Jonathan Cohn has a piece on Medicaid yesterday with which I agree. I want to amplify one related point.
National Review and Forbes writer Avik Roy believes that Medicaid is a “humanitarian catastrophe” which is actually worse than no insurance at all. Now Scott Gottlieb has taken up the argument in the Wall Street Journal. I’ve noted before that this is a bad argument. Medicaid should certainly provide better coverage. I’d also like to see the new exchanges provide poor people with better options outside of Medicaid. Yet the claim that people would actually be better off uninsured than they would be with Medicaid—this strains credulity.
Roy’s response to my initial column includes the following:
Many of the factors Harold raises as flaws of the study are actually flaws of Medicaid. It’s Medicaid that restricts access to the best hospitals and the best doctors and the best treatments. It’s Medicaid, i.e., welfare dependency, that leads to family breakdown and social disrepair. (For those who seek a more extensive discussion of this problem, read Charles Murray’s landmark book, Losing Ground: American Social Policy 1950-1980.)
I took umbrage at that, as indicated below. Roy then took umbrage at my umbrage, writing:
One aspect of Harold’s post is wholly unjustified, and a bit of a cheap shot: his assertion that I am “disrespectful” and “disparaging” to welfare recipients, because I’ve highlighted the corrosive effects of welfare dependency (something Harold dismisses as a “bromide”). We’ll never have a constructive debate on Medicaid policy if we can’t get past this kind of nonsense. The entire point of my series of posts on Medicaid is that Medicaid beneficiaries are the victims of an uncaring and bureaucratic system, and also the victims of those who, for ideological reasons, ignore the very real problems that Medicaid has.
Roy may not regard references to “family breakdown and social disrepair” as disparaging or disrespectful. I do. I would also note that liberal health policy analysts discuss Medicaid’s shortcomings all the time. No code of political correctness that prevents liberals doing this.
Personal experience provides another reason to take umbrage. As I noted in a previous post, my in-laws needed Medicaid benefits to care for my brother-in-law at home. Welfare dependency, family breakdown, and social disrepair played no part in their story or the story of millions of other people who rely upon Medicaid-funded care.
It’s particularly unfortunate that Roy invokes Charles Murray’s conservative polemic, Losing Ground. (For the youngsters: Yes this is the very same Charles Murray who co-wrote The Bell Curve.) Losing Ground appeared a quarter-century ago as a slam against the traditional welfare system–Aid to Families with Dependent Children (AFDC). That system doesn’t exist anymore. The 4.3 million people who participate in Temporary Assistance to Needy Families—the program that replaced AFDC–comprise less than 10 percent of Medicaid’s current caseload of 58 million people. The typical Medicaid recipient making serious use of medical services is elderly or disabled, or resides in a household headed by low-income people in the workforce.
I’m sure Roy has smart things to say about other aspects of clinical trials and health policy. Yet I hope he takes the time to ponder how he presents himself as a privileged financial analyst-blogger spouting, yes, bromides on welfare dependence within communities that seem very distant from him.
I’ve spent twenty years researching HIV prevention, substance abuse, and other public health challenges in urban communities. Last year, I oversaw a randomized trial of violence prevention services in 15 Chicago Public Schools. I’m rather familiar with many challenges in these communities: youth violence, high school dropout, substance abuse, unemployment. I’ve conducted or analyzed several surveys of young, poor minority single mothers.
Some of these women resemble the suspiciously archetypal picture that accompanied Roy’s post. I don’t see how Medicaid has made these problems worse. For many women and their children, Medicaid is an essential resource in staying healthy and traveling the path to economic self-sufficient. Whatever one believes about Charles Murray’s original account of welfare dependence, it has little pertinence to the Medicaid-health linkages now under dispute. Medicaid often provides a way out of welfare dependence, allowing people who take low-wage entry jobs that could not support health benefits for adults or children.
When critiquing Medicaid, Roy writes as if his main goal is to find ways to improve the program to save lives and promote health. Yet when you scratch the surface, he opposes the provision of greater resources to addressing the very programmatic problems he identifies. He repeatedly and rightly notes that Medicaid constraints recipients’ access to primary care doctors and specialists. Yet when the rubber meets the road in changing Medicaid policy, Roy writes:
[Pollack] does helpfully cite his own recommendation to increase Medicaid reimbursement rates: something that could help address the issue of access to high-quality physicians, but is incompatible with our present fiscal situation, unless it is accompanied by a significant contraction of Medicaid’s eligibility rules.
If Roy feels so constrained by “our present fiscal situation,” I’m not sure why he laments Medicaid’s administrative difficulties or why he laments our implicitly two-tiered insurance system. Medicaid has the problems it does because it must finance the care of 58 million people within a rickety state-federal partnership that does not provide the required resources.
I’m especially concerned by the rhetorical frame Roy embraces. He begins with a genuinely pressing on-the-ground question sparked by a specific study: Why are medical outcomes so poor among Medicaid surgical patients? Yet when the conversation turns to potential policy solutions, he suddenly changes the subject to issues of “welfare dependence,” “family breakdown,” and “social disrepair.” Suddenly, Medicaid moves from an imperfect vehicle to finance pap smears, nursing home stays, and gall bladder surgeries to a morally problematic program that undermines character and damages family life.
On Roy’s telling, improving poor people is the critical challenge facing Medicaid and (I presume) other assistance policies. This is not a new argument, or one that suddenly emerges from any one or even a handful of studies. This is one of the oldest arguments in American history: Do we help poor people or do we hurt them when we offer them different forms of economic support? How worried should we be that we will damage people’s character or self-reliance when we offer them imperfect, but publicly-funded access to medical services? Is it smart or political possible to expand the scope of these efforts?
I suspect my deepest disagreements with Avik Roy reflect our different answers to these basic questions.
Harold Pollack, PhD, is the Helen Ross Professor at the School of Social Service Administration and faculty chair of the Center for Health Administration Studies (CHAS). He has published widely at the interface between poverty policy and public health. Dr. Pollack regularly blogs for the Reality Based Community and other publications, as well as The Century Foundation’s Taking Note, where this blog first appeared.