THCB

Categories

Category: Health Policy

Gen Z Should Give Health Care a Stare

By KIM BELLARD

Last I knew, Gen Z showed its disdain for older generations with a dismissive “OK Boomer.” But that was a few years ago, and now, it appears, Gen Z doesn’t even bother with that; instead, there is what has become known as the “Gen Z stare.” You’ve probably seen it, and may have even experienced it. TikTok influence Janaye defines it thusly: “The Gen Z stare is specifically when somebody does not respond or just doesn’t have any reaction in a situation where a response is either required or just reasonable.”

It’s been blowing up on social media and the media over the last few days, so it apparently has tapped into the social zeitgeist. It’s often been attributed to customer service interactions, either as a worker receiving an inane request or as a customer facing an undue burden.

You can already see why I link it to healthcare.

It’s off-putting because, as Michael Poulin, an associate psychology professor at the University at Buffalo, told Vox: “People interpret it as social rejection. There is nothing that, as social beings, humans hate more. There’s nothing that stings more than rejection.”

Many attribute the Gen Z stare to Gen Z’s lack of social experience caused by isolation during the pandemic, exacerbated by too much screen time generally. Jess Rauchberg, an assistant professor of communication technologies at Seton Hall University, would tend to agree, telling NBC News: “I think we are starting to really see the long-term effects of constant digital media use, right?” 

Similarly, Tara Well, a professor at Bernard College, told Vox: “It’s sort of almost as though they’re looking at me as though they’re watching a TV show… We don’t see them as dynamic people who are interacting with us, who are full of thoughts and emotions and living, breathing people. If you see people as just ideas or images, you look at them like you’re paging through an old magazine or scrolling on your phone.”

Millennial Jarrod Benson told The Washington Post: “It’s like they’re always watching a video, and they don’t feel like the need to respond. Small talk is painful. We know this. But we do it because it’s socially acceptable and almost socially required, right? But they won’t do it.” Zoomer (as those of Gen Z are known) Jordan MacIsaac speculated to The New York Times: “It almost feels like a resurgence of stranger danger. Like, people just don’t know how to make small talk or interact with people they don’t know.”

On the other hand, TikTok creator Dametrius “Jet” Latham claims: “I don’t think it’s a lack of social skills. I just think we don’t care,” which might be more to the point.

ABC News cited some customer service examples that deserved a Gen Z stare: “I’ve been asked to make somebody’s iced tea less cold. I’ve been asked to give them a cheeseburger without the cheese, but keep the pepper jack of it all.” As Zoomer Efe Ahworegba put it: “The Gen Z stare is basically us saying the customer is not always right.”

Ms. Ahworegba doesn’t think a Gen Z stare doesn’t reflect Gen Z’s lack of social skills, but rather: “They just didn’t want to communicate with someone who’s not using their own brain cells.” As some Zoomers say, it is “the look they give people who are being stupid while waiting for them to realize they are being stupid.”

Still, as one commenter on TikTok wrote: “I think it’s hilarious that Gen Z thinks they’re the first generation to ever deal with stupidity or difficult customers, and that’s how they justify the fact that they just disassociate and mindlessly stare into space whenever they are confronted with a difficult or confusing situation, instead of immediately engaging in the situation like every other generation has ever done before them lol.”

Or perhaps this is much ado about nothing. Professor Poulin noted: “To some degree, it’s a comforting myth that all of us who are adults — who’ve gotten beyond the teens and 20s — that we tell ourselves that we were surely better than that.” When it comes to displaying socially acceptable behavior, he says: “This isn’t the first generation to fail.”

———

Interestingly, Gen Z is already skeptical of our traditional healthcare system, as well they might be.

Continue reading…

Why Multi-morbidity Requires Two Health Systems, not One

By JEREMY SHANE

What’s behind the coming health care reckoning? Most industry leaders have their preferred list of culprits: not us! Left-leaning critics blame large insurers, drug companies, and private equity firms. Take the profit and self-dealing out of health care. Those on the right blame excessive regulation, poorly-designed insurance markets, or limits on individuals’ ability to pick their own coverage. Debates yo-yo between these views in a political stalemate. While the views are diametrically opposed on solutions, they share a belief that financial issues are the root cause of systemic dysfunction. That manipulating how clinicians are paid or insurance is structured can improve health outcomes. 

A half century into efforts to fix health care, it is clear that both views are wrong. Americans’ healthspans are shrinking while costs spiral upwards thanks to chronic disease. Progressively worsening illness throughout adulthood eventually explodes in multimorbidity, driving cancer and dementia, and protracted hospitalizations. Clinicians know this, with their well-worn chorus of “if only” laments. If only we could reward prevention instead of treatment. If only we intervened earlier before advanced pathology takes hold. If only clinical care was not fragmented. If only people had a direct stake in their longer-term health. Yet the debate in Washington DC, even shaken up by the MAHA movement’s focus on chronic issues, regresses into an interminable blame game, and conflicting ideas about how Congress or CMS could end the madness. 

It is time to break the cycle and say clearly what we know to be scientific fact. It’s impossible to use a system built to solve acute issues to also solve multi-decade, highly variable disease threats. Yet this presumption, that one system can do it all, addressing everything from colds to car crashes to cardiovascular issues to cancer, is so deeply ingrained in our thinking as to escape scrutiny. 

It is folly to continue. We need two systems, not one — the first for routine, emergency, and elective treatments and the second to confront long-term, complex challenges. Absent this change it will take far longer than it should, and cost far more, to decipher chronic issues or create economic arrangements that can bring forward the ultimate value of preventing disease.  

Resetting Assumptions

It’s illuminating to focus on the scientific drivers of disease rather than the financial after effects. It becomes clear why Medicare Advantage is imploding, and no, it’s not because CMS changed payment rates. Since 2000, the percent of Americans entering Medicare with multimorbidity has jumped by two-thirds, from a quarter of new entrants to over 40%. Software may be eating the world but multimorbidity is eating Medicare, Medicaid, and private insurance, and with it, most Americans’ healthspans. 

Most Americans now live a decade more than their grandparents, only to spend all the additional years, and then some, in poorer health.

Continue reading…

We’re Gonna Need a Bigger Boat

By KIM BELLARD

My friends, we are like explorers of yore standing at the edge of a known continent, looking out at the vast ocean in hopes of finding new, unspoiled, better lands across it. True, we may have despoiled the continent behind us, but certainly things will be better in the new lands.

In the metaphor I’m thinking of, the known continent is our shambles of a healthcare system. For all the protestations about the U.S. having the best health care in the world, that’s manifestly untrue. We don’t live as long, we have more chronic diseases, we kill each other and ourselves at alarming rates, we pay way more, we have too many people that can’t afford care and/or can’t obtain care, we have too much care that is ineffective, inappropriate, or even harmful, and we spend much too much on administration.

We don’t trust the healthcare system, we don’t think its quality of care is good, we have an unfavorable opinion of it, we think it fails us. The vast majority of us think it should be fundamentally changed or completely rebuilt. That’s what we want to flee, and it’s no wonder why.

Across that metaphorical ocean, in the distance, over the horizon, lies the 22nd century healthcare system. It will, we hope, be like magic. It will be more equitable, more effective, more efficient, more proactive, less invasive, more affordable. We don’t know exactly what it will look like or how it will work, but we’ve seen what we have, and we know it can be better – much better. We just need to get there.

This leads me to the next part of the metaphor. I recently read a great quote from the late nature writer Barry Lopez, from his posthumous book of essays Embrace Fearlessly the Burning World. Mr. Lopez laments: “We are searching for the boats we never built.”

The boats aren’t coming to save us, to transport us to that idealized 22nd century healthcare system. Because we never built them. Because we still don’t have the courage to build them.

We’ve never built a system to ensure universal coverage. We rely on a hodgepodge of coverage mechanisms, each of which is struggling with its own problems and still leaving some 25 million people without insurance – and that’s before the 10-20 million who are predicted to lose coverage due to the “Big, Beautiful Bill” – plus the tens of millions who are “underinsured.

We’ve never built a system that was remotely equitable, just as we never did for housing, education, or employment. Money matters, ethnicity matters, geography matters. Discrepancies in availability of care and in outcomes show up clearly for each of those, and more.

We’ve never built a system that prizes patients above all. We deferred to doctors and hospitals, not calling them out when they gave us substandard care or when they charged us too much. Now health care has gone from a “noble calling” to a jobs and wealth creator. A recent New York Times analysis found (among other things):

  • Health care is the nation’s largest employer;
  • In 1990, health care wasn’t the largest employer in any state; now it is in 38 states;
  • We spend more on health care than on groceries or housing.

Pick your favorite target: private equity firms buying up health care entities, for-profit companies extracting profits from our care (or nominal “non-profits” doing the same), the steady corporatization of health care. Throw in favorite boogeymen like health insurers, PBMs, or Big Pharma. One way or another, it’s about the money, not us.

The adage about Big Tech comes to mind: we’re not the customer, we’re the product (or, as I’ve written before, we’re simply the NPCs.).

We’ve never built the systems to make administration easier. So many codes, so many rules, so many types of insurance, so many silos, so many administrators. By now you’ve no doubt seen the chart of the growth of administrators versus clinicians in our health care system, and are aware that around a quarter of our healthcare dollar goes to administration. It doesn’t have to be this way, it shouldn’t be this way, but administrative bloat is getting worse, not better.  

We’ve never built the systems to properly track our health or risks to it.

Continue reading…

Water, Water, Everywhere . . . but Not a Drop to Drink

By MIKE MAGEE

In the wake of last week’s human tragedy in Texas, it would be easy (and appropriate) to focus on the role played by Trump’s reckless recent dismantling of FEMA and related federal agencies. But to do so would be to accept that the event was an anomaly, or as Trump labeled it on Sunday on his way to a round of golf at Bedminster, “a hundred year catastrophe.”

In reality, tragedies like this are the direct result of global warming, and last week’s suffering and loss are destined to be followed by who knows how many others here and in communities around the world.

In 2009 President Obama joined global leaders in New York City for the Opening Session of the UN. One of the transboundary issues discussed was Global Warming. All agreed that the Kyoto Protocol had failed. It failed because the target to decrease emissions by some 5% was too low. It failed because large transitional nations like India and China were excluded. And it failed because US leadership opted out.

The global community today has a deeper hole out of which it must dig. In doing so we would do well to focus on health and safety as outcome measures, and define strategies to manage the obvious consequences of this ongoing crisis.

Two decades ago, the warnings were clear. Left unattended, we would soon not only need to plan mitigation, but also need to prepare and resource intervention to deal with inevitable human injury and disease fall-out. Of course, back then, we could not have predicted that wise disease interventions in climate ravaged hot spots around the globe, like expansion of USAID funding in the Bush and Obama administrations, would be X’d out under Trump/Musk. Who could have imagined such reckless and ultimately self-destructive moves?

And yet, here we are:

Continue reading…

Microplastics Are Here, There, Everywhere

By KIM BELLARD

Vaccine experts are going rogue in response to RFK Jr’s attacks on vaccine safety. Health insurers promise – honest…this time – to make prior authorizations less burdensome (although not, of course, to eliminate them). ChatGPT and other LLMs may be making us worse at learning. So many things to write about, but I find myself wanting to return to a now-familiar topic: microplastics.

I first wrote about microplastics in 2020, and subsequent findings caused me to write again about their dangers at least once a year since. Now there are, yet again, new findings, and, nope, the news is still not good.

A new study, from researchers at the Food Packaging Forum, Swiss Federal Institute of Aquatic Science and Technology (Eawag) and the Norwegian University of Science and Technology, and published in npj Science of Food reviewed 103 previous studies about the impact food packaging and “food contact articles (FCAs)” can have on micro- and nanoplastics (MNPs) in our food. They found that even normal use — such as opening a plastic bottle, steeping a plastic tea bag, or chopping on a plastic cutting board – can contaminate foodstuffs.

“This is the first systematic evidence map to investigate the role of the normal and intended use of food contact articles in the contamination of foodstuffs with MNPs,” explains Dr. Lisa Zimmermann, lead author and Scientific Communication Officer at the Food Packaging Forum. “Food contact articles are a relevant source of MNPs in foodstuffs; however, their contribution to human MNP exposure is underappreciated.” 

Their collected data are freely accessible through the FCMiNo dashboard., which allows users to filter included data by the type of FCA, the main food contact material, the medium analyzed, and whether MNPs were detected, and if so, for their size and polymer type.

Removing the plastic from items you purchase at the grocery store may contaminate it with microplastics, as might steeping a tea bag. Simply opening jars or bottles of milk can as well, and repeated opening and closing of either glass or plastic bottles sheds “untold amounts” of micro- and nanoplastics into the beverage, according to Dr. Zimmerman, who further noted: “The research shows the number of microplastics increases with each bottle opening, so therefore we can say it’s the usage of the food contact article which leads to micro- and nanoplastic release,”  

Dr. Zimmerman told The Washington Post: “Plastic is present everywhere. We need to know what we can do.” Examples of what she suggests we can try to do include avoiding storing food in plastic whenever possible and avoiding heating plastic containers. She admitted, though: “We have not really understood all the factors that can lead to the release of micro and nanoplastics.”

Continue reading…

American Medicine’s Meagerness Paradox

By MARC-DAVID MUNK

In our palliative medicine clinic in the working suburbs of Boston, my colleagues and I tend to some of the sickest patients in the city. Through the window, I can see the afflicted pull up to our squat building in family sedans, wheelchair vans, and subsidized municipal ride cars. Few drive themselves: most bear terrible illnesses that make them too frail or sedated. I watch as patients who are barely able to dress themselves, somehow arrive in their Sunday best for clinic.

Our job, as their doctors, is to manage their pain and provide moral support and practical help with things such as rent and transportation, sometimes spiritual support too. It’s important work, among the highest callings in medicine. Yet, as noble as this work might be, our clinic doesn’t begin to support itself financially. If there was ever a reason to spend graciously on patients and their needs, these visits, with their sick and vulnerable patients, would be exemplars. In fact, we don’t receive enough payment from insurers to cover the costs of the complicated work that’s needed. Practically, this translates to few staff to help with appointments, not enough follow-up calls, nobody to help with insurance headaches or pharmacy shortages, nobody answering the phone. Our facilities are tired. The simplest niceties—coffee in the waiting room, magazines, a comfortable chair—are long gone.

There is a feeling of “meagerness” in the air. It’s the feeling of being rationed. It’s an absence of all but the truly essential; no plenitude, a lack of graciousness. I see meagerness when my friend, an emergency physician at a major trauma center, shares pictures of his decomposing ER: desk chairs held together with medical tape, rooms without functioning equipment. Medical supplies that are so scarce that doctors keep stashes in their desks and coat pockets.

The administrators will say that these barren conditions are a consequence of financial scarcity. There isn’t enough money to pay for more than skeleton support and upkeep. Hospitals are running deficits and downsizing. Keeping the lights on is apparently a question of saving pennies at every opportunity. And, with every cut, meagerness grows. This all sounds, on its surface, understandable till you take a step back and realize it isn’t. We know that American healthcare consumes more money than any other country, per capita. Money is pouring, truly flooding, into our healthcare system. Family health insurance premiums rose 7% from 2023, after another 7% increase the year before. The average family policy now costs around $25,000 per year.

Which leaves me wanting to reconcile how there can be so much money entering the system, with so little left for essential front-line care. I know that this isn’t a complicated answer.

Continue reading…

Now is the Time to Modernize Communication in the Medicaid Program

By ABNER MASON

What do television shows 60 Minutes, Roseanne, Designing Women, and Murder, She Wrote all have in common? They were top 10 prime time shows in the 1991 – 92 season according to Nielson Media research. Obviously, what Americans want to watch has changed in 34 years. The decline in market share the major networks – ABC, CBS, and NBC – have experienced, and the dramatic growth of streaming services proves the point. It makes sense to let people watch what they want to watch on the device of their choice, and use new technologies like streaming services to access the shows they want to watch.  It would be foolish for us to insist that Americans watch only shows from the legacy networks on traditional TVs. But this is basically what we are doing now when we force Medicaid Managed Care Plans (Plans) to comply with a 1991 Federal Law when they communicate with Medicaid recipients.

Here’s the problem. Federal legislation called the Telephone Consumer Protection Act (TCPA), enacted in 1991, makes it very difficult for States and Plans to use text messaging to communicate with their members, even though texting is the primary, and preferred mode of communication for all Americans including Medicaid recipients. TCPA requires a State or Plan sending a text to have permission from the person receiving the text before the text is sent. Violations of TCPA result in significant financial penalties for each infraction, and penalties are tripled if the sender knowingly sent the text without consent.

Medicaid recipients are typically assigned to Plans, they do not choose their Plan, and as a result, in light of TCPA, and potentially enormous financial penalties being assessed, plans have taken the position that they do not have consent from recipients to text them. And that is the problem.

Texting is the way most Americans communicate today. Other modalities like US mail (called snail mail for a reason), phone calls (who answers calls anymore?), and email (likely to go without a response for days or weeks) are dramatically less effective. Because they are low income, many Medicaid recipients often do not have a landline, or a laptop. They rely on their mobile phone for all their communication, including healthcare related communication. Texting is their preferred, and often only way of communicating.

As Founder and CEO for SameSky Health, I spent over a decade working with Plans to help them engage their members and navigate them into healthcare at the right time and the right place. Again and again, we found when we could maneuver around the outdated restrictions TCPA placed on Plans, we got higher engagement which translated into more well child visits, more breast cancer screenings, more diabetes (a1c) screenings, and so on. Using modern tools of communication is a way of meeting people where they are. It builds trust and leads to better health outcomes. But sadly, because of TCPA, we were not able to text members in most instances.

What has been a significant problem will be made exponentially worse when Federal Work Requirements are implemented as now seems likely. A Federal Medicaid Work requirement will dramatically increase the need to modernize how States and Plans communicate with Medicaid recipients. Compliance with TCPA is standing in the way of this modernization. And if it is not fixed, many, many people will lose their Medicaid benefits for purely procedural reasons.

To improve health outcomes, allow efficient communication to verify work status,  and provide twice yearly redetermination information, States and Plans must be exempted from the outdated provisions of TCPA. Senate action on, and final passage of the Reconciliation legislation offers the best opportunity to get an exemption from TCPA passed and signed into law.

The time to act is now.

So lets focus on (1) getting the exemption language in the Senate version of the Reconciliation legislation, (2) working with HHS and CMS to ensure post legislation guidance directs States and Plans to include texting as a best practice when implementing work requirement programs and communicating with recipients more generally, and (3) implementing a media strategy to build support for using modern technology to create easier more efficient ways for Medicaid recipients to comply with the new work requirements.

We have two months – June and July – to get action on an exemption in the Senate, and the remainder of the year to influence Administration guidance on work requirement programs.

Medicaid beneficiaries will be the biggest winners if we succeed because an exemption is a key strategy to reduce unnecessary loss of Medicaid benefits.

What can you do? Call your Senator and ask them to support modernizing how States and Plans communicate with Medicaid recipients. And please share this blog post with your network.

Abner Mason is Chief Strategy and Transformation Officer for GroundGame Health. He serves on the Board for Manifest MedEx, California’s largest health information exchange, is Vice-Chair of the Board for the California Black Health Network, and is a member of the National Commission on Climate and Workforce Health. Here are are just some of articles and interviews he has published over the past 10 years pushing for States and Plans to be able to text Medicaid recipients. 

Personal and Professional Choices in PSA Testing: A Teaching Moment

By KELLI DEETER  

I was intrigued by Daniel Stone’s piece on THCB in May titled “Biden’s cancer diagnosis as a teaching moment”. In my practice as a board-certified nurse practitioner, I am frequently asked about prostate specific antigen (PSA) testing by my male patients.  

Nursing practice and medical practice often get blurred or lumped together. In the state of Colorado, nurse practitioners practice under their own license, and can independently diagnose and treat patients. In some settings where I have worked, I found myself frequently correcting patients who refer to me as ‘doctor’. “I am not a medical  doctor, I am a nurse practitioner,” is repeated by me multiples of times per day. In this discussion of PSA testing, I want to share my decisions to order or not to order PSA testing for individuals, based on my nursing training.  

It is important to refer to the guidelines for PSA testing recommended by the US Preventive Services Task Force (USPSTF), and published by the Journal of the American Medical Association (JAMA). The last updates made to the guidelines were in 2018. It is key to remember that these are guidelines, and that medical doctors, physician assistants, and  nurse practitioners use these guidelines in their consideration of the patient. In nursing, a holistic and team approach with the patient’s preferences, history, cultural considerations, and desired outcome are all weighted in decision making for assessment, testing, referral, and treatment. Guidelines are just that, a GUIDE, not an absolute.  

Guidelines state that for patients aged 55-69: Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction… Clinicians should not screen men who do not express a preference for screening. And for patients  aged 70 and older: The USPSTF recommends against PSA-based screening for prostate cancer. This does not mean that we as providers should not test men younger than 55 or older than 70. We need to look at each patient case independently of one another and not  lump everyone together. 

Additionally, patients may not know how to “express a preference for  screening”. It is imperative that providers have the allotted time to explore their family history of prostate and other cancers, explain to them the benefits and risks of testing, listen to and discuss their signs and symptoms, perform a digital rectal exam (DRE) if appropriate and agreed on by the patient, take into consideration their medication regimen and their age, as well as if they would want treatment or not. Certainly, if they are symptomatic, and a new medication for their symptoms is being prescribed, or if they are symptomatic and a DRE is obtained that is abnormal, a PSA should be obtained with the  patient’s approval to establish a baseline, and a follow-up appointment made with repeat  labs or referral, if desired by the patient. If there is a family history of prostate cancer, an  early PSA screening test to establish a baseline might be preferable. Again, patient  preferences must be taken into account.  

People have very different feelings about western medicine and about what they want for  themselves and their bodies. We must realize that just because someone has an ever increasing PSA with or without symptoms, they may not agree to a DRE or to referral to  urology, surgery, or oncology. As a provider, we should obtain a refusal of recommended care. It is ok to not want testing, follow-up, or treatment, no matter one’s age. In Biden’s  case, there had been no PSA testing since 2014, during his vice presidency. The fact that no reason was given is irrelevant, in 2014 he was 72 years old. Guidelines are not to test  starting at age 70. The PSA level if drawn may not have aƯected his health outcome or  treatment, but it may have affected the outcome of his nomination for the presidency, thus politicizing nursing and medical practice. Pointing fingers now at the past changes nothing. I agree with Stone, that this is a teaching moment: advocate for yourself as a patient, advocate for your patient as a provider, and consider that so much of one’s health is a personal choice and that it should be honored and protected.  

I agree with Peter Attia’s contention in his May 24, 2024, A timely though tragic lesson on  prostate cancer screening, that the PSA screening guidelines are out of date; the last revision was in 2018. Attia indicates many men remain healthy and live well past the age of  80, and aggressive cancers if caught early and treated, will better benefit the patient’s quality of life and length of life. I would also argue this is true of screening earlier in life, at age 50. Access to health care is an issue for many in our society. Marginalized populations such as  the indigent, homeless, geriatric, mentally ill, and incarcerated experience greater  disparities, and have a higher risk of missing any PSA testing at all. In my work as a nurse  practitioner in the correctional system, for individuals entering jails and prisons this is  often the first time they have ever seen a healthcare provider. These individuals often have  a history of indigence, homelessness, and/or mental illness. Additionally, new cancer diagnoses are increasing and for men; 29% of new cancer types are prostate. 

Age 50 is a  milestone for most individuals, and they know they are supposed to get screening for colorectal cancer at this age as well as other screening tests. Consolidating care by capturing a PSA at this same time would establish an early baseline; there is never a guarantee that a patient with healthcare access issues will ever return for another appointment, due to finances, transportation, fear, or other factors. Another consideration for revising the PSA screening guidelines is lowering the threshold for PSA levels based on patient age that drive referral to urology for imaging, and putting simple language into the guidelines to look at a two-fold increase in PSA over 6-12 weeks as likely urgent referral to  urology. Initiating early watchful waiting with PSA screening has the potential for saving  more lives and maintaining desired qualities of life.

Kelli Deeter is a board-certified family nurse practitioner with 12 years of experience in geriatrics, rehabilitation, correction, women’s health, mental health, and complex chronic care.

Waste, Fraud and Abuse – Oh, My!

By KIM BELLARD

So the House has passed their “big, beautiful bill,” by the narrowest of margins. Crucial to the bill are large savings from Medicaid, which in past years Republicans would have taken some glee from but now they are careful to explain away as just cutting “waste, fraud and abuse,” having finally realized that many MAGA voters depend on Medicaid.

Much of those savings come from proposed work requirements for Medicaid recipients, long a favored Republican tactic that the Biden Administration kept rejecting. Speaker Mike Johnson is very vocal about their importance. The people impacted by the work requirements, he insisted on Face the Nation:

If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system. And no one in the country believes that that’s right. So there’s a moral component to what we’re doing. And when you make young men work, it’s good for them, it’s good for their dignity, it’s good for their self-worth, and it’s good for the community that they live in.  

He’s convinced that, instead of working, too many of them – especially young men – “playing video games all day.” He and other Republicans want to return Medicaid to what they see as its original purpose: “It’s intended for young, you know, single, pregnant women and the disabled and the elderly,” Speaker Johnsom said. “But what’s happening right now is you have a lot of people, for example, young men, able-bodied workers, who are on Medicaid. They’re not working when they can.”

He’s generally right that, for most of its existence, Medicaid was not truly a program for the poor so much as for certain kinds of poor people, especially low income pregnant women and children, and the medically impoverished. It took Obamacare to widen coverage to all people under the poverty line, although the Supreme Court allowed states to decide if they wanted to do so, and ten states still have not.

It is, indeed, a moral question, just not the kind that Speaker Johnson likes, about whether there is a moral imperative to give more people, especially poor people, health coverage.  

The issue of these non-working Medicaid recipients is something of a shibboleth. Kaiser Family Foundation, for example, found “that 92% of Medicaid adults are either working (64%) or have circumstances that may qualify them for an exemption.” A 2023 CBO analysis cast doubt that such work requirements wouldn’t have much impact on the number of Medicaid recipients working. Work requirements are a solution in search of a problem.

Continue reading…