A6 EZ RE THE WASHINGTON POST.WEDNESDAY, SEPTEMBER 18 , 2019
crowds the president regularly
addresses.
On Monday, for example, the
president held a large campaign
rally in Rio Rancho, N.M. — a
state that Clinton, as the Demo-
cratic presidential nominee, won
by more than eight percentage
points.
“Every venue President Trump
visits reaches capacity, frequent-
ly setting individual venue at-
tendance records, with overflow
crowds remaining outside to
watch on big screens,” Tim Mur-
taugh, a Trump campaign
spokesman, said in an email
statement. “There’s no move-
ment of this magnitude in mod-
ern political history.”
He added, “It’s no great feat
for a leftist to attract people in
Manhattan or Seattle and it
probably took Warren’s cam-
paign weeks of planning to do
even that.”
Still, one R epublican operative
in frequent touch with the White
House, who spoke on the condi-
tion of anonymity to offer a
candid assessment, noted that
for all the dismissiveness, Trump
himself did pay attention to
Warren’s event.
“It was noticed by the fire
marshal in chief,” the operative
quipped.
[email protected]
[email protected]Linskey reported from New York.
Amy B Wang and Sean Sullivan
contributed to this report.ly-voting states in favor of large
rallies in Republican strong-
holds such as A labama a nd Geor-
gia. Trump also held events in
solidly Democratic states, like
Massachusetts.
“Trump would go have the
greatest show in t own, and it was
hard to tell how many people
were turning out because they
supported him versus just com-
ing for the free entertainment,”
Conant said. “Everyone was late
to appreciate the seriousness of
his candidacy, but once he start-
ed winning places, it became
apparent that people weren’t j ust
turning out because he put on a
great show, but there was real
support there.”
Conant added that, like
Trump, Warren is drawing her
biggest crowds not in early-
voting states such as Iowa and
New Hampshire but in Demo-
cratic strongholds like St. Paul,
Minn., and Manhattan.
But, he said, “it is an indica-
tion that there is widespread
support and deeper enthusiasm
for her than there is for some of
the candidates. If you’re going to
go t o the trouble t o show u p at a n
event, you’re probably going to
vote, and you’re more likely to
donate or talk to your neighbors
about voting, too.”
Trump allies say that while
Warren’s supporters may have
provided an impressive showing
this week, the events by her and
other Democrats still pale in
comparison to the overflowstrength.
“Hillary Clinton supporters
were the ones saying crowds
don’t matter” in 2016, said Patti
Solis Doyle, who ran Clinton’s
2008 presidential campaign.
“When you have the ability to get
20,000 at a rally, it is significant,
and your opponents should be
concerned.”
Sanders continues to draw
some sizable rally crowds, in-
cluding about 10,000 at a recent
event in Denver, and aides like to
post pictures of his more impres-
sive crowds on social media. But
in other settings, his attendance
has been more inconsistent. His
first stop on a college tailgate
tour in Iowa one Sunday after-
noon this month drew an under-
whelming number of attendees.
Sen. Kamala D. Harris (D-
Calif.) attracted an estimated
20,000 people to Oakland for her
campaign kickoff rally but noth-
ing that big since then. Former
vice president Joe Biden, who
has the highest name recogni-
tion among the Democratic pri-
mary field, has so far favored
smaller-scale events.‘It was noticed’
Alex Conant, a Republican
strategist w ho w orked as a senior
adviser on the 2016 presidential
campaign of Sen. Marco Rubio
(R-Fla.), said it was initially diffi-
cult to know h ow much weight to
give to Trump’s massive crowds,
in part because he often es-
chewed events in traditional ear-barrier.
Those who attend Warren
events also tend to file in shortly
before she starts speaking and
then stay hours afterward for a
photo. Many of Trump’s backers,
meanwhile, come hours early —
including some who camp out
the night before — but then
sometimes trickle out early as
the president is still speaking.
For years the conventional
wisdom among campaign strat-
egists was that big crowds don’t
matter much in actually turning
out voters, but the 2016 cam-
paign cycle scrambled that as-
sumption. Now key Democrats in
Iowa, which holds the first pri-
mary contest, are keeping a care-
ful watch.
“Everyone is obsessed with
finding the most ‘electable’ can-
didate, but no one really knows
what that means,” said Zach
Si monson, the chair of the
Wapello County Democrats in
Iowa who was impressed with
Warren’s New York event. “For a
lot of people, part of electability
is seeing that a candidate can
generate excitement and draw
big crowds. Hillary Clinton
didn’t really do that last time;
Trump does in a way Republi-
cans usually don’t. Ta king back
some of that populist momen-
tum would be huge.”
In 2016, Sen. Bernie Sanders
(I-Vt.) also pulled in massive
crowds for his Democratic presi-
dential run. At the time, Clinton’s
supporters played down his“They were staying at her
events for hours and hours after
she finished,” Katz said. “There’s
a lot of talk about raising money
and electability, but there’s noth-
ing nearly as important to win-
ning in 2020 as voter enthusi-
asm.”
To Warren supporters, too, the
overwhelming crowd size was
meaningful.
“It’s so democratizing for a
major presidential candidate to
stand and wait for all the people
who obviously want to see her,”
gushed Devon Racinelli, 25, who
was last in one of two lines that
formed for photos with Warren
on Monday night. The wait was
so long that he had attended the
rally, went to dinner and then
returned for the picture.
The size of the crowd also
inspired some to view a Warren
candidacy as truly viable.
“When you see the crowds
turn out, and you see the energy
and what she has to say, you
realize that the message can start
to reverberate,” said Townsend
Barber, 45, a student at New York
University.
In s ome ways, both Trump and
Warren are making similar ap-
peals to fiery populism, but with
very different approaches. War-
ren’s supporters chant “Two
cents!” — a shorthand for her
proposed annual wealth tax on
those with fortunes over
$50 million — while Trump’s
crowds cheer “Build the wall!” in
reference to his promised border“Yeah, the lines keep getting
longer,” Warren told reporters in
New York on Tuesday, when
asked about the four-hour wait
for photos with her that capped
her Monday rally, which was
attended by more than 20,
people. “That’s a good thing!”
Once widely regarded as an
interesting but ultimately incon-
sequential novelty of political
campaigns, crowd size is now a
potentially meaningful metric of
electability — one that
can translate into volunteers,
donors and, as Trump demon-
strated in 2016, actual momen-
tum. Ever since, Trump has con-
sistently drawn large audiences
to his rallies, many of them held
in less populated parts of the
country and attracting support-
ers who often drive hours, across
multiple states, to attend.
Speaking to reporters on Air
Force One on Tuesday en r oute t o
California, Trump rejected the
significance of Warren’s Monday
night masses — and with no
evidence rebutted her crowd
count — saying that “anybody”
can attract crowds “standing in
the middle of Manhattan in the
most densely populated area of
the country.”
“I get these crowds in areas
that nobody’s ever seen crowds
before,” Trump continued. “Pret-
ty amazing. Certainly if I went to
Manhattan, if I went there —
number one, she didn’t have
20,000 people, and number two,
I think a nybody would get a good
crowd there.”
Nonetheless, the multitudes
who gathered after a light rain to
hear Warren’s plan to fix what
she describes as systematic cor-
ruption — and to cheer her
rebuke of Trump as “corruption
in the flesh” — provided clear
evidence that Warren, even in a
Democratic primary, can com-
pete on the same terms as a
president who revels in crowd
size above almost all else.
“Big, structural change in
Washington Square Park with
@ewarren,” tweeted Warren
communications director Kris-
ten Orthman, captioning a photo
of the park’s marble arch over-
flowing with Warren supporters
— so many specks of frozen
fervor — and glowing incandes-
cent in the moonlight.
The missive captured Warren’s
pitch of major government and
corporate overhaul but also
seemed a clear allusion to her
crowd size, which New York
City’s park service initially ex-
pected to number between 8,
and 10,000 people before more
than doubling those early esti-
mates.
‘Hours and hours’
Warren’s crowds show “that
not only does she have broad
reach — she has broad enthusi-
asm,” said Rebecca Katz, a liberal
strategist who hasn’t endorsed a
candidate in the presidential pri-
mary. To defeat Trump in the
general election, she said, Demo-
crats will need to nominate
someone who generates the
same excitement — pointing to
the long line of Warren support-
ers who waited until nearly mid-
night for photos of her as one
indication of her appeal.
CROWD FROM A
BY AMY GOLDSTEIN
Te nnessee unveiled a plan on
Tuesday to convert Medicaid into a
block grant — an idea long sup-
ported by conservatives that would
rupture the federal government’s
half-century-old compact with
states for safety-net insurance for
the poor.
Te nnessee is setting up the na-
tion’s first test case of how far the
Trump administration is willing to
go to allow a state the “flexibility”
that has become a watchword of
the administration’s health-care
policies.
If Te nnCare, as that state calls its
Medicaid program, wins federal
approval for its plan, it could em-
bolden other Republican-led states
to follow suit. It also almost cer-
tainly would ignite litigation over
the legality of such a profound
change to the country’s largest
public insurance program without
approval by Congress.
Medicaid, originated as part of
President Lyndon B. Johnson’s
Great Society of the 1960s, is an
entitlement program in which the
government pays each state a cer-
tain percentage of the cost of care
for anyone eligible for the health
coverage.
Under block grants, first
broached during the Reagan ad-
ministration, the government
would instead pay a state a lump
sum each year while freeing it from
many of Medicaid’s rules, includ-
ing who must be allowed into the
program and what health care is
covered. Proponents contend the
model would save money and let
states run the program more effi-
ciently; opponents contend it
would strand states and vulner-
able residents during economic
downturns or as expensive new
therapies emerge.
Medicaid block grants were part
of unsuccessful Republican legisla-
tion two years ago that would have
dismantled major parts of the Af-
fordable Care Act, although block
grants do not inherently conflict
with the law. Internal GOP dis-
agreements over the idea were a
significant reason those bills
failed.
Since then, President Trump has
called for Medicaid block grants in
his budgets, though Congress has
ignored the idea. Seema Verma,
administrator of the Department
of Health and Human Services’
Centers for Medicare and Medic-
aid Services (CMS), has urged
states to move toward block grants,
although guidance she has written
for states has been under review
for months at the White House’s
Office of Management and Budget.
Te nnessee is the first state that is
coming forward.
Its draft proposal would affect
more than 1 million of the 1.4 mil-
lion state residents on Te nnCare,
according to the state’s Medicaid
director. The block grant would be
used for medical services for chil-
dren, pregnant women, parents
and other core groups of peoplesuch as those who are blind and
disabled. Some aspects of Medic-
aid would be excluded from the
change, such as coverage of pre-
scription drugs and payments to
hospitals that treat a large share of
low-income patients.
In a n interview, G ov. Bill Lee (R)
said Trump administration offi-
cials “need some examples to show
the rest of the country how to do
this, and we have an example....
We consider ourselves as leaders,”
having run Medicaid in cost-effi-
cient ways for years, he said.
“It would be very important for
the country to see an opportunity
to lower the cost of Medicaid ser-
vices without changing the quality
or level of those services to the
Medicaid population,” Lee said.
“For Tennessee to be an example of
how we can deliver that would be a
very big deal.”
The draft plan is not a pure
version of a block grant. It would
rely on fixed annual payments, ad-
justed yearly for inflation. The
state would get extra money per
person in years in which enroll-
ment grew but would not get less
money if enrollment shrank.
If the state spent less in a given
year than it would have under the
traditional Medicaid system, Te n-
nessee would split those savings
with the government, according to
the draft plan, in another depar-
ture from a classic block-grant ap-
proach. It is proposing not to cut
back on eligibility rules or benefits.
Te nnCare Director Gabe Rob-erts said in an interview that he
and his staff have had several con-
versations with CMS officials, giv-
ing them “a sense of what to expect... from a conceptual level.” Rob-
erts said that the federal officials
have largely listened without pro-
viding feedback.
A CMS spokesman, Johnathan
Monroe, declined to discuss the
agency’s recent interactions with
Te nnCare, saying only, “CMS sup-
ports efforts to improve account-
ability for cost and outcomes in
Medicaid, and we look forward to
working with Te nnessee once they
submit their proposal to help them
achieve these goals as effectively as
possible within our statutory au-
thority.”
Under a law the Te nnessee legis-
lature adopted in May, the state
must submit a final version of its
plan to the Centers for Medicare
and Medicaid Services by late No-
vember. Starting Tuesday, t he draft
is open to a month of public com-
ment. Critics are trying to turn out
in large numbers in opposition.
National patient-advocacy or-
ganizations already have been pro-
testing. A dozen groups wrote to
the governor in late April that, for
sick and vulnerable patients,
changing to a block grant “jeopar-
dizes their access to treatment and,
in turn, their health.” More than
two dozen groups wrote to CMS’s
Verma in July, urging her to reject
states that ask for block grants.
Within Te nnessee, opponents
have been mobilizing. Michele
Johnson, executive director of the
Te nnessee Justice Center, a group
representing vulnerable residents
needing health care and other as-
sistance, said the proposed chang-
es to Te nnCare would be “devastat-
ing for our health infrastructure,
for the Te nnessee economy, a nd for
our communities.”
Johnson disputed the gover-
nor’s assertion that the state has
been uncommonly efficient in run-
ning Te nnCare, saying that enroll-
ment fell when the state had diffi-
culty adapting its Medicaid eligi-
bility system to comply with ACA
rules.
“If the block grant is approved in
a way that violates the law,” John-
son said, “there is no question
there would be a lawsuit.”
Te nnCare has an important role
in a state with large pockets of poor
residents. Half of Te nnessee chil-
dren depend on the program.
With Republican supermajori-
ties in both chambers of the state
legislature, Te nnessee is one of 14
states that have not expanded
Medicaid, as the ACA allows, to
people with slightly higher in-
comes. Roberts, the Te nnCare di-
rector, said that savings the state
might generate under a block grant
would probably be used to improve
benefits for certain groups already
covered through the program,
though he did not rule out narrow
expansions of eligibility.
Te nnCare has a history of being
distinctive. In 1994, it became the
nation’s first Medicaid program toenroll all its recipients in man-
aged-care plans. At the time, it
used cost efficiencies from HMOs
to fold into the program people
classified as uninsurable — essen-
tially a precursor to the ACA’s guar-
antee that Americans with preex-
isting medical conditions may not
be rejected or charged more by
insurers.
In the early 2000s, Te nnCare
made news again, when the pro-
gram was overspending and a
Democratic governor made cuts
that forced 300,000 Te nnesseans
off the rolls.
Recently, Alaska flirted briefly
with the idea of asking for block
grants. Utah has asked for federal
permission for a related idea —
per-person limits on Medicaid
spending — a nd is awaiting a reply.
James Capretta, a resident fel-
low at the American Enterprise
Institute specializing in health
care, said that many other states
might be fearful of the financial
risks. Still, he said, “people have
been talking about block grants
forever. It wouldn’t be bad to have
one state try it and see what hap-
pened.”
But Johnson, of the Te nnessee
Justice Center, said: “The down-
side is, we are going to have less
money in a state that is incredibly
poor. Both Gov. Lee and President
Trump are treating Medicaid as a
piggy b ank, and half the kids in our
state are relying on this piggy
bank.”
amy. [email protected]Tenn. becomes first state to answer Trump’s call for Medicaid block grants
‘The lines keep getting longer,’ Warren says after 20,000 turn out for rally
GARY HE/EPA-EFE/SHUTTERSTOCK
Sen. Elizabeth Warren (D-Mass.) speaks to supporters Monday in Washington Square Park in New York, where high attendance offered Democrats a rebuttal to President
Trump’s long-standing focus on crowd size. Trump played down the presidential candidate’s rally, saying “anybody” can attract crowds “standing in the middle of Manhattan.”