Brendan W. Williams, M.A., J.D.
Brendan W. Williams, M.A., J.D.

As a kid I was obsessed over the idea of a doomsday device. As an adult, I think I have found one – it would look a lot like a Medicaid block grant.  Why, especially with a growing population of older adults with long-term care needs, substitute an arbitrary formula, or cap, for a system in which the federal government matches state Medicaid spending?

The illogic hasn’t daunted some conservatives. Tennessee Gov. Bill Lee (R) wants his state to be the first to volunteer to have its federal Medicaid funding rationed. With a Federal Medical Assistance Percentage of 65.2%, Tennessee gets the 18th-highest proportion of its state Medicaid costs covered by the federal government, and shouldn’t question its good fortune. 

Healthcare advocates have expressed alarm.  While not protecting Medicaid beneficiaries, or care providers, the bill passed in Tennessee would artfully exclude “administrative costs from the block grant financing amount and permits the state to continue to draw federal matching funds for administrative costs[.]”  Because, after all, heaven forbid you put the bureaucracy at risk!

Alex Azar, President Trump’s Department of Health and Human Services secretary, has suggested the Trump Administration may allow block grants without congressional approval, even though they run contrary to precedent dating to the 1965 establishment of the Medicaid program.

In Alaska, Gov. Mike Dunleavy (R) who began his tenure by proposing a devastating 32% cut to Medicaid, hyped a desire for Alaska to be the first state to get a block grant, only to reportedly be contradicted in legislative testimony by his own health commissioner – whose background, prior to being tasked with safeguarding the well-being of the most vulnerable Alaskans, was a “family-owned truck-driving and construction academy[.]”  Prior to his confirmation, that commissioner reportedly ended benefits through Alaska’s Senior Benefits Program to more than 4,000 seniors.

As Becky Hultberg, the president and CEO of the Alaska State Hospital and Nursing Home Association, has written of Dunleavy’s proposed cuts, “It is impossible to quantify the impacts without analysis, but the governor is pushing cuts without that information.”

The same could be said of the rush by states to be the first to embrace one of conservatism’s Holy Grails: block grants. There is no evidence to support the idea that cost-cutting efficiency would increase – instead all we know for certain is that states would be left with less money. The Center on Budget and Policy Priorities has written that block grants would be especially risky in an economic downturn, noting ‘Fixed funding levels would require states to absorb higher costs — or to cut eligibility or benefits. And the economy would lose an automatic stabilizer, which would worsen the downturn.” 

With Alaska’s governor already looking to slash Medicaid, imagine how much worse things could be under a block grant if the economy tanks? Similarly, despite the robust economy, Tennessee has already been busily purging over 100,000 children off Medicaid.

Block grants would also have a risky interplay with the misplaced enthusiasm for Managed Long-Term Services and Supports (MLTSS).  If there is a third guarantee in life beside death and taxes, it is that MLTSS insurance companies will always get paid, even if providers go without payment or patients go without care – now a matter of federal investigation in places like Iowa and Texas.

The New York Times recently published a sobering article on how few Americans are prepared to pay for long-term care.  Eviscerating the social safety net through block grants can only further contribute to a dystopian future for aging adults and all others on Medicaid.

Brendan Williams is the president/CEO of the New Hampshire Health Care Association.