THCB

Medicaid and (supposed) Welfare Dependence

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.

I’ve basically said my piece regarding the causal impact of Medicaid in various studies. I want to pick up a different aspect of this debate.

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.

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nate ogden
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nate ogden

Margalit come on you know causeation doesn’t equal correlation. Historically college graduates made more money because only weatlheir and smarter people went to college. It wasn’t college that made them more money it was starting with money and being smart. Smart people will make money with or without a college education. Nothing you cite is a direct effect of college, if you take an idiot and give them a degree they won’t make more money. We had an entire liberal wing of congress that didn’t read the bill either and most of them are college educated. Its this exact liberal… Read more »

Margalit Gur-Arie
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Nate, outliers notwithstanding (as I proposed earlier) college graduates on average make more money, vote in larger numbers, have higher upwards mobility, live longer and I am willing to bet my socks that there were very few folks in the high-school diploma crowd that even attempted to read the health care reform bill before making an informed decision on whether it is a good thing or a bad thing.

nate ogden
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nate ogden

How detached from reality are you? Dead jobs like; plumber electrician construction mechanic all of those make considerably more then people with liberal arts degrees and history masters. Many jobs in the health sector don’t require a college degree just certification The dead end jobs are those with worthless college degrees. I have more people with college degrees applying for entry level jobs making 10 an hour then people that don’t have degrees. Not only is a degree worthless to millions of jobs but those with degrees aren’t learning anything any ways. All the college cares about is them paying… Read more »

Margalit Gur-Arie
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Sorry, Nate. I meant illegal immigrants in my previous comment. And to your and Barry’s suggested that college is not for everyone, I respectfully disagree. There is no need for anyone to amass huge loans for a college education and a college education, not only is not worthless in today’s job market, but it is pretty much assumed in a 21st century economy, unless of course you are talking about dead jobs. In addition to that, a free democracy cannot survive with an uneducated citizenry and if nothing else, a college education, any college education, should better prepare folks to… Read more »

Barry Carol
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Barry Carol

Nate – The wealthy school district that the state would not allow citizens to vote in favor of raising their own school taxes was Shawnee Mission, KS. It sounds crazy to me. Perhaps they could form a private foundation instead and use that money to benefit its schools. Regarding the illegal immigrants, on my vacation a couple of years back, I met a nurse from El Paso, TX. She said that fully 80% of the babies born in El Paso were to illegal immigrants who come there specifically to have their children so they can be U.S. citizens. They call… Read more »

nate ogden
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nate ogden

“Are you implying that immigrant children are not “cut out” for college?” Not implying anything, I am factually stating it. Please don’t twist quotes around, this discussion is about illegal immigrants not legal ones, I’ll give you the benefit of the doubt that it was an honest mistake but watch it going forward please. Look at the statistics most are not, blindly sending everyone to college is a waste it accomplishes nothing but getting them in debt. “BTW, in this day and age, there’s not much you can accomplish without a college degree.” BS this is just rank ignorance. Any… Read more »

Margalit Gur-Arie
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Are you implying that immigrant children are not “cut out” for college?

BTW, in this day and age, there’s not much you can accomplish without a college degree. College is the new high-school, if you want to get ahead and if you start from nothing. Otherwise, there may be more economical choices…..
And please don’t quote an outlier example of some billionaire who didn’t go to college, or some content mechanic that went to trade school and nowhere in hell will he be able to pay for medical care if something went wrong.

nate ogden
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nate ogden

“Just remember that without illegal immigrants there will be no one to boil syrup for $2 an hour. I am more than fine with that. Hope you are too…” Been doing it ourselves for 20 years so it doesn’t matter to me one way or the other. No sooner we settle one liberal myth then you raise another. College is a scam and waste billions of dollars. Sending a kid not cut out for college to college does nothing but waste 20-40+K per year. Sending every illegal immigrant child to college would accomplish nothing but adding more to our debt.… Read more »

Margalit Gur-Arie
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OK, so illegal and poor immigrants are a drain on the tax payers. All the more reason to make them all legal, so at least their children, who are getting those expensive educations can go on to college and not be a drain on tax payers.
If you want to amend the Constitution and invalidate the birthright citizenship, go ahead and do that after solving the current problem.
Just remember that without illegal immigrants there will be no one to boil syrup for $2 an hour. I am more than fine with that. Hope you are too…

nate ogden
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nate ogden

Perry County in Ohio has a nuclear reactor and thus a ton of tax revenue. There was a huge lawsuit where it was determined it was illegal for that county to spend more then other counties to educate their kids. This was 15+ years ago. In Texas or someplace else in the news last week was another lawsuit where a rich county wanted to spend more but was prohibited by law. Classical liberal thinking, better to dumd everyone down then some people be allowed to spend their own money to better their kids education. What is really worrying, as always,… Read more »

Barry Carol
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Barry Carol

Thanks, Nate for saving me the trouble of responding to Vikram’s incorrect comments. I’ll just add a couple of points. Here in NJ, a landmark court decision bank in the late 1970’s requires our state’s taxpayers to provide sufficient funding to allow 31 low income school districts, out of 586 districts in the state, to spend as much money per pupil on primary and secondary education as our wealthiest districts do in order to provide a constitution mandated “thorough and efficient” education. As a result, many of these districts from Newark and Camden to Asbury Park spend well north of… Read more »

nate ogden
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nate ogden

How is Medicare a subsidy for someone that paid Medicare taxes and other taxes that far exceeded their consumption?

” Most people get health insurance subsidies from there employer ”

Now they don’t Peter, most people have a portion of THEIR income redirected to pay for health insurance, it is not anything like someone getting someone else’s money

Peter
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Peter

I have to chuckle at those who oppose support for poor, especially those getting Medicaid. Most people get health insurance subsidies from there employer and of course we know Medicare is to a large part is a subsidy program even for upper income seniors. Upper income earners who itemize also get mortgage interest deduction and all of us get our food subsidized.

nate ogden
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nate ogden

“property & sales tax both paid by illegals” Its a questionable argument how directly a renter pays property tax. With or without the renter the tax would be paid. Their contribution to those taxes don’t even come close to paying their consumption of public services. Remember they send a large portion of their money home so they only buy the basics here, like food which doesn’t have sales tax. “So per student expense is likely to be low.” Obviously have never looked at per pupil funding in LA, Las Vegas, or any other metro area. ” It is no fault… Read more »

Margalit Gur-Arie
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“For those who think we should not provide care to those who cannot afford it, why do we require hospitals to care for these patients when they show up as emergencies? Why dont conservatives repeal that law? ”

Because it may be aesthetically uncomfortable to watch the resulting spectacle, particularly for the well-heeled and white-gloved ladies, I presume.