The dirty little secret about Obama’s preferred HCR plan (besides the part where he sold the public out on the public option, then went before Congress and lied about it still being on the table) is that much of the expansion in coverage doesn’t come from the vaunted (and largely useless, massively overpriced) Exchanges, but through an expansion in Medicaid.

That’s not really the dirty part of the secret, it’s just common sense; the Exchanges will see premiums soar so quickly, and cost so exhorbitantly much, that there was no hope, ever, of even getting them off the ground if the truly poor got to buy ‘private’, ie corporatist, insurance. They’ll fall apart due to prices eventually, but it would be better if it took a while, politically at least.

So they expanded Medicaid, and rolled up the popular SCHIP programs into it. All sounds good, right?

Wrong. First of all, many doctors won’t touch Medicaid with a ten foot pole, because it pays so little. Nor is there any legal requirement to accept it.

Secondly, however: Medicaid is a jointly funded operation, part federal, part state… and the states are broke.

So for the first few years, the expansion is paid for entirely by the Feds, to make sure it actually happens; then in 2017, the Feds cut the subsidy back dramatically, and the states are expected to pick up the tab. These subsidy rates are actually more generous than I would have expected; for poorer, IE, more typically Republican states, the Feds might still pick up the whole tab. Others, like California, will get stuck with a quarter of the bill for the newly eligible, plus the usual rate for the rest in the program.

What happens if they don’t, or even can’t, pick it up? And keep in mind, the boosted subsidies only apply to the ‘newly eligible’. So what if they cut the overall program to the bone?

Like, say, they’re considering now in Washington:

Some 500,000 Washington adults whose prescriptions are covered by Medicaid could soon lose that benefit unless lawmakers provide special funding when they reconvene in January.

Medicaid’s adult drug program, which provides medication to the state’s poorest individuals through a combination of state and federal funding, will be eliminated in March if the Legislature can’t come up with $40 million before Feb. 1, according to the Department of Social and Health Services (DSHS).

…

The adult-prescriptions program cannot be protected in the DSHS cuts because federal law requires states to maintain many other Medicaid benefits, Porter said. Those federally required benefits include pharmaceutical coverage for children and prescriptions dispensed in health-care facilities such as hospitals and nursing homes.

Got that? States can, and will, slash Medicaid to plug holes in their budget, and something as simple as a basic prescription drug benefit for adults is on the table.

So, much like in the exchanges, people will be given a lousy service, full of holes and light on doctors, that they can’t effectively utilize, and lo, it will be called ‘health care reform’ by Obama’s wide-eyed and incredibly gullible followers.

Lather, rinse, repeat.