Evolution of politics around health care has been breathtaking

ON March 23, after a decades-long congressional battle, a new federal commitment to ensuring health-care access was signed into law. For many it was a triumphant moment.

Yet just two months later, on May 28, the House stripped $24 billion in promised Medicaid funding out of a federal jobs bill.

Medicaid is a 35-year-old federal commitment — in partnership with the states — to serve the medically indigent. Most states counted on the $24 billion, a six-month extension of a higher federal match rate for state spending. After the House action, the Senate failed in three votes to restore the funding — even just two-thirds of it — and has removed the money altogether from the jobs bill.

Meanwhile, physicians, and the Medicare patients they serve, waited until June 24 for Congress to adopt legislation reversing a 21 percent cut in Medicare rates that began June 1.

Medicare, of course, is yet another 35-year-old federal commitment — to those 65 and older. The adopted "Doc Fix" only lasts until Nov. 30, at which point, barring an extension, Medicare cuts resume. How can physicians budget based on this insecurity?

Thus, in a year in which a landmark new bill was signed, observers, based on neglected 35-year-old obligations, might be forgiven for asking if there's really any federal health-care policy.

As a frustrated state legislator, I can attest states pay for this federal incoherency.

Washington was one of 30 states budgeting for the extra federal Medicaid assistance that began in 2008 and has averted worse health-care cuts. For Washington, it's worth $480 million toward a budget otherwise in the red.

States in the same boat include many with Republican governors — for instance, Florida hoped for $1 billion and New Jersey for $570 million.

Nor is Washington, which normally only draws a matching federal dollar for every state Medicaid dollar spent (a 50-50 split), as fortunate as states with higher match rates.

For example, Republican Gov. Bobby Jindal's Louisiana has been counting on the feds picking up 81.5 percent of Medicaid spending. It's easier to be fiscally conservative when someone else covers the bills.

With $5 billion cut from Washington's budget over two years — and a $3 billion revenue shortfall looming in the next budget cycle — health care will suffer more.

Effective July 1, almost 11,000 nursing-home patients across Washington already face an average Medicaid funding cut of $4.06 per day. At the other end of the long-term care continuum, in-home care providers are receiving cuts in service hours despite only making $10.03 an hour. Washington's hospitals were only able to avert cuts by asking for, and receiving, a tax that draws additional federal funds.

Many states, including Washington, have lasting commitments to health-care access for their citizens. Those pioneering efforts are in jeopardy without federal funding. In fact, Washington was forced to raise premiums for Basic Health enrollees by 71 percent this year along with a 66 percent deductible increase. More than 100,000 are on the waiting list.

Meanwhile, the National Governors Association expects state Medicaid caseloads to rise an average 6.6 percent next year — following the biggest one-year enrollment increase in history. Joblessness increases medical indigency.

In response, expect cash-strapped states to cut Medicaid eligibility, reduce benefits and increase co-pays. All with an additional 16 million Medicaid enrollees expected in 2014 when the federal health-care-reform bill expands eligibility.

This is hardly what was hoped for back in March. A federal commitment to health care cannot be only rhetorical. Nor can we feel sanguine about the ability to assume new obligations when old ones are neglected.