February 21, 2025

Dateline – Seattle, Washington

Today was an uneventful travel day. I had to get up at a god forsaken hour for an early morning flight but every line, transfer, flight, and piece of public transportation functioned as designed and I was deposited at my father’s place after some eleven hours of totally benign travel. This is just as well as I am on day thirteen of the current viral infection. It is slowly improving. I don’t feel all that bad, just tired. The noise my bronchial tree is making is changing somewhat. It has morphed from seal with croup to walrus with diphtheria. I’m not sure if it’s much of an improvement. As I have to speak in the morning, I’m taking large quantities of Mucinex and cough suppressant. At least the laryngitis is better and I have a voice today when I did not yesterday or the day before. Fortunately, I will have a microphone and I won’t be asked to sing any of my answers to questions in geriatric medicine.

Paterfamilias looks fairly robust for 92 years of age and I am detecting nothing of serious concern as I cast my jaundiced eye over his form and function. I can breathe easier for the next six months or so. Haven’t seen anyone else in the family yet. They all know where I am and how long I’ll be here and I assume they’ll pop up when they can. Can’t say much about Seattle. It’s raining and rather dreary, which is pretty typical for February. I’m not planning on doing a lot of running around this weekend, just keeping family company and working on some writing.

As I was listening to the dinner conversations of the other silent generation residents of my father’s senior community, the big topic were the latest moves of the current administration, and their feelings of helplessness regarding the negative effects coming for society. These are people with living memories of the Depression and World War II who know what bad is and they all sense bad returning like we have not seen since those times. The Boom and younger generations have no real living memories of serious societal turmoil (with the possible exception of a few years in the late sixties) so they are still not completely understanding where all this can lead. If I have one piece of advice for today, listen to your oldest family members and have them tell you how and where they are drawing parallels.

When I started to comment on our political moment last month with the change of administration, I plainly stated that I am not and cannot write the kind of pieces I wrote during the pandemic as I don’t know the world of politics and socio-economics as well as I know the world of medicine and public health. I’m trying to stay within the borders of subjects I know something about and not be another deranged keyboard warrior opining on things of which I know little. I strongly recommend reading Heather Cox Richardson for a good regular placement of modern politics in historical context. But, there are things I do know a bit about in regards to health, medicine, senior care, and their ilk so I will try to stay in my lane.

In choosing what to right about today, I had a lot of options – Elon and the muskrats continued stomping through the bureaucracy without seeming rhyme or reason which seems to have led to the firing of park rangers, those who manage the nuclear arsenal, and a rather large number of recent veterans as the Biden administration had prioritized the hiring of veterans into federal positions so a large percentage of those still in their probationary period are of this type. The continued fallout on academic health centers of the lowering of indirect costs. (I will have to correct myself here – I had calculated that the hole blown in the UAB budget was $75 million a year. I was wrong, it’s only $70 million). The continued destruction of the post war European order. The annual freak show at CPAC. But I’ve decided to discuss Medicaid and how the dominoes are likely to fall if the proposed budget which calls for up to $880 billion dollars in cuts to Medicaid. I’m not exactly sure how this is supposed to work given that the 2024 federal contribution to Medicaid was about $620 billion dollars. I assume it’s some sort of multi-year reduction but the actual numbers are still quite nebulous.

What is Medicaid and why is it first up on the chopping block? As I alluded to in my last essay, the big money in federal expenditures is in health, defense, and social security. Medicaid is likely the most politically palatable to dismember because, as he says in his best Anna Delvy, it’s for the poors. Medicaid cuts are unlikely to affect the major donors to political campaigns or their nearest and dearest. When the US, through historical accident, created an employment based health care system post World War II, it led to some significant populations being excluded, the post employed and the unemployable. Twenty years later, congress passed Lyndon Johnson’s great society programs including Medicare (giving the post employed access to health care for treatment of their acute illnesses) and Medicaid (giving children, the impoverished, and the chronically ill – all poor populations) – access to health care for both acute and chronic issues.

Medicare was created as solely a federal program. It’s morphed a lot over sixty years but in its pure form, it was designed to be federally funded (with contributions from individual beneficiaries) and the same nation wide. Medicaid was not. It was created as a joint federal state program with both state and federal dollars flowing into it. It is therefore different in every state in terms of its benefits and ability to qualify and range of programs that it covers. Wealthy states such as California and New York have many more options under Medicaid that a poor state such as Alabama. The creation of Obamacare in 2010 led to an expansion of Medicaid eligibility under federal law to create a mechanism and funding to better cover the working uninsured. Politics of the time kept it from being a mandate and every state was free to participate as they saw fit. Most did. Some poorer Republican dominated states such as Alabama did not and their programs remain similar to what they were in the last century.

Medicaid is about 9% of the federal budget and about 19% of total health spending. About 27% of the population is a Medicaid beneficiary. Massive cuts would likely start with rolling back of the Obamacare expansions which allowed people of low, but not poverty level incomes to participate, removing millions of the working class and their families from access to health insurance. Some may be able to return to employer sponsored insurance (but it’s becoming more and more unaffordable). Others might be able to find a plan on the exchanges assuming they aren’t blown up. A lot will return to the ranks of the uninsured.

Medicaid and the related Children’s Health Insurance Program (CHIP) covers 60% of American children. If large numbers of children are removed from coverage and easy access to health care, there will be more sick children. As healthy adults come from healthy children, the disease burden on the population as a whole will rise. More children will die of preventable causes. Life expectancy will fall. We already have the highest child and maternal mortality rates in the developed world (in some parts of the US, worse than sub-Saharan Africa) and are life expectancy is significantly lower than Europe. Life expectancy is currently about 78. In 1900 it was 47. I doubt it will drop that low again but we could quite easily dip back into the low 70s are high 60s where we were when Medicare and Medicaid came into being.

Medicaid is the largest payor of long term care services. Medicare, as it is designed to get people over an acute illness, does not cover long term care or nursing home stays, other than in limited form as part of a recovery plan. Roughly six of every ten dollars going to long term care facilities in this country is from either federal or state Medicaid funding. It’s one of the biggest expenditures to state discretionary spending. In most states somewhere between 20-25% of discretionary spending flows to Medicaid long term care and total Medicaid is 35-40% of discretionary spending. The demographic changes of the aging boom have led health economists to predict roughly a 70% increase in these dollar figures over the next decade. The math isn’t mathing very well.

So we slash the beneficiaries or the reimbursements to make the math math again. I mentioned sicker children and populations above. What about long term care? The pandemic has done a number of nursing homes and other long term care institutions in this country. They can’t find good trained staff willing to accept low salaries and grueling jobs. Many have been bought up by corporate interests as profit centers and, if they cease to bring in profits, will be closed or downsized. If your plan for a carefree retirement is placing mom in a senior community and have someone else look out for her, you might need to rethink that as there simply may not be places extant to provide such care. This means taking in ones elders, a difficult task in a culture which prizes the nuclear family over the extended family model, and likely removal of adults from the paid work force to stay home and look after granny and keep her from falling or running over the neighbor’s mailbox with the car again.

The most chilling thing I have been seeing as I look through thought pieces from those who approve of the current administration’s policies is the rise of rhetoric discussing those not capable of contributing to the economic success of the country through paid work.. Words such as parasitical and takers appear constantly. I find this disturbing. The holocaust did not begin with the gas chambers of Auschwitz-Birkenau. It began with the decision of the German state to humanely remove the chronically ill, the mentally and physically infirm, those with birth defects, those who required significant assistance in maintaining their own bodies, all done in the name of economic necessity and humanitarian goals. Will be start down that path? I don’t know but if we do, I will not be part of it.