Despite promises that the emerging
* History suggests that structural changes to Medicaid would be very difficult to reverse. The basic concept behind the per capita cap is to impose a cap on federal funding per beneficiary, replacing the existing commitment of the federal government to pay a fixed share of state Medicaid costs. Experience with other programs suggests that such radical structural changes won't be reversed. The conversion of the Aid to Families with Dependent Children (AFDC) entitlement program to the Temporary Assistance for Needy Families (TANF) block grant in 1996 is instructive: TANF's block grant structure has not only persisted but also led to a continuing erosion of the program's funding and effectiveness.
* Indeed, the history of block grants (the closest analogy to a per capita cap) is that this structure enables deep cuts over time. Since 2000, funding for the 13 major housing, health, and social services block grants has fallen by 27 percent, after adjusting for inflation (and 37 percent after adjusting for inflation and population growth).
* Experience shows that spending cuts are also difficult to undo - due to both legislative and political constraints. Commentators have analogized the future increase in the Medicaid cuts to expiring tax provisions or cuts to Medicare payments to physicians under the "sustainable growth rate" (SGR) formula -- measures that threatened sudden and painful cuts or tax increases, which
* Indeed, while canceling the planned SGR cuts was highly popular and supported by a vocal and powerful interest group, for nearly 20 years -- almost without exception --
* Reversing Medicaid cuts would require both a political consensus that they shouldn't have been enacted and sufficient congressional support to either waive budget rules or find painful offsets to achieve them. To be sure, Medicaid has broad-based support and affects a wide range of seniors, people with disabilities, and families with children. But reversing these cuts would require mobilizing support not just for a low-income program but also for the revenue increases to pay for it.
* The cuts under a per capita cap would grow substantially over time -- making them harder to undo. That's true for both the destructive House cap and the even more destructive version under consideration by the
* States would have to plan for cuts in advance -- meaning they'd have no choice but to act pre-emptively, even if
Finally, it's worth noting that the
Thus, while pundits may be right that the bill's Medicaid cuts will unfold differently over time than anticipated today, the cuts would likely end up bigger, not smaller, than those enacted now.