Three months ago the Republicans opened debate on the FY2012 budget when Rep. Paul Ryan released The Path to Prosperity: Restoring America’s Promise. In that plan, he proposed a remaking of Medicaid that would eviscerate the program’s core purpose: provide health care to the most vulnerable.

Many labor under the misconception that Medicaid is health benefit open to any low-income American. In reality, states are only required to cover impoverished children (including those in foster care), pregnant women, some disabled persons, some adults with dependent children, and the elderly. In fact, more than 2/3 of Medicaid spending pays for services for the disabled and elderly; children consume about 1/5 of the total funds with the rest going to adults.

Childless adults, even those with incomes far below the poverty line are not automatically eligible for Medicaid. Nor are the parents of Medicaid-eligible children automatically eligible for coverage. For example, in Alabama, parents’ incomes cannot exceed 24% of the federal poverty line – less than $5000 a year for a family of three. Eleven other states all have income eligibility well below the FPL.

Mr. Ryan, and Republicans in general, have argued that Medicaid is too expensive. Yes, it is expensive precisely because it is the payer of last resort. Children on Medicaid receive Early Periodic Screening Diagnosis Testing (EPSDT) services, aimed at preventing health problems. EPSDT includes childhood immunizations, medical and mental health exams, lead toxicity screening, vision and dental services, and lab tests. Apart from poor children, some kids come by their eligibility via inpatient medical or psychiatric stays (sometimes called institutional eligibility, as opposed to community eligibility) or via SSI because of extreme low birth weight.

Medicaid is expensive precisely because it operates as a safety net and covers services unavailable via private insurance or Medicare, such as long-term institutional nursing care.

Republicans are expending a lot of breath arguing that Medicaid's quality of care is poor. I can only guess willful ignorance of any of major public health literature on the social determinants of health. Medicaid beneficiaries rely on food aid (SNAP or WIC), are more likely to live in areas with high lead levels, more likely to live in areas too remote or unsafe to exercise, and more likely to suffer stress. Having a health benefit does not convey some magical immunity to disease or disability. Medicaid is a medical benefit for people who have concomitant health challenges and outcomes to match.

I will more than agree that Medicaid is straining states' budget. Combine a major recession (lower revenue) with massive unemployment (loss of benefits) and you end up with the perfect fiscal storm of reduced state revenue at precisely the same time that more people need services. The federal government did help some, via TARP, when they raised the federal share of Medicaid funding for states. And it will help more in 2014 when it pays 100% of the costs for newly eligible beneficiaries, many of whom are at this moment sitting in EDs running up the uncompensated care side of the ledger.

(Oh, and by the way, no word on whether the Republican proposals will preserve family planning’s special status. Unlike other health services, the feds pay 90% of the cost for family planning, out of recognition of its incredible effectiveness and cost savings. Somehow I doubt that Republicans are very concerned about the unmet health needs of women.)

The Republicans straight up lie when they say that Medicaid is completely inflexible as-is and needs to be turned into a block grant.

Block grants are Beltway-speak for bucket of money. Entitlement programs like Medicaid impose requirements and limits on the states to receive money. Do the limits impinge upon states' flexibility? Yes of course. Which is why the federal government allows demonstration projects and waivers – Section 1115, 1915(b) or (c) or some combination thereof, Money Follows the Person, and 1915(i). Without block-granting anything, Congress managed to grant scads of flexibility to states through the normal legislative process. Maybe someone should remind the Republicans that they can, y’know, amend existing laws.

Block granting Medicaid means we lose the federal floor of eligibility. The minimums now required of states will evaporate. Instead of guarantees for the most vulnerable citizens, governors get oversight. Do we really want to leave Medicaid eligibility to the political winds? In Virginia, a governor can serve only 1 term. Might families have to grapple with new and different eligibility every.four.years? If the Republicans are so very concerned with outcomes, why potentially interrupt continuity of care?

The Republicans can only pretend that cuts to Medicaid will solve the economic crisis as long as we let them. Remind them of what LBJ said when he signed Medicaid into law:

"But there is another tradition that we share today. It calls upon us never to be indifferent toward despair. It commands us never to turn away from helplessness. It directs us never to ignore or to spurn those who suffer untended in a land that is bursting with abundance….And this is not just our tradition--or the tradition of the Democratic Party--or even the tradition of the Nation. It is as old as the day it was first commanded: 'Thou shalt open thine hand wide unto thy brother, to thy poor, to thy needy, in thy land.'" [Deut 15:11]

We must confront Republicans with the reality of Medicaid -- a child, a pregnant woman, a bed-bound senior, or a disabled adult. If they still refuse to give up tax breaks for hedge funds managers, preferences for fossil fuels, and tax cuts for families making a quarter-million a year, then we should -- we must -- confront them at the ballot box.