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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62 replies »

  1. 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 myth that harms so many people. THey waste tens of thousands of dollars and years of their life chasing a piece of paper they think will auotmatically grant them more money and a happy life only to find out it was all a lie.

  2. 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.

  3. How detached from reality are you? Dead jobs like;

    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 tution and leaving with a piece of paper, not actually learning anything.

    What 21st century jobs require a college degree? Guarantee I can name more, and better, jobs that don’t then you can come up with.

    “In addition to that, a free democracy cannot survive with an uneducated citizenry ”

    Educated does not require a college degree. By two measuring test I am better educated then 98% of the popualtion. I didn’t need a college degree to get there. The couple years I did waste there cost me time and money that would have been better spent doing something else.

  4. 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 make the complex decision that voting citizens must make, instead of relying on flaming rhetoric from either extreme.

    As Thomas Jefferson put it very succinctly “”If a nation expects to be ignorant and free, in a state of civilization, it expects what never was and never will be.”
    Now, more than ever, education for every citizen is imperative.

  5. 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 them “anchor babies.” I think eliminating birthright citizenship, coupled with a robust national ID card with a name, address, a picture and fingerprint or other biometric identifier would probably be more effective than a border fence in stemming the flow of illegal immigrants into the U.S. Too many people want to come here because they perceive the opportunity for a better life for themselves and their children. Unfortunately, we can’t accommodate them all. That’s why we have to set limits and enforce them.

    Finally, college is not for everyone. Millions of kids would be better off going to a trade or vocational school that trained them for jobs that actually exist. Or, join the military. Far too many kids are emerging from mediocre colleges with huge loans that are not dischargeable in bankruptcy and an education that is all but worthless in today’s job market.

  6. “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 of the skilled trades pay better then a liberal arts or history degree. Graduting with a degree in womens studies doesn’t make you a penny more then classes in medical billing or CNA

  7. 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.

  8. “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.

    ” All the more reason to make them all legal”

    No all the more reason to deport them, we tried the make them legal route and it only invited more to come.

  9. 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…

  10. 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, is how the liberals making these comments are so clueless about the facts. Based on what they know no wonder they butcher ever policy matter they comment on. Are they to blame for their lack of knowledge or is that society’s fault?

  11. 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 $20K per student and the results are still lousy. Combined state aid for these 31 districts costs state taxpayers $4.5 billion or about half of all state school aid.

    Second, poor people whether they are working two jobs, on welfare, or elderly, at the population level are net tax eaters, not net taxpayers. Between food stamps, housing vouchers, subsidized school lunch, education for their kids, Medicaid, and eventually, Medicare and Social Security, as you note, they consume far more in public resources than they pay in taxes. For the illegal immigrants, educating their kids alone costs more than they will ever pay in taxes without even counting the cost of maternity care and L&D.. Moreover, in NJ, there is no sales tax on groceries, clothing, housing costs or medical care. While property taxes are indeed embedded in rent, housing vouchers limit rent to 30% of income which is often significantly understated by working in the underground economy and keeping a male spouse’s name off the lease even though he lives in the house or apartment.

  12. 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

  13. 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.

  14. “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 of Pedro that hospital billing system charged $500″

    BS, its 100% Pedro fault he is here illegally, no one forced him to break the law and come here.

    “Now onto other side of equation is how much illegals subsidize middle class lifestyle. ”

    Or rich liberal lifestyle as that is whom most of them seem to work for. The real reason liberals are pro illegal is they don’t want to have to cut their own lawn or clean their own toilet.

    ““For those who think we should not provide care to those who cannot afford it, ”

    Strawmen argument who has ever said that? There is a difference between saying if you don’t have money you don’t get any care and saying if your going to blow your money on drinking and drugs your not going to spend mine for your living expenses. There is also a difference between no care for the poor, hospital services, and spending millions on rare treatments with low success rates and best case outcomes of 2 weeks more of life.

    Not that I would expect a liberal to honestly debate that argument, much easier to murder another strawmen

  15. “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.

  16. The discussion has veered a little bit, but is fair turn since Medicaid is about welfare.

    Onto Barry’s assertion and Nate that illegal immigrants cost a lot of money.
    Here is the other side of story not covered.

    1. Local schools are covered by property & sales tax both paid by illegals. Further illegals stay in run down areas and schools with low scores. Which subsequently reduces their funding. So per student expense is likely to be low.

    2. Income tax doesn’t mean much, because average salary for illegals is too low to be taxable.

    3. Yes, illegals do not pay medicare & medicaid. In medicaid- maternity services should be main benefit. Rest expense is inflated because it is received in ER and price does not reflect it’s value. It is no fault of Pedro that hospital billing system charged $500 for keeping him in waiting room overnight and handing pain killer and tylenol.

    Healthcare markets & Mega, the skimpy insurances, their customers are in fact no better than illegals because they will dump onto medicaid when real need arises.

    4. Social security- illegals do not pay. I don’t know if SSI gives any benefit to them. On other hand lot of legals go back leaving social security money. So it’s neat change money.

    Now onto other side of equation is how much illegals subsidize middle class lifestyle. Barry, any figures on that?

    Also what would be US birthrate without immigrant’s children?

    Onto birthright citizenship, many people have been saying, including Matt Holt, that 200 years old constitution tree needs to be revisited.

  17. “please, tell me one instance where regulated prices has caused reduced pricing and maintanence of competitiveness.

    Nearly every other OECD country has universal health care. They all have health care that costs less. It is possible to provide care for the poor, it is a matter of politics not economics.

    Some clarification from Carroll on what Medicaid covers.

    “Medicaid has to cover poor kids, poor pregnant women and people who receive Supplemental Security Income. It also has to cover parents up to 1996 welfare levels. But that’s it as far as the federal requirements go. Some states do cover “optional” populations and services under Medicaid. Many do not.
    Notice what states are not required to do: They need not cover adults without children. And so, in most states in the United States, it does not matter how poor you are, you can’t qualify for Medicaid if you don’t have kids.
    Moreover, although parents can get coverage, the levels can be surprisingly low. For instance, a couple with a child who live in Arkansas and make $3,200 a year are too “rich” for Medicaid. You read that correctly. Even for parents, Medicaid doesn’t go nearly far enough.”


    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?


  18. its an argument not statement of fact, but turn it around, any study ever done that shows we pay twice as much for healthcare and actually controls for what was delivered? The correct statement is we spend twice as much which is not nearly as strong of an argument.

  19. “Name one other nation that performs better then us with 12 million illegal south americans”

    South Americans???

    “If we are getting three times as much services and better services for only twice the price then its a great deal.”

    Any numbers to back this assertion up?

  20. Nate, good article here on RUC and CMS.


    “If we instead spent our money on foreign goods”
    Do you want that regulated or are you an open markets guy? Where the money goes is a result of the market, how domestic companies compete for it is up to them. Certainly if U.S. companies could pay less for health care they could make their products more competitive.

    Aren’t taxes and government spending supporting domestic spending and the incomes of American business? Doesn’t government spending influence GDP?

    Europe has to deal with illegal aliens as well. What do you mean by, 14% black?

  21. Peter you just never learn do you?

    “Is paying double for health care making us competitive with other nations?”

    If we are getting three times as much services and better services for only twice the price then its a great deal. You can’t compare the prices of apples and cars and say cars are over priced. Well, actually you can because you just did, it just isn’t logical.

    ” Is paying the close to 20% GDP for health care not reducing what could promote the growth of other industries in the economy?”

    Actually once again you are completly wrong, our high healthcare spending helps or GDP and certain businesses. If we instead spent our money on foreign goods it would drastically reduce GDP and millions of jobs. Thats not to say 20% is good but your logic is terrible.

    “Maybe you prefer the RUC regulating physician reimbursements over what government could do on a system wide basis.”

    ? Uh who do you think set and institutionalized the RUC, thank you CMS we love RBRVS, more please.

    “un-regulated financial sector”

    WOW, nothing called the Fed, Fannie, Freddie, or any of the other millions of financial regualtions. you really have to be clueless to call the financial sector un-regualted.

    ” Other nations regulate their health care sector and provide as good or better care.”

    Name one other nation that performs better then us with 12 million illegal south americans, 14% of the population African American, and our level of obesity.

  22. “please, tell me one instance where regulated prices has caused reduced pricing and maintanence of competitiveness.

    First you’d have to define “competitiveness”. Is paying double for health care making us competitive with other nations? Is paying the close to 20% GDP for health care not reducing what could promote the growth of other industries in the economy? Do you really think the U.S. has a competitive health system that keeps prices low and quality high – if so you haven’t looked very far or are delusional? Maybe you prefer the RUC regulating physician reimbursements over what government could do on a system wide basis. I would think you benefit from regulated utilities, including auto insurance. Is the un-regulated financial sector that led to this latest economic melt down what you call healthy non-governmental un-regulation? Other nations regulate their health care sector and provide as good or better care. You should read the link here to the paper, “It’s the Prices Stupid” an international comparison.
    http://content.healthaffairs.org/content/22/3/89.abstract The link also includes links to other articles on this subject.

    “But, you see, it remains so easy to say “We can be like other countries”.
    That is the code for ‘liberal highroad’. but really is an intellectual joke.”

    No, we could learn from other countries who regulated and organize health care many different ways that achieve much better costs and maintain excellent service.

  23. UMC in Las Vegas has a 80 illegals that use it for Dialysis, costing tax payors tens of millions, at a hospital that is so poorly ran by Democrats it losses 10 of millions every year for as long as I remember. Premies are also a huge problem. Don’t even get me started on the quality of schools in Las Vegas.

  24. Margalit and Nate –

    Everything I’ve read about illegal immigrants suggests that they are, for the most part, young and healthy and don’t actually use much healthcare except for maternity and childbirth related services. At the same time, since a 1982 court decision requires us to pay for educating their children, that’s a significant financial cost. If one-third to half of illegal immigrants are school age children and it costs $10K per year per child to educate them, that’s $40-$60 billion.

    Historically, the U.S. has the best record for assimilating people from other countries into our society and we are perceived as the land of opportunity. So, as Nate suggests, there are many millions of people who would love to come here if there were no restrictions on entry and ultimately attaining citizenship. The problem is that there is a limit to how many people we can handle without completely overwhelming both our society’s ability to provide healthcare for that population and to educate their children. It would also likely overwhelm our culture itself. There has to be limits on how many people can come here each year and they need to be enforced. To deal with this issue, we probably need to rethink the issue of birthright citizenship.

  25. i must add, that since illegal alien was mentioned.

    to all my “progressives”. A few hard hitting facts that wont ever in my lifetime be discusses on msnbc, cnn, abc, nbc – oh wait, all networks mostly or in wp, nyt, latimes,etc.

    1) Clinton passed NAFTA and in a stroke forever began the process of outsourcing our manufacturing
    2) Wilson was a ‘progressive’, and was highly bigoted and racist.
    3) Kennedy, whose love affair for amazes me, never could warm to a civil rights bill. In fact, it was a reformed texan LBJ who did so. Kennedy was too worried about losing votes in the south.

    AMAZING the reality of history. I bet 95 percent of progressives had no idea about even 1 of those 3 things above.

    Thanks “progressive media” for being empty of propaganda.

  26. please, tell me one instance where regulated prices has caused reduced pricing and maintanence of competitiveness.

    see, this is the great social fallacy. you can spout out anything. you can say you are labeling me, or you are wrong here and there, or look at other countries.

    All a canard. Other countries have different socioeconomic, demographic, and competitiveness profiles. my favorite is the Switzerland comparison. do me one favor, go look at the population dispersion and other characteristics.

    But, you see, it remains so easy to say “We can be like other countries”.
    That is the code for ‘liberal highroad’. but really is an intellectual joke.

    As you so eloquently proved, the ability to say anything illustrious or golden, or really, what is ideology, wins the argument. Because this way, fact does not matter, and ideal reigns.

    I paint myself the realist, and you the social programmer. Neither intellectual nor idiot come to bear. Simply what is and what is not.

    But you proved my own point. so this discussion is over.

    Thought expirement: How would all the health policy professors survive being shoved out of their walls of university and think tank comfort and into a venture company.

    Would they a) survive and succeed, by definition make more right moves than wrong (even if company failed).
    b) grossly fail

    Here is what one of those individuals reading this now is likely thinking
    a) i would survive, i would think it through. be logical, make right choices.

    by all accounts, in fact, most fail. they have no grip for what private markets are, how companies work, how regulation works and does not work, and how health care competes in really many avenues of restriction.

    Right there my friends, is your answer to why we have a complete failure of policy. Because these so called “minds” have dictated health policy for the last decades and failed us all.

    in the private world, they all would be fired. but that is such a harsh term for you “minds” to even think right. so reprehensible. so unnecessary, right.

    I lament.

  27. “we’ll give you coverage. Everyone will have insurance. And costs will go down”
    “A universal system will neither control annual medical CPI nor reduce total size and cost of health care.”

    No, costs will only go down with regulation of prices and use of QalyMetrics.

    We cannot afford true universal care with these prices, this system’s billings abuse and our increasing sickness rates. There can be gained some savings from reducing administration, from both eligibility rules policing, and coverage policing done either by government or providers, as was the gist of the discussion about Medicaid eligibility. You need to just look at what other countries are doing to see this is possible, but not perfect.

    Harold, you try to smugly paint yourself as the intellectual realist, and me as the social programmer idiot and liberal free rider – on both counts you are wrong.

  28. just for today I would support legalizing a couple immigrants, collecting sap and boilin syrup is killing my back, if I could pay someone $2 an hour I would be all for it.

    • Very good…one day at a time and we’ll get it all done, only I will have to insist on at least minimum wages, particularly for the sap part. Minor socialist stuff….

  29. ” I want to make them all legal.”

    Of course you do. Is that just the 12 million currently here or the 4 billion that wish they where here? I hope you know we can’t handle 4 billion more people so which person is the one you finally say sorry we don’t have any more room, I assume you have thought it out this far.

    Fraud in private pay is 1-2%, Medciare it is 10+%. It happens but on a much smaller scale. We actually caught one of these in CA a number of years ago, years before Medicare ever would have had a clue something was going on.

    “Would this arrangement work for you?”

    Not at all. First government would only select a few connected firms that paid major kick backs, or campaign contribution, which ever you prefer to call them. Next with this new monoply these firms would have no requirement to actually do a good job so service would suck. It would be a captive market, someone doing it better or cheaper doesn’t gain more business, there is no motivation to evolve. Medicare Advantage is a closed system, a mom and pop shop can’t enter the market with promise of better service and more efficent payments.

    There is no free market with government contracting so there is little value.

  30. Let’s take this to town, Nate 🙂

    I actually don’t want to ignore illegal aliens. I want to make them all legal. Who knows, maybe we get to collect some taxes to cover all this “free riding”.

    That fraudulent extra visit your doctor is offering, can occur with private payers as well as public ones, and I bet it does occur, just like all those back fusion (or whatever they’re called) surgeries also occur for no good reason.

    Yes Medicare payors are, but if the Government just stuck to collecting and transferring fees to private plans, based on enrollment, and allowed those plans to do what needs to be done as long as they payed the minimum federally defined benefits, I am certain that those plans would not allow government type inefficiency to drive them out of business.
    Would this arrangement work for you?

  31. “Can we stay away from the fringes for a little while?”

    Decades ago we had a few hundred thousand, liberals said its a fring issue leave it alone

    Decade ago we had a few million illegals and liberals said its a fring issue leave it alone

    Now we have 12 million illegals and guess what liberals say, its a fring issue leave it alone.

    How many tens or hundreds of millions and how many billions of dollars Margalit before its no longer a fring thing? Liberals want to ignore illegal immigrants becuase its fring. They want to ignore hiding income becuase its fring, they want to avoid eligibility fraud becasue its fring. Wake up its these 2 dozen fring things you keep ignoring that are costing all the money.

    “Cost sharing can be simplified so that fraud is not possible”

    Instead of doctor charging you $10 he says hey you come back next week for a follow up visit I’ll waive your $10 co-pay for both visits, it will save you money. 45+ years of Medicare and fraud only gets worse, obviously its not that simple.

    “Why do you assume government employees?”

    ? Maybe becuase everything government does grows government? Look how many new federal jobs PPACA created.

    Medicare payors are notorious for their fraud and government would never do anything but slap their hands and fine them pocket change. None of the Medicare payors are know as high quality innovative payors. Governemnt contracting breeds waste and inefficency.

  32. It is always fascinating to watch people defend government intruding into a profession’s practices and reimbursement rates, as long as it it not intruding into the defender’s own profession! It is even more fascinating and equally repulsive at the same time when higher learning tells everyone else how to think, act, and accept payment when literally they are living in the shields of ivory tower lifestyle and would howl louder than 200 mile hour winds to be told to back off and shut up!

    Which is one reason I would never work in academia; the hypocrisy, politics, and sheer cluelessness of how the real world operates is not their borders, their reality, their expectations. And how convenient that PPACA is so embraced and defended by institutions of alleged higher learning.

    Getting back to the point of this post, Medicaid has it’s place for a sizeable portion of the population it supports. I would never refuse to treat people who genuinely want care and responsibly participate in the treatment process if they used Medicaid as their insurance coverage. BUT, note the capitalization of that transition word, sizeable does not infer the vast majority of this population using Medicaid. And, one factor that just drives me nuts as a provider is the level of dependency and entitlement that is just metastasizing in our culture, not just in Medicaid populations mind you, but prevalent and by the sheer volume of it, is more and more validated until confronted and challenged by those who have the intestinal fortitude to say so!

    Does anyone else here at this blog believe that just because someone means well in advocating for a cause, such person possesses well intended passion and concern to support such an agenda, aren’t some issues just so overtly gray if not ignorantly supported recklessly, can’t such individual(s) be called on it even though they have no ulterior motive of harm or evil intent? I am so sick and tired of people claiming they have only the public’s well being in defending issues that are not cut and dried in public welfare for the better, that to challenge them is heresy just because they are nice people.

    No good deed goes unpunished. That is going to be on my tombstone. But, I will not go undeterred in fighting this final disgusting intrusion into my profession that is PPACA. When this issue is finally debated to it’s conclusion, the majority of people who are paying attention and want to do what is right and appropriate will realize that the way Democrats created this legislation, it did not have the public’s best interest at heart by these heartless politicians.

    Remember, incumbency in Washington is a reason to NOT vote for said individual in 2012. Irregardless of party, irregardless of past history. They didn’t get it done mostly right or effectively these past 12 years, so , move on!!!

  33. Can we stay away from the fringes for a little while? Yes, there will always be illegal aliens. This requires a different solution from a different part of government.

    Cost sharing can be simplified so that fraud is not possible (you show up – you pay $10, no matter who you say you are…. or something similar).

    Why do you assume government employees? Government should collect taxes and pay private contractors to run this thing. Lots of private contractors. Actually that’s what all private payers should become – fight fraud and split the difference.

  34. to go one step further, we are the only country that offers birth right citizenship.

    we are so wealthy and so generous in our offerings. The side of effect of such a country is the demand by the proclaimed conscientious to redistribute until equality is justified in research.

    As Lincoln stated,and I paraphrase, tearing down one class to build another is preposterously hazardous and with fruitfulness, nor results.

    But they do not teach that at Harvard or Stanford. They only teach that one day it will make the difference.

    too bad such intellectually talented individuals from all over buy in to such a dumbfounded concept. irony at its best.

  35. Most universal systems don’t cover illegal aliens, there would still be cheating with illegals trying to get coverage and services, we already have problems with family members using other family members ID to get care.

    Any system would require some sort of premium and cost sharing, you mention taxes but it would extend to designed cost sharing people would try to circumvent.

    abuse is patient generated as well as provider. See paid medication and scooters.

    Finally it takes 3-4 government workers to do what one private worker does and even then they don’t do it as well. On the bright side it would fix our unemployement problem.

  36. Peter, like many social program justifiers, to deviate from common sense and logic is common. But do let me digress. centralized negotiation power at government entity has always been a distasterous effect on budgetary items. Second, the ability to control costs, which is an indirect position to corporate reimbursement for technologies (think CER here too), would be virtually impossible.

    A universal system will neither control annual medical CPI nor reduce total size and cost of health care.

    This is the fallacy that is easy to make by so many because it has true sex appeal.

    “we’ll give you coverage. Everyone will have insurance. And costs will go down”.

    You can argue any ideology quite easily, because its deviation for realistic mechanisms are never known.

    And guess what, when the program fails, it is because “it was not implemented ideally, to our wishes”.

    The typical cat and mouse game of all great thinkers who cozy next to grandiose social programs.

    easy isnt it…
    no wonder idealistic college kids gravitate so quickly to these themes. Or is it because those professors behind green curtains espouse it. oh , thats for another post…

  37. Nate, all due respect, that is the light-end of true costs.

    It would be between 150b and 300b.

    These are estimates, and there is not one social program that has ever been measured correctly, and therefore costs are always more than any estimates.

    Likely, the total annual cost would be 300b to 400b more. I dont believe it would exceed 450b the first 7 to 10 years, but likely thereafter.

    Universal is idealogical in perspective, there is not cost savings. That is what the “smart” and “intellectual” crowd pushes and drops some study here or there to try and say “see, its true”.

  38. “Most of the cheating is under our universal system, that wont go away.”

    Cheating comes from trying to beat rules. If this were a true universal system, as in other countries, there wouldn’t be any eligibility rules, hence no cheating, except by providers. Support for the system would be through taxes, so you’d have the same cheating that goes on with the IRS/State now. A national sales tax for health care would help get cash earners/hiders to pay.

  39. Well Margalit if we assumed a system similar to Medicaird it would cost us roughly 150 billion a year more then what we already spend. Most of the cheating is under our universal system, that wont go away.

  40. Just how much money would we be saving if health care was universal and we could do away with all this insane bureaucracy and the equally insane shenanigans to cheat the system?

  41. nate ogden says:
    March 14, 2011 at 2:15 pm
    “All I am saying Peter is HHS and SSA has clearly without qualification said;
    “Peter has no idea what he ia talking about these are Federal means tested benefits”
    Personally I think it was excessive of them to call you out by name and point out you don’t know what your talking about but they did. If it makes you feel better, not any smarter sadly, I won’t vote for this administration next election, I don’t think they should treat people like that.

    PS you might want to google the requirements that come with those federal matching dollars, just saying it might be enlightening.”

    What the “H” are you talking about Nate?

    Either Medicaid recipients are means tested or not. Yes the feds have a say on the program because they provide $$$, but qualification by individuals applying for Medicaid is done at the state level.

    “means test
    –noun, an investigation into the financial position of a person applying for aid from public funds. ”

    Here is the process in NC:

    “Applying in Person

    You may apply at the County Department of Social Services (DSS) in the county where you live.

    If possible, take the items listed below with you when you go to the DSS office to apply. If you do not have some or all of these items, please apply anyway because it is very important to protect your application date. The DSS can assist you in obtaining these items and information.

    * Certified birth certificates or other proof of citizenship/alien status for each individual applying for Medicaid/NCHC
    * Identity documents for each individual applying for Medicaid/NCHC
    * Social security cards, social security numbers, or proof that you have made an application for a number from the Social Security Office, for each individual applying for Medicaid or NCHC
    * A copy of all pay stubs for last month
    * Copies of all medical or life insurance policies
    * A list of all cars, trucks, motorcycles, boats, etc. you or anyone in your household own, including the year, make, model, and vehicle identification number (VIN) for each item
    * Most recent bank statements
    * A list of all real property you own
    * Current financial statements/award letters from other sources of income, such as social security, retirement benefits, pensions, veteran benefits, and child support.”

    So what do YOU mean by means testing?

  42. All I am saying Peter is HHS and SSA has clearly without qualification said;

    “Peter has no idea what he ia talking about these are Federal means tested benefits”

    Personally I think it was excessive of them to call you out by name and point out you don’t know what your talking about but they did. If it makes you feel better, not any smarter sadly, I won’t vote for this administration next election, I don’t think they should treat people like that.

    PS you might want to google the requirements that come with those federal matching dollars, just saying it might be enlightening.

  43. So Nate, do the states administer Medicaid or not? Do the states set their own levels of income/asset to qualify for Medicaid? Do Medicaid recipients apply to the state agency or to a federal agency?

  44. Ahhh here’s the clueless Peter we all know, misinformed and clueless as always.

    “got a problem with means testing then take it up with the states as they set the means bar.”


    “Under the HHS and SSA interpretations, TANF, Medicaid, and SSI are federal means-tested public benefits that are not otherwise exempted under the Act.”

    HHS and SSA disagree with you.

  45. I will assume everyone realizes (especially from the tone) that the “Peter” posting above, is not me, the usual Peter who posts regularly here. I had hoped this new blog format would have prevented double name uses as it prevents double postings.

    Nate, got a problem with means testing then take it up with the states as they set the means bar.

  46. “You can say health care is a right”

    Dr. Mike, I actually agree with you…. to some extent. Not sure why you stopped at “(at least for routine and preventive services)”. What about the non-routine, a.k.a. expensive stuff? Is that not health care?

  47. People need health care, not insurance. You can say health care is a right but IMHO you absolutely are an idiot if you say insurance is a right. Insurance is only one way to achieve heatlh care, but for routine and preventive health care, it is the worst way. Give the poor health care (at least for routine and preventive services), stop giving them insurance, and many of the problems will disappear.
    The stumbling block to liberals is of course equality. They cannot stomach the fact that life is not fair. If the capitalist pigs have insurance, then by golly everyone is entitled to insurance – hence obamacare.

    • Unhelpfully simplistic. But, then, I’m not a “liberal.’

      Not that I disagree with a core point about “insurance,” which is properly a hedge bet one should hope to never have to use. Otherwise, as Joe Flower and J.D. Kleinke have noted, it becomes an open-ended “pre-payment” service requiring legions of non-value-adding intermediaries.

  48. “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”

    Up until it was replaced Liberals defended AFDC the same way you defend TANF now. When welfare reform was passed you promised people dieing in the streets. Never happened but you continue the same demonizing . You don’t carwe about the beneficiares all you care about is the program.

    “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.”

    BS, we spend more then enough money, its the way the money is spent that is a problem. Its the way Liberals refuse to be smarter with the money we spen that is a problem. Medicaid in most States has over 13% fraud/error in eligibility, that is the State’s who’s records are even good enough to audit. If the 13% that are no eligibile would be removed from the rolls that would be billions we could spend on improving care for those that should be there.

    If we did more aggresive means testing of parents millions of them have access to afforable coverage for their kids but choose Medicaid because that is another $100 a month they can spend elsewhere.

    before Obama killed the child(ren) only insurance market you could cover kids for $50-$80 per month. That is less then the average cost of a smoking habit or drinking 1-2 times a week.

    Look how long it has taken and how many millions of liberals still won’t admit public housing was a failure or ruined generations of lives. Medicaid and Medicare are the same way, collosal failures that won’t die until liberals have ruined 100s of millions of lives.

    To further MGs comment, prior to Medicare only 13% of seniors needed some financial assistance to pay medical bills, now 19% of Medicare beneficiares are also on Medicaid. Both programs have done far more harm then they will ever do good. Not only directly to their beneficiares but to the larger systems as a whole.

  49. Police and fire protection are paid by taxes. I don’t think I have an intrinsic right to polic, fire, or military protection. You guys are living in a dream world. Why don’t you adopt a poor family and pay all their needs personally. Leave the rest of us alone. Health care is a luxury. End of conversation.

    • So, Peter, I take it you’re not buyin’ any of that “self-evident” stuff, ‘eh? “Inalienable rights”? Was all that just high-minded liberal naivete?

      The functional extent of ANY right is a function of the rest of the social order to voluntarily acknowledge it, defer to it and to enforce it when necessary. Otherwise all you got is the Yard at Corcoran.

      Enumerate for us what you see as rights worth enumerating and communally defending.

  50. This is ridiculous. Democrats lay cover over a central premise, Medicaid helps some, so its humanity we are saving. Really, what is your “some”. And how much is it costing to help those few. Democrats have this idea that a successful social program is without cost barriers, and whatever it costs as long as one more person lives.

    And then the raise the flag and say, see you are a despondent lackey against mankind for not believing in Medicaid.

    to which i say. get a grip. your social program (and others!) have neither raised the bar for poor people or help much at all. In fact, Medicaid is a direct correlative to the rising systemic cost of healthcare, which IN TURN, destroys the ability for poor and low income to receive better insurance and cares through a greatly improved Medicaid system.

    Until all this social huggers stop this non-sense and realize their idealogical goals are breaking the opportunity for real change, which is real care, we will have this die on a hill mentality.

    Oh, and yes, that means we will continue to throw endless billions towards largesse ideals such as “save the poor”.

    If you really want to save the poor, you would reform your own ideas. And, yes, that includes Medicaid.

    Costs matter. get in reality !!

  51. Medicaid is a disgrace to this country. As I wrote in response to Avik Roy’s post on this blog, Medicaid was intended to be a second class system for second class citizens.
    Medicaid should be replaced by a Federal program of at least the same quality as Medicare, preferably one and the same. States have shown that they are incapable (and unwilling) to deal with this issue.
    The argument that Medicaid is better than nothing, and that’s all the charity we can afford does not resonate well with me, for two reasons: medical care should be viewed as a basic human right, not optional charity, and I am not convinced that this is the best we can afford after getting rid of all undue profit extraction from our health care system. Perhaps those engaged in the latter should have their characters scrutinized as well…

    • “medical care should be viewed as a basic human right”

      Agreed. How about this


      “The discoveries of healing science must be the inheritance of all. That is clear. Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion. Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

      – Prime Minister Winston Churchill, March 1944, arguing for the establishment of a British National Health Service.


      As I wrote on one of my other blogs:

      ‘How can we say that people have an “intrinsic right” to military defense, or to police and fire protection, (or to safe food and water, or to otherwise safe products that won’t electrocute us when we plug them in)? Well, we simply SAY it. And then we codify it. And, then, having codified it, we don’t lie awake nights worrying that everyone will demand a Special Forces FOB dug into his or her front yard, or an occupied Metro PD Black & White, an ambulance, and a hook & ladder truck parked at the curb 24/7.’

  52. The nasty secret is that a notable amount of spending is on the elderly especially the dual-eligibles in Medicare. It is basically a larger part of the narrative that is missed in our society in that at the federal level we currently spend over a 4:1 ratio on programs for the elderly (age 65 and older) vs. children (16 and younger).

    • Yeah. When I got Guardianship over my late Dad in early 2008 (he’d been in a nursing home with dementia since 2001, though covered by the VA), my lawyer tried to get me to explore artful asset shifting (“asset protection” in her words) so that my Mother might qualify for Medicaid. I told her “I don’t even want to discuss it.” Consequently, I pay (out of the family estate, for which I am responsible) about $6,300 – $6,500 a month for my Mom to be in long-term care (for more than 3 years now).

      The largest Medicaid expense item in my state (NV) is long-term care, and a ton of that is the result of asset shifting.

      Our prior governor had seriously considered getting NV out of Medicaid entirely, which would just have shifted that stratum to the “uncompensateds” — and from there eventually to the commercially insured (and truly “self-payers” like Mother) via rate hikes. I estimated that my Mom’s bill would go up 20-25% or so as a consequence.

      BTW, my late daughter was on Medicaid (“Medi-Cal”). She too had a “bad outcome,” notwithstanding more than two years of 5-star effort on ALL of the providers’ parts.


      “Conservatives” such as those cited in the foregoing would no doubt have preferred that she die in the gutter outside Cedars after she first presented.

  53. My husband and I have always worked but have had problems securing jobs with health benefits. We are educated and hard working. My husband is diabetic and since we had no health coverage, he would only go to the doctor when absolutely necessary. Two years ago he was very sick. After seeing our local MD we finally went to a specialist. That visit was $300, a fortune for us. The specialist said there was another test he felt my husband should have but because we didn’t have insurance the specialist suggested we wait a week to see if his symptoms might clear up. Well, in that week my husband ended up in the local hospital, had multiple surgeries and was finally transported to UCSF. In the end, the care he received cost tax payers $300,000.00 — and it could have been prevented had we had access to affordable coverage. So a $1200.00 test could have prevented a huge bill, preserved my husband’s health and kept him off of permanent disability. We want to pay our share and we don’t want a hand out but as long as people feel that health care is a privilege it will always be out of our reach.

    Too many people talk about health care with so little understanding of what real people with real issues face. If only they walked in our shoes!

    I follow your blog and I really appreciate your thoughtful, careful and compassionate perspective.

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