was too small and the study population was too healthy to show anything at all about the impact of Medicaid coverage on diabetes, blood pressure, or cholesterol.

Press accounts of this study were highly misleading about results that involved diabetes, blood pressure, and cholesterol. Winners were 18% less likely to have diabetes, 17% less likely to have high cholesterol, and 8% less likely to have high blood pressure. In layperson’s terms, these effects were surely “significant.” But in scientific parlance, the effects were not “statistically significant” because of the relatively small size of the study and the relatively small number of people suffering from those conditions.

In the losing group, for example, only 5% of participants had diabetes, 14% had high cholesterol, and 16% had high blood pressure. Therefore, the study would have needed 23 times as many people to be able to detect whether the observed improvement in diabetes was caused by Medicaid coverage. In contrast, the study was able to detect a statistically significant effect on depression because depression was relatively prevalent in the studied population, with 30% of participants in the losing group screening positive for the condition. Put simply, this study was not capable of showing whether two years or less of Medicaid coverage led to observable changes in clinical measures of diabetes, high blood pressure, or high cholesterol.

Fact #4: Other studies that were capable of evaluating the relationship between Medicaid and physical health found dramatic and positive effects.

Several studies that were able to analyze Medicaid’s impact on physical health found it to be significant and positive.

For example:

• A recent study comparing states that expanded Medicaid coverage to nearby states that did not expand found that, after five years, Medicaid expansion was associated with a 6% decrease in all-cause mortality among adults ages 20-64. The reductions were the greatest in counties with high poverty rates and among nonwhites and older adults. Both this study and the Oregon study were published in the same journal.

• A study on hospital care following automobile accidents found that uninsured individuals received substantially less care than Medicaid beneficiaries and had a 4.7 percentage point higher mortality rate.

• A study on the effect of insurance status on mortality among HIV+ patients found that, compared to being uninsured, Medicaid reduced mortality by 60%.

• A study on the impact of termination of Medicaid coverage found that loss of coverage resulted in deterioration of health status. After six months, the proportion of hypertensive patients with uncontrolled blood pressure in the group that lost coverage rose from 3% to 31% and the mean diastolic pressure increased by 10 mm Hg.18 A sustained increase of 10 mm Hg increases risk of death by 40%.19 There were also multiple deaths in the group that lost coverage compared to no deaths in the control group that retained coverage. 20 Deteriorated health status persisted after one year, especially among those patients who neither regained insurance nor received intervention from the study team.

Of course the House GOP goes after abortion here as well:

Further, Medicaid will often provide funding to abortion providers, violating the right to life while failing to provide quality health care for beneficiaries. RSC’s budget would ensure that none of these funds go to entities that provide abortions.

Feel free to shout that from the rooftops, guys.

Obamacare provides an inflated contribution for these new Medicaid expansion populations, incentivizing states to pull funding from other needs of the core populations under Medicaid. Not only does this reduce spending for vulnerable populations— the poor, aged, disabled, and children—but the enhanced federal share for healthy, able-bodied adults forces taxpayers to subsidize those who would likely be able to purchase private insurance. As noted by Chris Pope of the Manhattan Institute, “…economists Jonathan Gruber and Kosali Simon estimated that 60% of those newly covered previously had private insurance. This crowd-out rate increases the higher up the income distribution that eligibility for Medicaid is expanded.

This is referring to Federal Medical Assistance Percentage (FMAP). In short, depending on the state, the federal government pays for anywhere from 50 - 77% of the cost of "traditional" Medicaid (that is, Medicaid enrollees eligible under pre-ACA rules), but it pays fully 90% of the cost for ACA Medicaid expansion enrollees. The state covers the other 23 - 50% for non-ACA enrollees versus just 10% for the ACA expansion population.

Now, I actually agree that this is a rather strange disconnect, but House Republicans seem to think that this is causing states to reduce funding to non-ACA Medicaid enrollees in order to cover the 10% of the cost they're obligated to pay for ACA expansion enrollees. This makes...absolutely no sense whatsoever. If the state can't come up with their 10% share of the cost, they could raise taxes or fees on something or another (as many states have done) or, if they don't want to do that, they could pull some of the funding from literally anywhere else in their state budget (alternately, they could simply refuse to expand the program, as ten states are unfortunately still choosing to do as of this writing). There's nothing in the ACA which forces them to cut non-ACA Medicaid spending specifically.

As for the claim that 60% of newly-covered Medicaid enrollees "previously had private insurance," if you check the link provided, the claim by Mr. Pope is referring to expansion of Medicaid to more people IN THE 1990's, not ACA Medicaid expansion, which didn't even go into effect in most states until 2014:

As Congress expanded the program in the late 1990s, economists Jonathan Gruber and Kosali Simon estimated that 60% of those newly covered previously had private insurance. This crowd-out rate increases the higher up the income distribution that eligibility for Medicaid is expanded.

I don't know of any studies which focus on the prior healthcare coverage status of ACA expansion enrollees specifically (if I find one I'll update this), but I do know that the number of uninsured Americans in the United States has dropped from 44.4 million in 2013 (just before ACA expansion went into effect) to just 25.3 million in 2023...even as the total U.S. population grew by nearly 24 million people. That's a net coverage increase of around 43 million Americans over the past ten years.

(As an aside, the combined total of ACA Medicaid expansion (around 24.5 million in June 2023) and ACA exchange enrollment (around 21.3 million), plus another ~1.3 million in ACA-enabled Basic Health Plans in NY & MN, is 47.1 million people. Make of that what you will).

So, what do House Republicans propose doing to Medicaid and CHIP?

For these reasons, the RSC Budget proposes to create five new block grants by repurposing funding for these programs and the Obamacare exchange subsidies. First, Medicaid funding for children and CHIP funding would be combined into a block grant that states can use to help families acquire health insurance. The grant would have no income floor so states could use it to provide for the needs of all low-income children. Medicaid funding for the elderly, people with disabilities, and pregnant women would be allocated into three more separate block grants for states to provide services for those populations in a flexible manner. A fifth grant would be available to states to support programs that ensure guaranteed insurance coverage, which would include funding for the guaranteed coverage pools mentioned earlier.

BLOCK GRANTS! DRINK!

From the Center for Budget & Policy Priorities:

Block grants are fixed pots of money that the federal government gives to states to provide benefits or services. Some policymakers call their block grant proposals "Opportunity Grants" or “merged funding streams.” Block grant funding levels typically are fixed; this contrasts with an entitlement structure, in which anyone who is eligible for benefits or services can receive them and funding increases automatically and immediately to respond to increased need due to economic downturns, natural disasters, or higher-than-expected costs (such as when a new drug or procedure increases health care costs).

The federal government’s entitlement programs reflect a commitment to meet low-income people’s basic needs in a few essential areas, including health (through Medicaid), food (through SNAP, formerly known as food stamps), and support to people with disabilities (through Supplemental Security Income, or SSI). All people who meet the programs’ eligibility criteria can access these programs without delay.

Block-granting these programs would strip away the federal commitment to help vulnerable individuals and families who are eligible for these programs when they need them. Fixed annual funding would render the programs unable to automatically respond to increased need, as they do today. As need increases, states would have to cut eligibility or benefits or establish waiting lists to stay within capped funding.

The major problems with replacing entitlement programs with block grants include:

• No automatic response: When people or communities are most vulnerable economically, block grants don’t respond to increased need.

• Capped and falling funding: Block grants’ funding levels tend to fall short of meeting need, requiring benefit cuts, eligibility restrictions, or waiting lists. Funding levels are often inadequate initially and typically erode over time.

• “Increased flexibility” and lack of minimum standards: States can shift the federal funds to other purposes or to replace state funding, or they can make program cuts that federal law doesn't permit now.

There's a whole other section of the RSC budget proposal which delves into further privatizing Medicare, weakening Social Security and other horrors which I may delve into in the future, but for now I'll just say, elections have consequences, so vote (and donate, and volunteer) accordingly.