Medicaid is a lean, efficient, program and is in fact far
less expensive than the rest of our healthcare system. It's also
very popular with its customers, more so than private insurance is with people who have it. So clearly the job for Republicans is to fuck all that up, and they're doing it by
adding layers of complexity and cost under Obamacare's Medicaid expansion program.
Take, for example, Arkansas—the state that got the ball rolling for red states seeking GOP twists on Medicaid expansion with its privatized version known as the "private option."Last month the state got approval for a byzantine new program, called Health Independence Accounts, that imposes co-pays on some beneficiaries unless they pay a small monthly fee. Those who have paid their fees are eligible, under certain conditions, for up to $200 to pay for the costs of private health insurance if their income goes up and they transition off of Medicaid. To run the program, the state will pay a third-party administrator about $15 million annually (covered by the feds as part of the cost of expansion).
Meanwhile, Iowa is now imposing low premiums, tied to a wellness program, on some beneficiaries. "The administrative complexity of the system the state is contemplating is somewhat mind-boggling," Joan Alker of the Georgetown University Health Policy Institute commented when Iowa's waiver was approved, adding that "[t]he wellness program is of questionable policy value." Indiana's proposal includes small premiums and savings accounts tied to different benefits packages, leaving advocates for beneficiaries worried that low-income adults "face categorization into a bewildering array of benefit plans and options." […]
"All of those ideas, leaving aside their policy merits, they all presuppose a pretty intensive level of government involvement in people's lives," Alker, an expert on Medicaid waivers, told me by phone. Alker points out that the original proposal by Pennsylvania suggested that the state would eventually be tracking everything from cholesterol level to work history to legal record. (In the end, the feds accepted just four of Pennsylvania’s initial 24 waiver requests.) The implicit bargain has been to offer a social safety net for the poor, but only via an intrusive nanny state.
Wait, isn't that what Republicans are always complaining about? Excessive and expensive bureaucracy and government intrusion into people's lives? There are a couple of possible motivations here, which aren't mutually exclusive. One is to make getting assistance as miserable and difficult as possible for poor people because that's what they deserve. Another is to wreck what is essentially a very good federal/state program that helps a lot of people, because the first step to destroying government is to make it not function.