The furor over the state option to turn down the Medicaid expansion provided for in the Affordable Care Act has obscured a much more fundamental reality: well before ACA, and certainly before the Supreme Court made expansion a state option, Republicans both in Washington and around the country were working hard to significantly pare back the existing Medicaid program. That’s made most plain by the Medicaid block grant proposal in the Ryan Budget, which Mitt Romney has explicitly embraced. But even as Republican governors whine about the budget-bustin’ impact of having to pick up between zero and ten percent of the cost of the expansion, they are betraying their more radical bad faith towards Medicaid itself.

That’s being made especially clear by the self-proclaimed Tea Party Governor of Maine, Paul LePage, as reported by Stateline‘s Jim Malewitz:

The governor, who commonly refers to the federal-state insurance program for the poor as “welfare,” continues plans to boot thousands of people from Maine’s Medicaid rolls, The New York Times reported Thursday (July 19).

Though federal officials disagree, LePage contends that the high court ruling gives states authority to tighten eligibility for Medicaid, a move which would normally require a waiver under the federal health care law.

LePage isn’t alone, either. Lest we forget, Texas’ Rick Perry was threatening to pull out of Medicaid altogether some time ago.

Now it’s important to understand there is a dual deception that often masks the malevolent feelings of conservatives towards Medicaid. Federal-level Republicans are forever pretending that if you give the states enough “flexibility” over Medicaid eligibility and coverage issues (which they already have to a very significant extent), they’ll save a lot of money magically. Meanwhile, state-level Republicans justify repeated efforts to cut back Medicaid eligibility and coverage by citing all the costs imposed by Washington. Truth is, the ill-disguised game plan is to give states total flexibility over Medicaid which they will then use to cut eligibility and coverage. The math of the Ryan Budget makes that inevitable, particularly for states under Republican governance.

A more fundamental deception, however, involves conservatives’ attitudes towards the entire New Deal/Great Society safety net, and for that matter, towards what they like to call “big government.” Every survey ever taken shows strong, persistent, majority support for the safety net programs, combined on occasion with support for “reforms” that might make them less expensive. Republican politicians have proven themselves adept over the years at supporting “reforms” that just happen to disable the programs or change them into something far from a safety net. One of the most interesting things about the Tea Party/”constitutional conservative” movement of the last few years has been the growing willingness of some GOP pols to come right out and admit they consider programs like Medicaid to be “welfare”–fiscally unworthy and morally unwholesome–and proclaim as a goal the return of American governance to the limited government paradise of the 1950s or even the early 1930s.

That’s why the Medicaid expansion debate is important yet potentially confusing. Progressives and many “neutral” observers look at the terms of the Medicaid expansion and wonder how any state lawmaker in his or her right mind could turn down its astonishingly generous terms. But it makes perfect sense if you think the existing program is wildly over-generous to poor people, and/or undermines their “moral fiber.”

This reflects the larger confusion over what most Republicans actually mean when they talk about a “repeal and replace” agenda for dealing with the Affordable Care Act. They do not simply mean returning the health care system to the status quo ante, much less to a semi-reformed situation where the “popular” provisions of ACA remain in place. When you look at their overall proposals–Medicare vouchers, Medicaid block grant, interstate insurance sales, elimination of the employer deduction for health insurance, etc., etc.–it represents a radically different, 1950s-style health care system in which far more Americans are quite literally “on their own” when it comes to their health. “Repeal and reverse” remains the most accurate term for where they want to take the health care system, and progressives need to understand that clearly. And if they need help, they can just ask Paul LePage.

Ed Kilgore

Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.