One thing you saw last night in spades is that Bill Clinton is willing to go where other politicians fear to tread—deep, by speech standards, into the weeds of public policy controversies. One worthy outcome of that is that while this week in Charlotte and last week in Tampa we’ve heard a lot about Medicare, it took Clinton to bring up Medicaid.
This is good because while Medicare is the larger and costlier of the two big federal programs, Medicaid is the one where much more is at stake on the ballot. The Romney plan for Medicare and the Obama plan for Medicare are different from one another in ways it’s worth trying to understand but the difference is being vastly exagerrated by both campaigns. The real gap on Medicare is between budget wonks in both parties who want to limit spending growth to GDP+1% and a general population that doesn’t really want to see any cuts at all.
Medicaid is a different story. Mitt Romney and Paul Ryan are proposing steep near-immediate cuts in federal Medicaid spending paired with shifting the program to a “block grant” structure so state governments will have wide latitude to find ways to kick people off the program.
The Obama administration also has some plans to restrain per patient Medicaid spending growth, but near the heart of the Affordable Care Act is the appropriation of a large sum of money to vastly expand the program’s coverage. If Obama is re-elected and the ACA is fully implemented, then over time all low-income will become eligible for Medicaid. What’s more, as Clinton argued last night, even though Medicaid is primarily known as a health care program for poor people the majority of the spending actually goes to disabled or elderly patients:
This is an important subject to inject into the campaign both because the policy differences between Romney and Obama are large and also because of the way it intersects with larger themes. In Tampa Republicans painted a portrait of an America in which there are basically three kinds of people. On the one hand you have the upwardly mobile job creators pulling themselves up by their own bootstraps. On the other hand you have the moochers and looters angling for handouts. And then there are our beloved seniors, very much entitled to their Medicare benefits. The key clients of Medicaid—children who didn’t have the wisdom to avoid being born to poor parents, people suffering from medical and physical disabilities beyond their control, senior citzens who need nursing home care—have no real place in that schematic view of America. But even though Democrats have, in practice, been pretty dogged in their defense of money for this program they don’t normally like to talk about it. While Paul Ryan wants to turn the banalites of partisan politics into an apocalyptic world-historical struggle, Democrats often like to portray the debate as a purely technical one in which their own pragmatic goodness faces off against unreasonable ideologues.
Medicaid is where the rubber hits the road in many ways. It’s about taking care of people who really need help. Democrats want to help them even if it’s expensive out of a serious ideological commitment and Republicans don’t out of an equally serious commitment. It deserves to be talked about more.