GOP Medicaid – It’s About Righteousness, Not Health

January 11, 2018
Posted by Jay Livingston

In yesterday’s post, I concluded that the principle goal of the Republican approach to Medicaid was not to improve the health of poor people but to punish their unvirtuous behavior. Today, the Centers for Medicare & Medicaid Services pretty much confirmed that. They issued guidelines allowing states to force Medicaid recipients to get a job, or failing that, to volunteer or participate in job training.  Here is the tweet from Seema Verma, director of the Centers.

Verna assumes that forcing poor people to work or volunteer improves their health. It doesn’t. At the Upshot (the New York Times’s data-heavy sector, here) Margot Sanger-Katz reviews the evidence.

It is not at all clear how much work or income alone improve health. In fact, there’s quite a lot of evidence that causality can move in the opposite direction . . . .“Having the medical coverage helps people to get a job,” said LaDonna Pavetti, a vice president at the liberal Center on Budget and Policy Priorities, who has studied work requirements extensively. . . . The earned-income tax credit, a program established specifically to raise the incomes of low-wage workers, wasn’t able to find any clear health benefit.

Sanger-Katz links to an article by Robert Rector of the Heritage Foundation, a right-wing think tank. Even he doesn’t think that the new rules will improve the health of the poor. And because people without Medicaid will wind up going to the emergency room (far more expensive that regular treatment), work requirements won’t save the government any money. Heritage published the article last March with the headline, “Work Requirements in Medicaid Won’t Work . . .”

A work requirement would just make it less likely for able-bodied adults without dependent children, known as ABAWDs, to register for the program. The work requirement would reduce Medicaid enrollments, but Medicaid costs might well go up because the eligible ABAWDs would go to the emergency room rather than receive routine care elsewhere. . . . Suppose a Medicaid eligible ABAWD enrolls in Medicaid and then fails to do his work assignment (a very likely outcome based on experience with other work requirements). This individual then shows up sick in the emergency room or clinic. Is the government going to deny him medical care because he did not do his workfare assignment? Of course not. [Well, maybe and maybe not. A lot of Tea Party types would gleefully deny him medical care. At a debate during the 2012 GOP primaries, they cheered at the idea of allowing someone without insurance to die. See this post.]

As Sanger-Katz says, Rector’s rationale for work requirements is not medical, it’s moral. The goal is not to make people healthy but to make them virtuous, to make them “personally responsible.”  And the way to do that is to punish them for their lack of virtue even though that may bring sickness and death. After all, since health is a matter of personal responsibility, it’s what they deserve. 

The new rules may not be very good at improving the health of poor people, but they will be effective at making the rest of us feel morally righteous. And isn’t that more important?