This morning Rep. Paul Ryan (R-WI) released a template for the FY2012 Budget Resolution. If The Path to Prosperity is, as the GOP promises, the road to restoring America's promise I encourage you to think about another road.
That is a picture taken during the Dirty Thirties, when our breadbasket crumbled. In the early 30s people turned their faces west. They did find work in California, though mostly as migrant laborers, picking fruit and harvesting lettuce. A few years later FDR would begin his New Deal of recovery, relief, and reform. Three decades on, the Great Society programs would reinforce our social safety net.
Mr. Ryan's budget doesn't even take pains to pretend to leave the safety net in place. Instead, he places all of us in the cradle of laissez-faire economics. The cradle metaphor isn't misplaced here, as it is children who are likely to suffer the most in Mr. Ryan's economic vision.
Mr. Ryan would turn the Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps) into a block grant (more on that in a minute). In 2015, when the economy is once again hale and hearty, benefits will be contingent on either holding a job or enrolling in job training.
This is replay of the 1994-5 debate on welfare reform, which required women to go to work. In general, I have no objection to requiring able-bodied adults to work given proper support. That means child care subsidies, food aid to cover the transition from cash assistance to full employment, transportation and housing subsidies, and so on. If we truly want women – and it is mostly women – to be self-sustaining, we must offer educational opportunities that end in a skilled job with family-supporting wages. How does Mr. Ryan intend to enforce a work or training requirement when very young children are in the home? Or if we have a double-dip recession and unemployment remains high?
Does Mr. Ryan not know that many food aid recipients are employed? They have minimum or low-wage jobs and, assuming a family of three, make less than $1,526 per month -- a couple grand more a year than a full-time, minimum wage worker would earn. Does he not know that increasing numbers of retirees -- again mostly women without pensions and with low Social Security benefits -– rely on SNAP? Will he require the elderly to work? And what about our service men and women who use food aid to make ends meet? Will they too have to get better jobs?
Medicaid is the health insurance program for America's poorest and most needy. The majority of beneficiaries are children and the elderly. I know that will surprise many, who think of it simply as program for the very poor. But Medicaid is much more restrictive than many imagine.
In general, states are only required to cover children (including those in foster care), pregnant women, low-income disabled persons, low-income adults with dependent children, and the elderly who have exhausted their savings and are in nursing homes. Childless adults, even those with incomes far below the poverty line are not automatically eligible for Medicaid.
Mr. Ryan, and Republicans in general, have argued that Medicaid is too expensive. Yes, it is expensive precisely because it is the payer of last resort. Children on Medicaid receive EPSDT services, aimed at preventing health problems. Children on Medicaid are sometimes medically complex and receive SSI income for extreme low birth weight or other serious maladies. Medicaid recipients under 22 or over 65 may be eligible via the need for inpatient mental health care. Elderly in a nursing home who have run through all their savings become eligible; Medicare doesn't cover long-term care. Medicaid is expensive precisely because it operates as a safety net and covers services unavailable via private insurance or Medicare.
Mr. Ryan argues about Medicaid's quality of care, pointing out that the health outcomes of beneficiaries is poor. He must have skipped the public health literature for the last decade or so. Medicaid beneficiaries are poor. Many rely on food aid and while I've save you a retread of Michael Pollan, our agricultural policies mean that healthier food is often more expensive. They are more likely to live in areas with high lead levels. More likely to live in areas too remote or unsafe to exercise. More likely to suffer stress. I recommend he look into the social determinants of health before commenting on Medicaid outcomes. Medicaid is not magic. It cannot heal all comers and then offer a ride home on a unicorn; it is limited medical benefit for people who have concomitant health challenges and outcomes to match.
Yes, Medicaid is straining states' budget and yes, reimbursement is too low to attract enough providers, particularly specialists. But block granting doesn't automatically solve those problems, nor does it solve the GOP favorite claims of fraud, waste and abuse. It just gives states the ability to hold the purse strings.
Mr. Ryan and almost every other R want to convert federal entitlement programs like Medicaid and Medicare to block grants. Block grants are Beltway-speak for bucket of money. Entitlement programs like Medicaid impose requirements and limits on the states to receive money (Rs call this bureaucracy). Do the limits impinge upon states' flexibility? Yes of course. Which is why the federal government allows demonstration projects and waivers – Section 1115, 1915(b) or (c) or some combination thereof, 1915(i). There are optional coverage services to be included or waived.
To simply gut the Medicaid rules that have guaranteed coverage for the most vulnerable citizens and instead hand governors a check is wrong. Mr. Ryan may decry the social safety net, thinking it is becoming a “hammock, lulling able-bodied citizens into lives of complacency and dependency” but I wonder how that image squares with the reality of Medicaid: a child, a pregnant woman, a bed-bound senior, or a disabled adult.
There are other changes in the budget. Ending Medicare for those under 55. Lowering corporate taxes from 35% to 25%. (I'd support that one, if it meant companies actually paid federal taxes.) Cutting federal workers salaries and benefits.
Mr Ryan may pretend that his budget represents some grand vision for America's future. But in truth it is the plan of someone who read too much Horatio Alger and Ayn Rand, of someone who has never lived in Section 8 housing, of someone who does not know hunger, of someone who never had to take their kids to mall to get warm in the winter, of someone who enjoys their comfortable, government-provided chair atop the House Budget Committee.