Before I begin, I want to again stipulate that Tom Cotton loves puppies.
Of more concern to voters is that Cotton, as we discussed in detail last month, aims to repeal the private option, kicking more than 200,000 Arkansans off of their health insurance, and then on top of that, slash hundreds of billions in Medicaid and ARKids funding which is used to provide health coverage for the state’s most vulnerable citizens: the disabled, poor children, the elderly in nursing homes, and extremely poor parents.
Piggybacking off of our post, Affordable Care Act enrollment guru Charles Gaba did some back-of-the-napkin calculations on what Cotton’s proposed funding cuts would mean for Arkansas and found that Cotton’s plan potentially means around 20 percent of the entire population of Arkansas could have their health insurance snatched away. The state might instead choose to spread the pain, with the potential for Cotton’s cuts to impact 33 percent of the state’s residents. We know that Cotton likes to demonize beneficiaries of the public safety net, but we’re talking about a third of the state.
Gaba took the total number of people on Medicaid and ARKids in 2010 (pre-Affordable Care Act), 721,000, and applied the cuts in funding (again, this is on top of repealing the ACA entirely) that Cotton has voted for — between 20-39 percent over ten years, getting worse over time with cuts up to 50 percent by the tenth year of implementation. (Using the 2010 Medicaid population as a baseline actually understates the raw number of people impacted in, say, 2024, since the Medicaid population will actually grow with population growth.)
As Gaba notes, this analysis is an oversimplification because while ending the private option, for example, means cancelling the insurance of those specific people, Cotton’s other proposed cuts are directed at the budget for Medicaid and ARKids. It would ultimately be up to the state to determine how to respond to the loss of funding. As I explained here, Arkansas would be faced with hard choices which would produce real harm: reducing already low reimbursement rates to providers, benefit cuts, or reducing eligibility and kicking people off their coverage. Again, we’re talking about the disabled, the elderly, children, and parents with basically no income at all.
One possibility, the possibility imagined by Gaba, is that the state would simply reduce eligibility in a one-to-one correlation with the budget cuts. But it’s more likely that states would try to spread the pain — perhaps slightly narrowing eligibility while giving benefit cuts to everyone else. Perhaps they would try to protect children and make the Medicaid program in Arkansas even stingier for adults (remember, Cotton would eliminate the private option entirely, and before the private option, the state’s Medicaid program was one of the most barebones in the nation). We know from past experience that nursing-facility care would likely be on the chopping block. They might also aim to cut provider reimbursements, but the state is already under-reimbursing for Medicaid, and further cuts could lead to a real access crisis that harmed all beneficiaries (or get the state sued).
In short, the state would have a choice between harming some beneficiaries dramatically, harming all beneficiaries a smaller amount, or somewhere in between. But make no mistake: billions in cuts to federal funding for the disabled, kids, and the elderly would lead to real harm.
Let’s dig into the numbers a little bit. Keep in mind, the cuts we’re looking at are based on Cotton’s votes and public statements.
* Latest numbers on the private option: 211,611 are covered. These people would lose their health insurance if Cotton was successful in ending the private option, as he has voted to do many times.
* Latest enrollment numbers on the Arkansas Health Insurance Marketplace, the health insurance exchange created by Obamacare: 38,210 are covered. These folks would also lose their health insurance if Cotton was successful in repealing Obamacare. If this happened, some of them would still purchase individual health insurance on the private market. But keep in mind, 90 percent of them are receiving subsidies to reduce the price of premiums, subsidies which Cotton would eliminate. Also, some of these folks have pre-existing conditions and might find themselves shut or priced out of the market if Cotton succeeded in repealing the ACA.
* Cotton voted to cut federal funding used for health coverage for kids, the disabled, the elderly, and parents who make less than 17 percent of the federal poverty level (this was the pre-existing Medicaid and ARKids programs, that were in place even before Medicaid expansion — Cotton wants to cut them too). According to analyses by the Center for Budget Policy Priorities (CBPP), the cuts Cotton voted for in the Ryan budget amounted to 20 percent over ten years; the cut cuts he voted for in the Republican Study Committee budget amounted to 30 percent over ten years. Because the cuts would be applied differently state-to-state, this actually understates the impact on Arkansas; when CBPP looked at the funding formula for Arkansas specifically, the cut was a whopping 39 percent over ten years. So, depending on how you look at it, somewhere between a 20-39 percent cut in funding over ten years for kids, the disabled, the elderly, and parents.
* If Arkansas responded to a 20-39 percent cut with a corresponding cut in eligibility, that would amount to taking away health insurance from an additional 144,200 to 281,190 people. This is based on the Medicaid/ARKids population in 2010; that population is likely to grow, so again, we’re actually understating the raw number of people who could be impacted. Meanwhile, the cuts increase over time; both the RSC cuts and the Arkansas-specific Ryan Budget cuts project to wipe out half of federal funding by the tenth year of implementation. We’ll stick with 20-39 percent, but if Cotton got his way, the impact would be much worse in, say, 2024***.
* Remember, though, Arkansas might instead spread out the impact. Instead of cutting health insurance entirely for 144,200 to 281,190 people (on top of kicking 211,611 people off of their private option coverage and 38,210 more off their Marketplace coverage), the state might choose to reduce benefits or access for everyone — 721,000 of the disabled, kids, extremely poor parents, and the elderly. In this scenario, less people would lose their coverage entirely, but more people would potentially be somewhat harmed.
Add all that up and Cotton is talking about taking away health insurance from between 394,021 to 531,011 people. That’s 13 to 18 percent of the entire state’s population!
Or, if the state spread the pain, the cuts to coverage could impact 970,821 Arkansans, or nearly a third of the state’s residents.
***If you want to look at the scenario for 2024, when the cuts could be up to 50 percent, rather than the 10-year average — then we’re talking about taking away coverage altogether from 21 percent of the entire state’s population or even more severe benefit cuts impacting up to 33 percent.
None of that is to say that Cotton hates puppies, or hates the people who would lose their health coverage or potentially see their benefits or access to an already narrow group of providers reduced. We don’t judge politicians by their feelings. We judge politicians by the consequences of their votes and their proposed platform. Cotton may not succeed, but his policy goals involve reducing or eliminating health coverage for between 13 and 33 percent of Arkansans.