Laughing at the Chutzpah of the Right on Medicaid

There’s no one that pisses off the right in this country as much as Paul Krugman, and there’s nothing that pisses off the right as much as welfare for the poor. So when Krugman wrote recently in the NY Times supporting a program that is welfare for the poor, and describing how Romney/Ryan would decimate it, well you can expect an explosion from the GRWC. Yes the topic of today’s right-eous indignation is Medicaid.

The place to go to see that explosion is the comments section of John Goodman’s blog. That’s the halcyon world where the poor are oppressed by government programs and would much rather be set free to swim in the happy waters of the free market. Goodman proves to himself that studies showing that people without health insurance on average die prematurely must be wrong because they’re not seen in any “credible, peer-reviewed social science journal” — just in biased rubbish like the American Journal of Public Health and reports from the crack-smoking wackos at the Institute of Medicine.

Having read the comments on Goodman’s article I’m very surprised that Heartland’s Peter Ferrera hasn’t gone on welfare to show how it’s now a guaranteed path to unlimited riches (as opposed to say the tough job of taking payola from a convicted felon) and that Goodman himself hasn’t rejected his health insurance and gone naked on the income of the single mom & waitress in Dallas that Uwe teased him about a few years back. After all it would give him so much buying power to impact the market!

Back in the real world, everyone on the left knows that Medicaid is a dog-meat last ditch program. But over the past seven decades the intense efforts of assorted whack-jobs, lie-factories and mean spirited Republicans–and many right wing DINOs– mean that there is no national comprehensive health plan. Medicaid is all the poor have, and all that keeps granny in the nursing home rather than living in the front room or on the street. It’s the politics of the right that prevented folding it into Medicare in 1965 and into a comprehensive plan in 1994, and made it impossible to do anything other than build on Medicaid in 2010. That’s why Daschle championed it as the least bad route to quasi-universal insurance.

To really suggest that Ryan/Romney won’t cut Medicaid means that the fools at the AP must have been very confused when they penned this article suggesting that block grants would reduce Medicaid by $800 billion. They must have meant that instead states like Texas, Florida and Mississippi would of course massively increase their Medicaid spending and cover more people because of the “flexibility” block grants would give them. Of course those states have been falling over each other to take the Federal dollars now on offer for Medicaid.

Oh and none of the right-wingers mention the facts that for the non-elderly & disabled Medicaid is already 65% run through private health plans (see p13 here)–much closer to that free market nirvana that the right aspire to than Medicare with its 25% rate.

But that’s all fine. Medicaid does relatively well with the pittance it gets, but if the right’s boy Romney wins we’re going to see just how huge the clout of the poor is when they get those Medicaid cards taken away from them and thrown off the rolls. And I’m sure Goodman and his buddies will all be lining up to explain to them how their new reality of being broke, sick and uninsured is so much better!

I’ll wait expectantly (no, not really!) for Obama et al to pick up this thread that Clinton left them at the Convention in the next week…

Matthew is the founder of THCB and is guilt-stricken about how rarely he gets to write on it!

27 replies »

  1. David and I may disagree on some issues, but as far as death rates go I am totally on his side.

    Mortality is a very bad way to measure the performance of a health insurance system.

    One reason is that people die from violence and genetic factors and bad habits, which no health insurance system can cure.

    Yes, there are poor women who lose a child due to a lack of pre-natal care.
    But I do not think this a large statistic in America, or has been since 1960 or was ever a big statistic outside the rural south.

    Using mortality as a measure of health insurance has another problem —
    we spend many billions in the USA extending the lives of cancer sutterers and dialysis patients, even when they are over 85 to begin with.

    Does this make our health insurance system the best in the world? It is not that simple.

    Finally I go back to the American Indian reservation culture. They have had a national health service for 100 years, and the death rates are the worst in America. This is tragic for all, and is partly due to discrimination by white society. But health insurance has NOT cured the situation.

  2. Well I haven’t read the study, so maybe it should have stated that being poor brings you closer to death.

    Needing a study to understand if everyone needs equitable healthcare or trying to find flaws in a study advocating we all need healthcare seems genuinely American, and, if I might say, “Romneyesk”.

    I’ll leave you PHDs to argue the finer points of Studies 101.

  3. I should have added, if uninsured and insured individuals do not live in exactly the same locations (e.g., perhaps the uninsured are more likely to live in densely populated areas), then yes, their chances of getting hit by cars may differ.

    I am in no way suggesting that being uninsured has no consequences (and my recent Health Affairs study documents how falling seriously ill while being uninsured has catastrophic consequences for one’s savings). I am merely pointing out that academics should take research methods seriously. There is no excuse in academia for sloppy econometrics even in pursuit of a worthy policy goal.

  4. The authors of that study make a specific claim about the number of deaths caused by a lack of insurance. Due to the underlying failure to properly identify a causal effect, their claim lacks validity. Perhaps fewer deaths are caused by the lack of insurance. Perhaps more. Due to the poor research methods, there is no way to know.

    If you will humor me and promise not to cuss again, I will offer a statistics primer. The authors show there is a correlation between mortality and insurance status and assume they know the direction and magnitude of causality. But there are many reasons besides the lack of access to the healthcare system that could create a correlation between insurance status and mortality. Insurance status could be correlated with (but causal to) living conditions, diet, stress, self-assessed health status, and so forth. Some of these factors increase mortality; others may decrease it. If correlated factors are unobservable to researchers (as seems likely), then regression will suffer from omitted variable bias of unknown direction and magnitude. These issues are covered in any basic econometrics textbook.

  5. “The study purporting to show that being uninsured causes premature death has methodological shortcomings. The authors fail to sort out causality”

    I don’t know David, do uninsured people get hit by cars more than the insured.

    Exactly how do people die if not by accident, would it be by disease? If you have good access to good care (eliminating poor nutrition and dangerous neighborhood) wouldn’t that prolong your life, unless of course, a frigging tree fell on you?

  6. The study purporting to show that being uninsured causes premature death has methodological shortcomings. The authors fail to sort out causality (in econometric parlance, the statistical model is not identified.) As a result, one cannot state with any confidence that the authors have demonstrated causality. I am the editor of a social science journal and I am reasonably confident that this paper would have been desk rejected.

    It is not unusual for social science studies to be published in medical journals. They should be treated with the same caution as one would treat medical studies published in social science journals. Of course, social scientists understand their limitations enough to know not to attempt to become medical researchers. If only certain doctors also understand their own limitations as social science researchers. As to how the paper was published by AJPH, one would have to ask the editors what they were thinking. Rest assured, not every published paper stands up over time.

  7. America has been divided for quite some time between states and businesses that are generous when it comes to health care (i.e.Minnesota, General Motors), versus states and businesses that are stingy about health care (Texas, the entire restaurant industry)

    The PPACA law, when you pull out the details, has many clauses which if enforced will require the stingy players to be more generous.

    This is not an intrinsically bad thing to do. We forced Southern states to be at least somewhat decent to black voters from the 1940 to 1970 and it didn’t kill them.

    No, the test of forced generosity will be whether it works.

    Medicaid is about as cumbersome a program as you can get. The feds want to set more uniform standards, but states pay for (on average) 40% of the cost with their own income taxes, and the voters in that state can and do refuse to pay taxes. The reason that Medicaid is “fiinancially broken” is that it is fiscally inconsistent to begin with.

    I have no great sympathy with Southern conservatives, but put yourself in Bobby Jindal’s shoes.

    Federal initiatives about ease of enrollment could bring an extra 500,000 persons into Medicaid even under the old eligibility limits. At a modest cost of $2500 per enrollee, that comes to an extra $1.25 billion. If the feds pay 40%, then Bobby must raise taxes by $750 million, or else start cutting back money for schools and roads.

    Something is deeply wrong with this picture, Let’s get busy federalizing Medicaid, and using the federal income tax to fund it.

  8. Michael Gerson wrote a great piece as to what could play a sizeable factor to Obama losing the election next week, which I link below. I want interested readers to read it all, but pay attention at the bottom 1/4 to what Gerson lists as a major reason why Obama has shown non partisan cronies and choir shriekers why he is not only lame, but why Democrats, in my opinion, have shown even more callous and ruthless qualities than what I have believed to be the ugliness of Republicans for decades now. You read and decide:


    I have absolutely no respect for hypocrisy and pettiness that ALL the Democrats showed in this legislative assault on America. Reading the garbage from many readers who just echo falsehoods and partisan platitudes at this site for the past two plus years, well, I hope the voters as a majority help you choke on it, and again, NOT expecting Romney to fix the matter, but it will be fun for me to see some incumbents possibly lose their fixtures, and post polling commentary show them that voters, at least in this country for now, still rule government. Oh, and that goes for Republican lame-o’s too!

    Hope and change, what a farce that campaign turned out to be! This guy in the White House is beginning to make Nixon look like he had a heart!

  9. If it is fair to sum up this election with one premise, it would be this:
    You are either voting for abandonment, per the republican dogma as is, or, enslavement, per the Democrat dogma as is.

    Wow, what a choice, in the end it is not about freedom, independence,and choice, but what will amount to brutal survival conditions, and isn’t it ironic, as well as cruel, that nature is giving us a preview now in the East.

    Frankly, we are stuck with a one party system of Republocrats, and as long as entrenched incumbents keep their seats, it is irrelevant who occupies the White House for the next 4 to 8 years max.

    And how does this relate to health care? Because Romney set the pace with his state program that Obama has basically emulated, but in the end, politicians want to control choice, access, and in the end, who has the right to live or die. Think politics won’t intrude into individual care? Yeah, anyone who answers “No” is as partisan as one could possible be!

    It is a shame there is no moderate site to discuss this issue. While THCB gives the illusion it is being balanced with partisan commentary from both ends of the group, it is obvious this site is wedded to PPACA surviving.

  10. I was at a meeting in Texas this year when one of the speakers told the audience that a single, childless adult has to have an income below 26% of the Federal Poverty Level to qualify for Medicaid. The panelists, all from out of state, repeatedly asked him to clarify that figure. It was incomprehensible to them that someone making $4,000/year was too wealthy to qualify for Medicaid. Health care is too valuable to allow just anyone to access it.

  11. Hey, in Texas Medicaid looks like it really helps reduce infant mortality. Which is kind of the opposite of what people who claim Medicaid doesn’t work would expect. Now if only Texas would expand their Medicaid program they wouldn’t have the highest proportion of their population being uninsured of any state in the Union.

  12. But how do you really feel Matthew? Nice piece. I think we all know where we are headed. (a single payer system with a thriving supplemental care private market sitting on top of it). Unfortunately things probably need to hit rock bottom before politicians find the political will to go there. Adding an additional 20M people to a broken system (financially broken not clinically) will just make it fail faster and get us to the end game faster. 2-3 years after it is implemented we will all be wondering how we wasted 60 years debating it whether it was communism/fascism/socialism/pure evil.

  13. Having just returned from the Medicaid Health Plans of America Annual Meeting last week (and I’m still recovering from the depression that ensued…talk about dinosaur energy) let me suggest two basic foundational problems that rarely get addressed in discussion of Medicaid.

    1) Medicaid programs are designed by the State – which is to say, state employees (with the occasional assist from consultants). Many, if not most of these folks, RARELY get any fresh air. There is no money in their budgets to attend conferences. No incentive to stretch. And the heads of these state agencies are typically decided by whomever wears the crown politically. Incentives are all about keeping your job and your pension.

    Yet these risk-averse, sheltered folks are the people that write the RFPs that MCOs respond to. Subsequently, there is not much “ask” from the MCOs and God knows there is zero incentives for the MCOs to offer anything extra. So we get the “same old same old” year after year, state after state.

    2) Medicaid MCOs (especially the pure-plays: AGP, WCG, CEN) are measured first and foremost by Wall Street (Shareholder Value, Shareholder Value, Shareholder Value), and secondly – how well they are meeting their obligations of their state customers. To wit: Centene’s recent “see ya” in Kentucky – largely applauded by the investor community – while leaving tens of thousands of beneficiaries up in the air while the remaining plans divvy them up.

    ACA doesn’t guarantee fresh air and/or changing of the guard within these state agencies, nor does it (in my opinion) offer up any meaningful carrot or stick to the publicly – traded MCOs.

    Disruption needs to start right where these two sets of folks meet. This is where the signal is. The rest is really just noise.

  14. Query: are those numbers in the Valley a result of Medicaid support or other grant programs targeting that specific area? Are there nationally supported charities contributing to healthcare in the region for pregnant women and children?

  15. In 1962, Bobby and Jack Kennedy had to send 1,000 armed troops into Oxford Mississippi, to let James Meredith register for classes at Ole Miss.

    In the ACA law, the federal government had to promise 95% funding for 5 years to get Southern and Western states to cover more of the working poor — and the states are still resisting.

    As Jeff Goldsmith has pointed out, there is a block of persons about 10 million strong who could be on Medicaid right now, ignoring the ACA expansion, but are discouraged from doing so by paperwork and their own confused lives. I suspect they do get signed up if they are hospitalized.

  16. Good post Matthew. Nice to see you getting write some more. I agree that our half arsed attempt with Medicaid (not to mention the uninsured) has been a chronic issue that has exacerbated medical cost inflation. Ironically, we would likely be paying much less on the aggregate now if we had have gone to single payer overall in 1965 (of course, the development of medical technology would be set back considerably due to the inability to attract private investment capital nearly as well). I tried reading Goodman’s recent book but had to put it down after a couple chapters. If we could go back to remake the world into a libertarian “paradise”, then some of his ideas might work. We left that station a long time ago and no one can beat the AMA, yet. Essentially, the rethuglicans want to go back to the Kerr-Mills Act of 1960 with their block grant idea, so we can further half arse the program. I give the democrats minor credit on this issue even if it is motivated by all the wrong reasons.

  17. “In Texas under current law, a single adult making $4000 a year is ineligible for Medicaid.”

    If it is a pregnant woman it is 185% of federal poverty level.

    Texas also has an infant mortality rate that is below the antional average, already at the Healthy People 2020 goals, and lowest for the three public health regions along the Rio Grande.

  18. One of the common right-wing slams against Medicaid is that the persons who receive it have ‘poor mortality and morbidity.’

    Let’s be charitable and assume that this criticism exempts the aged and disabled persons who make up about 2/3 of Medicaid spending. Their poorer mortality is rather obvious and cannot be caused by their getting Medicaid. Based on what nursing homes and polio wards were like in the 1950’s, it is likely that Medicaid has improved the health of this group.

    Now move over to the women and children now on Medicaid. Their mortality and morbidity is said to be worse than than the mortality of the uninsured.

    Makes Medicaid sound like a big waste of $.

    How about considering environmental health here? A Medicaid family living in a violent slum is going to have worse statistics than an uninsured 27 year old living in an off-campus apartment in Boulder Co.

    Health insurance cannot change everything in life. American Indians living on reservations have had free universal health care for 100 years, and their statistics are even worse.

  19. Simple. Better than the alternative of leaving poor kids uncovered, the working poor uncovered, and granny living in your front room. When you got no food, you’ll eat dog meat.

    I would rather we provided the health care equivalent of healthy nutritious meals, but Goodman and his pals on the right have made sure that’s not on offer.

  20. RNMPH is actually right in that a little known secret is that within Medicaid and the safety net providers, we’ve seen quite a lot of innovation–same is true with the VA.

    Having said that I’m reminded of the time in the 1990s when my colleague at Harris Poll Bob Leitman did a study of Arizona Medicaid which was already 100% in managed care programs way before any other state tried it in Medicaid. His one liner to the group of health care executives was–“this study shows that relative to other Medicaid recipients, the ones in Arizona managed care plans are healthier and happier. But I wouldn’t necessarily recommend that you become poor and sick and move to Arizona.”

  21. Maybe Joe you could explain why covering more people is so injurious to them?

    Actually I’m in favor of abolishing Medicaid as well and just enrolling them in Medicare. Would that suit you better?

  22. If you think Medicaid is “dog-meat, last ditch”, come to North Carolina, where the program is serving 1.5 million and saving the state more money each year from using medical homes and care management. Pt satisfaction is pretty high too.

  23. Matthew- if, as you say, Medicaid is

    “is a dog-meat last ditch program”

    how could you, or anyone, support a law that puts another 16 million people on it?

    That’s real chutzpah

  24. Good write Matthew, and Bob Hertz too. Where was this passionate truth from Obama in the first debate. My state and others heap millions on wealthy corporations attracting them to places they have already decided to go to – getting more corporate welfare from a decimated Medicaid would provide lots of back slapping for corporate hob nobs.

  25. The states which oppose Medicaid have either very low state taxes or, in some cases, no state income tax at all. These states ‘compete’ to attract affluent retirees, who are very sensitive to taxes. These states also want to keep the poor and minorities out as much as possible, and having a stingy Medicaid program is part of the ‘package.’

    In Texas under current law, a single adult making $4000 a year is ineligible for Medicaid. The political power of the South allows these vicious discrepancies to occur. (see Michael Lind’s Uninsured Like Me.)

    Supporters of Medicaid sometimes say that it improves infant mortality. The unspoken but rather brutal truth is for the racist right, that is actually the problem. Their view is that we have too many poor children being born as it is. (In Texas, one half of all births are paid for by Medicaid.)

    The war against the poor has been quite a failure, like most forms of Social Darwinism. But Medicaid is still a battlefield in the conflict.