We asked for workers, but they sent us men (and women, too)

Denying Medicaid-funded prenatal care to undocumented immigrants.

Denying Medicaid-funded prenatal care to undocumented immigrants. Cross-listed at The Century Foundation’s Taking Note section

I happen to be an immigration moderate. It seems a bit crazy to me that we handle birthright citizenship the way that we do, and that we don’t have a credible national ID card system to enforce immigration law. If there is a humane, intellectually coherent, administratively effective, politically feasible pathway to decent immigration policies, I haven’t seen it. One tragedy of the last decade has been the failure of such disparate figures as George W Bush, John McCain, Ted Kennedy, and Barack Obama to forge a sensible compromise.

The enemies of such a sensible policy continue to be an odd combination of hypocrisy across the political spectrum, xenophobia within the Republican base, and employers’ powerful desire to legally or illegally employ compliant and productive low-wage workers. There is also the unstated–but possibly correct–belief held by many people that the human and economic costs of our current muddle would be worsened if our dysfunctional political system now attempted to meet the challenge of comprehensive immigration reform.

Postscript: For further administrative details (including its harmful effects on low-income women legally authorized to be in the country), see Table 7 of this Voices for Children issue brief.
Continue reading “We asked for workers, but they sent us men (and women, too)”

Beware what you wish for….Governors and the block granting of Medicaid

In trying to duck their Medicaid responsibilities, Republican governors could be rushing into a long-term budget disaster for their states.

Fourteen years ago, Mickey Kaus and Peter Edelman held an engrossing bare-knuckled dialogue about the merits and pitfalls of welfare reform. For the youngsters, this 1996 bill abolished the 60-year-old Aid to Families with Dependent Children (AFDC), replacing it with the avowedly transitional Temporary Assistance to Needy Families (TANF), a block-granted program.

Looking back on that exchange, I suspect both antagonists have reason to feel themselves vindicated.

Edelman warned there–and in an embittered Atlantic article called “the worst thing Bill Clinton has done–that the recently-signed welfare reform would financially endanger the states because it removed their entitlement to federal funds for the needy people they were supporting. Edelman was wrong about that, because he was so right about something else: states’ eagerness and ability to punitively reduce the welfare rolls. In 1996, more than 12 million Americans received traditional welfare. Now only about 4.3 million do, despite population growth and the worst recession in several decades.

Republican Governors who support block-granting Medicaid may hope for a successful reprise of this experience. This won’t happen. In their haste to obtain immediate political victories and maybe some short-term fiscal relief, they are courting a long-term budget disaster for their states. At least that’s what I argue over in New Republic this morning.

Roy vs. Pollack on health outcomes, Medicaid, and welfare dependency

Avik Roy responds to my last post. I appreciate that he took the time to do so. There needs to be more talk across the ideological divide.

Still, I stand by what I said. In my further response to him, I’m also unimpressed by Roy’s bromides regarding Medicaid’s furtherance of “welfare dependency, that leads to family breakdown and social disrepair.”

Frakt vs. Roy on Medicaid

I’m baffled by Avik Roy’s continued argument that being on Medicaid is worse than being uninsured. I’m even more baffled that he mixes it up with Austin Frakt on these matters.

(This is cross-posted on Taking Note.)

Avik Roy is an creative and engaging blogger. So is Austin Frakt. In addition, though, Frakt is a highly-skilled empirical health services researcher. So it’s a bit odd that Roy chooses to mix things up with Austin regarding instrumental variables studies that explore the impact of Medicaid coverage on health outcomes.

It is odder still that Roy writes a piece called “Why Medicaid is a Humanitarian Catastrophe.” He cites a useful but readily-misinterpreted surgical study which finds notably higher adjusted mortality rates among Medicaid patients than among the privately insured. Estimated mortality rates among Medicaid patients were also higher than that found among Medicare patients and the uninsured. Roy concludes the following from these findings: Continue reading “Frakt vs. Roy on Medicaid”

Skin in the game

Representative David Camp believes poor people lack “skin in the game,” because they do not pay federal income taxes. OK, but what if Americans had real skin in the game as we contemplate retrenching government services in a deep recession.

George Will’s column today concerns Representative David Camp of Michigan, incoming Republican chairman of Ways and Means. Camp says:

Many conservatives, including Camp, believe that although most Americans should be paying lower taxes, more Americans should be paying taxes. The fact that 46.7 million earners pay no income tax creates moral hazard — incentives for perverse behavior: Free-riding people have scant incentive to restrain the growth of government they are not paying for with income taxes.

“I believe,” Camp says, “you’ve got to have some responsibility for the government you have.” People have co-payments under Medicare, and everyone should similarly have some “skin in the game” under the income tax system.

It’s hard to know what to make of such arguments. It includes the standard Republican move of noting progressive federal income taxes without noting that low-income people pay significant payroll taxes to the federal government, not to mention the state and local sales taxes these lucky free-riders pay every time they buy a toothbrush or a stick of gum. This “skin in the game” argument is also applied rather selectively. These days, anyway, few conservatives argue that everyone who might get hit by a car should have skin in the game by remaining insured. Maybe more people should pay estate taxes, for that matter. Very few us have skin in that game, which abets continued persecution of the dynastically wealthy.

Snark aside, though, Camp has a real point. Only he should apply it more broadly. Two hundred million Americans with decent health coverage have no skin in the game when they consider the millions of poor people who need to wait 12 hours in a cruddy public hospital emergency room or some overcrowded safety-net clinic. Most Americans have no skin in the game when Arizona Medicaid recipients find out that their heart, lung, or liver transplants will no longer be covered, when South Carolinians find out that Medicaid will not cover hospice care and will cut its weekly meals on wheels deliveries from fourteen to ten, when California Medicaid no longer cover routine dental care but at least still covers the eventual tooth extractions. Few of us rely on AIDS drug assistance programs, which are turning people away or placing them on waiting lists. To take an example at random, most Americans do not have to sit in a south Chicago welfare office with a disabled brother, waiting for hours under happy-talk posters say: “Work makes sense!”

Most of us lament from a distance the failing schools and unsafe streets of our inner-cities. Few of us are gay, or are college students who lack proper immigrant papers. We have no personal stake when Congress debates whether to extend benefits to the chronically unemployed. Few of us are uninsured people with preexisting conditions. Few of us depend on Food Stamps or TANF. Few of us are frightened young women dealing with unplanned pregnancies. (Few of us, for that matter, are National Guardsmen doing repeat tours in Afghanistan or Iraq.)

Will rightly notes: “Serious arguments about taxes are never just about taxes. They are about government’s proper size and purposes.” That’s for sure. Republicans assume the House majority with the general promise of austerity and retrenchment during a deep economic crisis. When influential constituencies have direct stakes in the resulting fight—as in the case of Medicare—we have a good idea how these arguments will be resolved.

I’m more worried about other matters, which affect the most politically and economically vulnerable people who depend on federal and state government. If more of us who politically matter had real skin in that game, we would see better and different public policies.

Hitting bottom on Medicaid: South Carolina gives Arizona some competition

What kind of state eliminates Medicaid hospice benefits and cuts meal deliveries to disabled seniors? I liked South Carolina much better when we were all joking about the Appalachian trail.

Here’s an entertaining fact for you: My brother-in-law Vincent receives toe and toenail care at the podiatrist. No he doesn’t wear toenail polish like Frank Burns did on M*A*S*H. A combination of skin issues, chronic obesity, and intellectual disability create mundane but important foot problems for Vincent that require serious attention.

He’s unlucky enough to require Medicaid. Luckily for him, though, he doesn’t live in South Carolina (h/t Diane Meier’s valuable tweets), since that state will no longer cover these mundane but important services. As today’s WYFF4 news puts it:

Starting in February 2011, Medicaid will no longer cover podiatry services, routine eye exams or dental services for anyone older than 21. Routine circumcisions for newborns, diabetic equipment and services and some wheelchair accessories are on the list. Hospice care services will also be eliminated.

You read that last one correctly. The state will no longer provide Medicaid coverage for hospice care.

Like an anxious investor watching a crashing stock market, I’m seeing what’s happening with Medicaid and wondering when states will finally hit bottom. One might think Arizona’s transplant policy provides a credible floor (listen here if you haven’t been following this). But maybe not. Here’s what is coming later to South Carolina:

In April, Medicaid will eliminate services under the state’s Community Long-term Care Program, which provides services to people at their home. That includes chore and appliance services, nutritional supplements, adult day health care nursing services and respite service. There will also be a reduction in the number of meals delivered to the home each week.

That’s a new one. Meals on wheels will apparently reduce its weekly meal deliveries from fourteen to ten.

I don’t quite know what to say, except to hope that this is some budgetary game of chicken, and these cuts don’t actually happen. Given what is happening around the country, there’s little reason to be hopeful.

We’re becoming sadly accustomed to states which deny Medicaid recipients dental care and eye exams, not to mention the circumcision thing. But what kind of state withholds hospice care and cuts meal deliveries to disabled seniors? I liked South Carolina better when we were joking about the Appalachian trail.

Postscript: South Carolina provides a sad example of the trend noted in this terrific Monica Potts piece posted at TAP yesterday on southern cuts in anti-poverty programs. Hard times.

Don’t forget about Medicare’s waiting period when reading about Arizona’s awful transplant policies

Arizona richly deserves the bad publicity for its draconian Medicaid transplant policies. Medicare deserves blame, too, for its draconian disability waiting period policies.

It’s gratifying to see New York Times reporters and columnists pick up the story of Arizona’s disgraceful Medicaid policies towards transplant patients. We’ve rightly hammered Arizona Republicans on this site for their death panel policies–policies which are linked with actual deaths and with at-best horribly callous treatment of very sick or dying patients.

One angle has not received sufficient attention. Many transplant patients profiled in these news stories have been deemed eligible for federal disability benefits. Yet they are stuck in the required waiting period to become eligible for Medicare. This issue reflects a complicated policy debate that has been invisible to all but a tiny fraction of the American public. Incidentally, issues such as this one illustrate why arcane policy details really matter for real people, and thus why complaints that the Affordable Care Act ran over 2,000 pages were so juvenile when there is such a need to get these details right.

Congress should modify Medicare’s terrible waiting period policies, particularly for patients who lack access to private coverage. Such policies were always problematic. These policies are particularly unjustified after the passage of health reform.

Arizona richly deserves the bad publicity it is getting. The federal government, too, could do much better.