The fiscal plan proposed this week by House Budget Committee Chairman Paul Ryan (R-WI) would profoundly change the way seniors and younger adults with disabilities receive health care and personal assistance.
For many programs, it would reduce funding from today’s levels even though the population of those over 65 will double by mid-century. In many ways, it would end the Great Society’s vision of a federal safety net for these vulnerable populations and place the burden of their care on states or their families.
This budget will pass the House sometime in the next few weeks. And make no mistake, though it has no chance of becoming law, this plan will be a touchstone in what will be a game-changing debate over federal deficits and the role of government.
The House Republican budget would do the following:
Medicare: It would replace traditional Medicare with subsidies that seniors would use to buy insurance on the individual market. It would raise the age of eligibility from 65 to 67. The Congressional Budget Office estimates that the federal government would spend about one-third less on Medicare by mid-century than it would under current federal policies. That means health spending would become remarkably efficient or seniors themselves would pay more.
The Affordable Care Act: It would repeal the 2010 health law, including its important initiatives aimed at better integrating care for seniors and others with chronic disease.
Medicaid: Instead of automatic federal funding for a share of this program, states would receive only an annual grant, which Congress could adjust at will. In return, states would have the flexibility to operate Medicaid as they choose. CBO projects that by mid-century federal funding for Medicaid would be only half what it is today as a share of the economy, and less than one-quarter of what it would be under today’s policies. The budget would cut planned Medicaid funding by $800 billion over 10 years
The Ryan budget does not mention, or appear to recognize, the important role Medicaid plays in financing long-term care supports for the frail elderly and younger people with disabilities, even though it pays more than 40 percent of these costs and these services represent a third of its budget.
Non-Medicaid services: These critical supports for those receiving care at home, such as transportation, nutrition, and counseling, as well as caregiver assistance—already under severe budget pressure— would take the biggest hit. While the budget outline does not make specific program cuts, it would likely mean federal funding for most of these programs would be entirely eliminated. Some programs would be turned over to the states. Others would disappear.
If the Republicans win the coming election, the House budget will frame the way they will govern. Not all of it would become law, even under a President Romney or President Santorum, but a lot would.
Even if President Obama is re-elected, services for seniors and the disabled will likely face deep cuts. In last August’s budget debate and in the fiscal plan he proposed in February, Obama showed that he too was willing to sharply slow the growth of programs such as Medicare, Medicaid, and non-Medicaid services.
He’d preserve these programs in their current form, but he’d fund them at much lower levels than under current government policy.
The other day, an advocate laughingly dismissed the idea that programs for seniors and others with disabilities will face such dramatic cuts. That attitude is naïve and dangerous. The parameters for the coming budget debate are clear: Substantial cuts in services under an Obama White House or an historic remake of the safety net and even deeper cuts under Republican government.
Either way, seniors, service providers, and their advocates need to prepare for a much different world.