Louisiana's Republican elected officials have targeted the Medicaid program as a behemoth that will suck up every available dollar if the state, which is struggling with continuing financial problems, doesn't get it under control.
By fulfilling one of his major campaign promises, Gov. John Bel Edwards has given them more ammunition for their grousing, by boosting the program's costs dramatically with his Medicaid expansion.
As in most budget debates, the numbers are complex — and can be bent to fit multiple narratives, depending on who's doing the talking.
Republicans have called Medicaid unsustainable, suggested fraud is prevalent and criticized the program as offering too many free services. GOP U.S. Sen. John Kennedy lambasted Medicaid spending levels last week in a letter to the Democratic governor.
"He knows this is unacceptable and we can't afford this, and what galls me is there's absolutely no effort to control costs," Kennedy said in an interview. "It's just, 'Give me more. Give me more. Give me more.'"
Edwards' spokesman Richard Carbo responded that Kennedy was "spreading misinformation" and trying to strip health coverage from the needy while receiving a taxpayer-financed salary and benefits of his own.
"Sen. Kennedy believes Medicaid is a bad thing, and that the elderly, disabled and working poor people of Louisiana should be on their own," Carbo said in a statement. "However, to hundreds of thousands of Louisianans without any other access to medical care, Medicaid is a chance at a better life, to find a job or fight an illness."
Medicaid is an easy punching bag because of its sheer size.
Louisiana's Medicaid budget is $12.5 billion in the current 2017-18 financial year, 44 percent of the total $28.3 billion state operating budget. Five years ago the program cost $7.7 billion.
That's a growth of 62 percent.
The money isn't coming straight from state coffers. Three-quarters of the Medicaid budget is financed by the federal government.
Most of the recent spike came when Edwards embraced the Medicaid expansion, giving government-financed health insurance to mainly the working poor, as allowed under President Barack Obama's health law. Nearly 440,000 people have been added to Louisiana's Medicaid rolls.
"We're buying something very important with that money, which is health care for half-a-million people who were stuck in an outdated, inefficient charity hospital system model before the expansion," said Jan Moller, director of the Louisiana Budget Project, which advocates for low- to moderate-income families and champions the Medicaid expansion.
Louisiana has 1.6 million people receiving health coverage through Medicaid, more than one-third of the state's population. Besides the expansion enrollees, other Medicaid recipients are elderly, disabled, pregnant women or children.
Medicaid spending grew by $1 billion this year alone, driven largely by the expansion.
Again, there's a nuance: State general fund spending on the program actually dropped by nearly $400 million.
The federal government is paying most of the Medicaid expansion cost. Louisiana is paying a share that eventually increases to 10 percent. Lawmakers also passed items to help cover the state's costs, including a tax hike charged on health maintenance organizations known as HMOs.
Louisiana also is saving millions by tapping into enhanced federal financing for coverage it already provided to the poor and uninsured that is now available because of Medicaid expansion.
State spending growth on Medicaid over the past 15 years actually is below the national average, about 6.7 percent compared with 7 percent nationally, according to a nonpartisan House Fiscal Division analysis. The analysis said Louisiana's per capita state general fund spending on Medicaid also is less than the national average.
Kennedy said it doesn't matter if the spending boom is financed by state or federal money.
"I've driven around Washington, D.C., the entire place. I can't find the money tree," he said. "Federal money is taxpayer money."
Kennedy's letter to the governor recommend that Louisiana try to rein in Medicaid costs by enacting work-requirements on some childless, able-bodied Medicaid recipients; requiring drug testing for some applicants; or charging monthly premiums or copays.
Some of those ideas, such as copays and work requirements, already have failed to win support in the majority-Republican Legislature — even as GOP lawmakers criticize the Medicaid spending levels.
Melinda Deslatte has covered Louisiana politics for The Associated Press since 2000.
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