During a 32-year tenure that flowered during the Cold War, the Los Angeles Congressman sought federal money to help Americans survive a nuclear war. He called for “a nationwide system of underground shelters” in which to huddle, safe from irradiated debris.
Though Holifield achieved success in other areas – he was known as “Mr. Atomic Energy” for his promotion of nuclear power — he left Congress in 1974 without fulfilling his subterranean vision.
Holifield was succeeded by a 35-year-old State Assemblyman who did not share his preoccupation with nuclear war. Henry Waxman was focused on putting the federal government in control of health care. Republicans who last month voted to reauthorize and expand some of Waxman’s pet programs can learn a good deal from his habit of planting small provisions in bills that yielded big results.
Those results continued beyond his retirement at the end of the last Congress. As I noted in my last post, the House two weeks ago overwhelmingly approved a bill that lavished billions on community health centers, poured more money into efforts to enroll children and their parents in Medicaid and Obamacare, and reauthorized the CHIP program despite CBO’s observation that it would at best negligibly reduce the number of uninsured children.
The homage to Waxman didn’t stop with reauthorizing redundant programs for children. It also produced a new entitlement program for low-income seniors.
Since 1997, states have been required to pay Medicare Part B premiums for beneficiaries with incomes between 120 and 135 percent of the federal poverty level ($14,124 – $15,890), through the Medicaid QI (“qualified individual”) program. Congress limited QI spending by stipulating in the statute the amount the federal government would spend each year on the program. H.R. 2 changes all that, essentially turning QI into an open-ended entitlement program by authorizing the HHS Secretary to increase spending annually and in perpetuity. The chart below traces the upward path of that spending.
Prior to H.R. 2, Congress never appropriated more than $885 million to the program, the result of a one-time splurge created by the Obama Administration’s “stimulus bill.” The House-passed bill allocates a record $980 million, then gives HHS authority to hike outlays annually based on population growth and increases in Medicare premiums. CBO projects that in 2025, annual federal QI outlays will total $2.2 billion. In the ten-year period from 2005 through 2014, the federal government spent less than $5.9 billion on the program; under H.R. 2, CBO estimates that the government will spend almost that much –$5.4 billion – over the next five years and a total of $14.2 billion between 2015 and 2025.
As with the rest of the H.R. 2’s $30 billion in new social welfare spending, Republicans seem not to have noticed the bill’s effect on the QI program. The QI spending spree starts small, but is projected to grow rapidly and without limit, a pattern Henry Waxman established in a series of Medicaid expansions that he engineered long ago.
When Waxman arrived in Washington in early 1975, Medicaid benefited a limited population. Eligibility depended on whether an individual was “categorically needy” – with little income, virtually no assets and qualified by age, disability or single parenthood for AFDC (a cash welfare program) or SSI (an income support program for indigent aged, blind and disabled people). Because income alone did not make people eligible for the program, growth in the number of Medicaid recipients was, to a great extent, constrained.
Waxman began to change that in 1984. The Democrat-controlled House was considering major deficit reduction legislation favored by the Reagan Administration. Some moderate Democrats supported the legislation, but Waxman argued that the White House should be forced to make some concessions to House liberals.
The concession he sought seemed innocuous enough. It required states to extend Medicaid coverage to certain women who were pregnant for the first time and to preschool children in two-parent families born after September 30, 1983. These two new sympathetic groups of beneficiaries were made eligible for Medicaid even if they were ineligible for cash welfare benefits under AFDC, although they were required to meet the program’s income and asset tests. The link between AFDC and Medicaid was broken, at least for these groups, setting a precedent for further enlargements of federal health care programs.
In 1986, the law was again amended, again as part of a deficit reduction bill. This time, it permitted (but did not require) states to cover children under age 5 living in households with incomes below the federal poverty level. For the first time, a group of individuals could gain Medicaid coverage solely on the basis of household income, without regard to their family’s assets or eligibility for AFDC.
In 1989, the state option became a federal mandate in yet another deficit reduction bill. Beginning in that year, the federal government required states to cover all children under age 6 in households with incomes less than 100 percent of FPL.
A year later, in the 1990 bill deficit reduction bill that famously saw President Bush break his “no new taxes” pledge, Congress went further. It mandated that states provide Medicaid coverage to low income children born after September 30, 1983, until their eighteenth birthdays.
Medicaid coverage had been completely transformed, at least for pregnant women and children, from a program for the categorically needy to one that covered every child under 100 percent of FPL without regard to parental assets and eligibility for other income support programs. The number of children on Medicaid increased year by year.
But the Waxman project wasn’t yet complete. In 1997, he worked for the creation of the Children’s Health Insurance Program (CHIP), initially intended for children under 200 percent of FPL. Congress provided so much money for the new program so rapidly that states couldn’t find ways to spend it all. They sought new populations to cover. Within a matter of years, states were obtaining waivers from CMS to spend “children’s” health insurance money on parents and even on childless adults.
By the time Obamacare was enacted, 24 states were covering children living in households with incomes over 250 percent of poverty. The Kaiser Family Foundation estimated that in June 2013, 33.7 million children were covered under Medicaid or CHIP and another 5.2 million kids were eligible but not enrolled. Waxman’s gradual expansions had made nearly 39 million of the nation’s 73.6 million children eligible for Medicaid or CHIP even before Obamacare was implemented.
With that implementation, three federal programs (Medicaid, CHIP and Obamacare) compete with each other — and employer-sponsored plans — to cover children from low and middle income households. Despite this redundancy, House conservatives last month voted overwhelmingly to reauthorize the expiring CHIP program as part of a larger measure to increase Medicare payments to doctors.
Republicans who would rather have eaten sushi from a gas station than vote for a bill to fund the Homeland Security Department for a few months lined up to spend tens of billions to finance a government health insurance program of dubious value, turn a relatively small program for low-income seniors into a costly entitlement, commit billions in new spending to community health centers, and pour more resources into the government’s efforts to enroll people in Obamacare.
House conservatives could sorely use a dose of Waxman’s legislative acumen. They provoke unwinnable confrontations over some bills, then inexplicably acquiesce in others.
Their lack of legislative strategy may have something to do with the circumstances that produced the Tea Party insurgency. It was born of well-justified hostility – to bailouts, to “stimulus” spending, to Obamacare. Now that they have power in Congress, they seem unsure of what to do with it. Making big changes in a short time against a determined opposition is harder than they’d imagined. So they seem to have transferred their hostility to their party leaders and to the legislative process itself. Their odd coupling of ideological passion with intellectual laziness has led them to prize the defiant pose over the hard work of legislative accomplishment.
That work, as Henry Waxman demonstrated, requires time, persistence and a neurotic attention to detail. It rewards workmanship over showmanship, incremental change over grand gestures. Most Republicans who voted in favor of H.R. 2 never took the time to learn what was in it. All they knew was that doctors back home (and Governors eager for more federal CHIP money) were lobbying for it and talk radio hosts weren’t fulminating against it. And that was enough to win their support.
Had they served in Congress during the 80s and 90s, they probably would not have noticed that Waxman was seeding deficit reduction bills with the antecedents of Obamacare. That audacious law did not arise ex nihilo. It was the product of small steps toward a federal takeover of health care, a project that has progressed gradually but inexorably over decades and still is not complete. It is a tribute to Henry Waxman that the most strident foes of his project voted to carry it another small step forward.
Now that they have embraced some of Waxman’s programs, perhaps Republicans might consider emulating his approach to lawmaking. The alternative is to doom the agenda of this extraordinary conservative majority to the same fate as Chet Holifield’s nuclear catacombs.