Bureaucrats a Conservative Can Love

July 2, 2018
Posted by Jay Livingston

Conservatives don’t like bureaucracy. They utter the word “bureaucrat” with the same sneering tone they use for “liberal” or “feminist.” They hate regulations and red tape.

But there’s something they hate even more – poor people. Well, not exactly. What they hate is the idea that some poor person somewhere might be getting food or medical care that he of she does not “deserve.”

So the Trump administration is allowing states to impose work requirements on people who get Medicaid. The assumption is that hordes of able-bodied people who could be working are idly whiling away their time in unproductive self-indulgence. We should not reward this indolence by giving them free medical care.

The reality of the lives of poor people on Medicaid is, of course, far from this image of dolce far niente. Most of them work. But under the work requirements, they will have to go through the bureaucratic process of documenting that they are employed. Those who can’t negotiate the red tape will lose their health coverage even though they were working. How many such people will there be, and how many freeloading idlers will be kicked off Medicaid?

Those are the questions that the Kaiser Foundation answers in its recent report (here). The answer is that most of the people who will lose coverage will lose it because of the paperwork, not because they failed to meet the work requirement.

Kaiser made estimates of what would happen in each of four scenarios – the cells in this 2 x 2 table. The top and bottom row are the high and low estimates of the percent of Medicaid recipients the work rules are aimed at — people who would lose coverage because they failed to find work (or some substitute like being in a job training program or volunteering). The Kaiser estimates are based on what happened when states imposed work requirements on people who received welfare (TANF) or food stamps (SNAP).

The columns are the low and high estimates of the collateral damage — people who really did meet the work requirement but who would lose coverage because they were not able to complete all the necessary paperwork each month (things like documenting the number of hours worked).

Even under the most favorable scenario, the people who are “disenrolled” for bureaucratic reasons outnumber those who are disenrolled because they didn’t work. – 62% to 38%.

The work requirement and the bureaucratic requirements surrounding it seem to assume that poor people have, or should have, a “job” – a regular place of long-term employment — the kind of job that middle-class people have.* In fact, the great majority of Medicaid recipients do work. But the work that poor people get is often temporary. In retail, food-service, and construction, hours are irregular and uncertain. Turnover is high. In a bad month, a low-wage worker may work less than the 80 hours required, and consequently lose benefits.

As for administrative costs, Kaiser says this:

States implementing work requirements will likely have to design new systems to reflect changes in eligibility rules, to enable enrollees to report compliance, to interface with other programs (such as SNAP, TANF, or employment training), to implement coverage lock-out periods, and to exchange eligibility information among the state, enrollment broker, health plans, and providers. New staff may be required to conduct beneficiary education, develop notices, evaluate and process exemptions, and review more applications as churn increases and enrollees appeal coverage lockout periods.

More money spent on more bureaucrats and more red tape. You’d think that conservatives would rise up and shout “No!” But the states that are most eager to impose work requirements are the states dominated by conservative governments — Kentucky, Arkansas, Tennessee, Indiana, and others.**

Sure bureaucracy and bureaucrats are bad, but apparently, if we can keep even one undeserving poor person from getting Medicaid, then all the bureaucratic regulations we impose on people and all the bureaucrats we pay to enforce all these new regulations, will have been worth it. Who cares if a few of the deserving poor are discomfited? How many of them could there be anyway among all these freeloaders getting Medicaid? The answer is: a lot, far more than the number of freeloaders.

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* Arkansas even assumes that poor people have broadband access. The state is requiring that Medicaid recipients submit their forms online. No in-person, no phone, no snail mail.

** Conservatives have a similarly flexible view of federal budget deficits.