Like millions of Americans, Jamie McBride and her family are scrambling to make ends meet on a fraction of what they earned in happier times. Her partner, Felipe, is in community college in Albuquerque, training for work in sheet-metal technology. She stays home raising her two young daughters and earns $100 a week providing childcare for her sister’s kids. Jamie has gone without a functioning pair of glasses since she broke her frames in 2009. When she went to get them repaired she was told that because of Medicaid cuts she now has to wait three years instead of one before her insurance will cover replacements. To repair the frames herself would cost $50, which she can’t spare. So for now she squints.
Cases of more dire medical needs going unmet are, sadly, no less common these days. Consider Patty Poole, a 42-year-old woman living in Endicott, New York, who suffers from chronic lymphedema, a nasty condition in which lymph nodes swell and tissues fill with undrained fluid. By the time she received the diagnosis in February, one of her legs had swelled to several times its normal size, and her skin was so badly infected that she had to be hospitalized to control the infection before a surgeon could operate on her. She urgently needs a $900 compression garment to keep the swelling under control, but Medicaid no longer covers the cost.
Over the past couple of years, Medicaid administrators and legislators around the country have been penny-pinching wherever possible to prevent their overstretched systems from snapping. Some cuts have already kicked in; many more will do so in 2012. But these short-term savings come with consequences that will have long-term costs: fewer services, lower-quality care, less access to doctors, more difficulties in getting impoverished residents enrolled. The crisis is particularly acute—and self-reinforcing—because surging poverty is raising the number of Americans who qualify for Medicaid. There will, in short, be more Jamie McBrides and Patty Pooles in the years to come.
All of this reflects a stunning reversal of fortune for the Obama administration, which saw the crisis coming early and acted aggressively to contain it. The American Recovery and Reinvestment Act of 2009 dramatically beefed up federal contributions to state Medicaid budgets for a two-year period and mandated that states maintain their existing eligibility criteria. And the American Healthcare Act of 2010, upon which President Obama has staked so much political capital, envisions expanding rather than contracting Medicaid access.
Now that the federal stimulus has tapped out, nearly all states are finding that their larger Medicaid populations are potential budget-busters. But if the crisis is in part indicative of the depth of state fiscal woes amid the Great Recession, it is also the product of GOP ambition in the wake of the midterm elections of 2010, when the Republicans opened up several fronts in an ideological war on the American safety net.
The energetic GOP attack on New Deal and Great Society programs has put Medicaid, in particular, in the cross-hairs. House Budget Committee chair Paul Ryan envisions block grants replacing federal eligibility mandates for the states. The grants would essentially remain constant even if the need for Medicaid increases considerably.