Some quick points (I am sure others will be able to make other important considerations):
-Bush is motivated by the increased enrollment and spending in Medicaid to "fix" the problem. But of course he fails to address the reason why enrollments are increasing--cost shifting employers, soft economy, high health insurance premiums and other out-of-pocket costs. He also fails to address why costs are increasing: high-cost/marginally beneficial care, expanding medicalization of all human ups and downs, and ad/consumer driven demand for unnecessary drugs and procedures.
-Bush is trying to fix the problem "over time" by getting states to "lock-in" current Medicaid payments to the states (well, a fight appears to be shaping up over the formulas). Now, this may win points in pub admin circles but it drastically changes the incentives for states. As long as states get federal matching funds for Medicaid services there is a decent incentive to expand/maintain services(even in hard times but obviously cuts are being made now because of extraordinarily bad state fiscal situations). After this is changed to a block grant, the fiscal incentive will be to cut/maintain services. Cuts will be draconian in future downturns.
-The benefit the states get is increased "flexibility". But what does this "flexibility" mean? Flexibility means cutting programs/services/care mandated in the original legislation. Generally, people with disabilities have the costs per members in Medicaid and require the widest range of services (e.g., Medicaid pays for transport for their medical/rehab care). Flexibility means the states can shave some of these services (like adult day nursing or day hab for the disabled or Renal Dialysis which impacts very few people but is pretty expensive for those cared for). Medicaid MCO's (managed care orgs) have always had flexibility and have made few inroads in care for the disabled--but they have experience in treating poor women and kids lousy! The point is "flexibility" means cutting programs.
-I am not a lawyer but nearly all cuts to Medicaid are heavily litigated. This just increases the burden to the states and if Medicaid members are able to restore their services, some other program or member will have to get the axe (it will be a fixed pie).
(I am sure I had more points but I am easily distracted).
More bad news,
Jim
Governors Get Sympathy From Bush but No More Money By ROBERT PEAR
WASHINGTON, Feb. 24 — President Bush told governors today that he would not support proposals to provide new fiscal assistance to states struggling with what governors say is the worst financial problems since World War II. . . . . http://www.nytimes.com/2003/02/25/politics/25GOVS.html _____________________
Bush Proposes Major Changes in Medicare and Medicaid By ROBIN TONER and ROBERT PEAR
ASHINGTON, Feb. 23 — President Bush has begun one of the most ambitious efforts to reinvent Medicare and Medicaid since the programs were created 38 years ago. Combined with his earlier plan for Social Security, the proposals offer a fundamentally different vision of social welfare policy, many experts say. . . . . http://www.nytimes.com/2003/02/24/politics/24AGEN.html ______________________
Governors, Hurting Financially, Ask Washington for Assistance By ROBERT PEAR
WASHINGTON, Feb. 22 — Leaders of the National Governors Association, experiencing fiscal problems unmatched since World War II, cried out today for help from the federal government as they opened their winter meeting here. . . . . http://www.nytimes.com/2003/02/23/politics/23GOVS.html ______________________
All Governors to Be Asked to Back Bush on Medicaid By Robert Pear, The New York Times February 20, 2003
WASHINGTON, Feb. 19 - Tommy G. Thompson, the secretary of health and human services, said today that he wanted the nation's governors to endorse President Bush's proposal for sweeping changes in Medicaid when they meet here next week. . . . . http://www.nytimes.com/2003/02/20/politics/20HEAL.html ______________________
"America's political problem solvers: spin, myth construction, maudlin sentimentality, and the real politik of screwing the poor."
--Jim Westrich