Yves here. The need for and extent of Medicaid is a yet another symptom of how the US medical system is profit and not patient health driven. Here in Thailand, Thai hospitals (as in with Thai speaking doctors and therefore de facto not for farangs), a doctor visit is 30 baht, or $1. The minimum wage varies by province, but is in the 337 to 400 baht a day range. And medicine here, even though having a bit of a bias to being standardized, scores well by world standards:
According to CEOWORLD’s 2021 survey of 89 countries worldwide, Thailand’s healthcare was ranked thirteen best in the world, beating out many renowned European countries like Norway, Germany and Switzerland as well as most other Asian countries except for South Korea, Taiwan, and Japan.
From the same article:
A recent report of research by John Hopkins University also ranked Thailand sixth best among 195 countries providing the strongest health security, as was reported at the Global Health Security Agenda Steering Group Meeting in November of 2019. Thailand was the only developing country ranked among the global top ten, and the first among Asian countries, scoring a total of 73.2 points out of 100.
By contrast, the US seems determined to double down on punishing the poors. As the article below points out, imposing Medicaid work requirements has done little to increase employment. The reasons include confusion about how to comply and difficult documentation requirement. It seems the point is to deny coverage and not boost workforce participation (even assuming that’s possible; consider obstacles like age discrimination).
In the meantime, there is perilous consideration of the broader public health impact of creating an underclass that gets no or very little medical care. Among other things, diseases can spread more readily in communities with a lower baseline level of health.
By Eloise Goldsmith, a staff writer at Common Dreams. Originally published at Common Dreams
As right-wing lawmakers pursue imposing conditions on Americans’ ability to access Medicaid and other social services, the Center on Budget and Policy Priorities this week published analysis warning that work requirements for Medicaid recipients could put 36 million Americans, or 44% of all Medicaid enrollees, at risk of losing their health insurance.
“Research shows that work requirements do not increase employment,” according to the authors of the CBPP report, which was published on Wednesday. The authors argue that these types of requirements are based on the premise that Medicaid enrollees do not work, when data shows that they do.
“Nearly 2 in 3 adult Medicaid enrollees aged 19-64 already work, and most of the rest would likely not be explicitly subject to the requirement based on having a disability, caring for family members, or attending school,” the report states.
The group estimates that of those 36 million people who could be impacted, 20 million are enrolled through the Affordable Care Act’s Medicaid expansion.
While almost all Medicaid enrollees either work or would qualify for an exemption under most Medicaid work requirement proposals, according to CBPP, the report points to multiple past examples that indicate many enrollees still lose coverage with the imposition of work requirements due to “administrative burden and red tape.”
For example, when Arkansas in 2018 temporarily implemented a policy that placed work requirements on Medicaid recipients, about 25% of enrollees subject to the requirements, some 18,000 people, lost coverage before a federal court paused the program seven months later.
As another example, New Hampshire implemented a short-lived Medicaid work requirement program in 2019 with more flexibility in reporting requirements and “more robust outreach efforts” in order to avoid Arkansas’ mistakes, according to CBPP, but 2 in 3 enrollees who had to comply with the requirements “were likely to be disenrolled after just two months, amid reports of widespread confusion among enrollees about how to comply with the requirements.”
The analysis—which the authors say is not an estimate of the number of people who will be impacted by a specific policy proposal—defines the population at risk of losing their coverage as adults between ages 19 and 64 who are not enrolled in Medicaid through disability pathways, i.e. a wider net of people than are specifically targeted in some recent GOP proposals.
The 36 million number is a larger group of enrollees compared to a previous CBPP estimate that was in response to a specific proposal whose work requirements would have targeted fewer people.
Multiple recent GOP proposals regarding Medicaid work requirements target “able-bodied” workers, though they vary in other specifics.
The far-right policy blueprint “Project 2025” calls for the Centers for Medicare and Medicaid Services to “clarify that states have the ability to adopt work incentives for able-bodied individuals” on Medicaid. And in late January congressional Republicans passed around a list of ideas for how to fund a bill full of GOP priorities that included imposing Medicaid work requirements for “able-bodied” adults without dependents, modeled after the Limit, Save, Grow Act, a bill passed by the House in 2023.
On Thursday, Sens. John Kennedy (R-La.) and Eric Schmitt (R-Mo.) reintroduced the Jobs and Opportunities for Medicaid Act, a bill that would require “able-bodied adults without dependents who receive Medicaid benefits to work or volunteer for at least 20 hours per week.”
Because the Kennedy and Schmitt bill includes an exemption for adults with dependents, it would impact a smaller number of people than the CBPP’s Thursday analysis. But still, as a general matter, “work requirements are simply another way to cut Medicaid,” according to the authors of the analysis. Republicans’ January list of cost cut options estimated that adding Medicaid work requirements along the lines of what was specified in the Limit, Save, Grow Act would yield $100 billion in 10-year savings.
In a Friday letter to Senate Majority Leader John Thune (R-S.D.) and House Speaker Mike Johnson (R-La.), all 47 members of the Senate Democratic Caucus wrote: “We urge you to reject proposals that use Medicaid as a piggy bank for partisan priorities and continue to defend the importance of this vital program.”
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Yves’s prefaces are always so interesting I want to comment on them rather than the article.
Re: lessons learned from Thai healthcare, I went to several different hospitals in Thailand (note: in Thailand as in much of the world, hospitals are common starting points for healthcare, not just a plac for emergencies and surgery). The most expensive hospital in Bangkok is like a 5 star hotel, I was really wowed.But the doctors there mostly also practice in public hospitals for much less money. I can’t say the care I got there was as impressive as the decor in comparison with other Thai hospitals. And I did go to a Thai public hospital in the provinces (I knew an English speaking doctor who navigated for me), and the care was excellent.
Meanwhile back in Boston USA there are months-long waiting lists for the world famous hospitals and doctors affiliated with the world’s most famous university. I’ve settled for actually getting treated in community hospitals by doctors who graduated from UMass or even (gasp!) out of state schools and I have no complaints about the competence shown.
Lesson learned: prestige and cost do not have a linear correlation with quality of care.
“Lesson learned: prestige and cost do not have a linear correlation with quality of care.”
I have found this to be true not just in medicine but also in many other professions and personal services. And sometimes with regard to products as well.
Funny anecdote: I have a friend who is dedicated to the proposition that the most expensive version of anything is without exception the best. Once I served her an ad hoc appetizer of crackers along side a block of soft white cheese covered with home-made cranberry chutney. She spread some on a cracker, tried it, and went into rapture. “WHAT is this incredible cheese?” she demanded to know. I replied that it was Kraft Philadelphia cream cheese. At first she refused to believe me, but after being shown the empty package, she exclaimed “Think how much BETTER it would be with goat cheese” (at three or four times the price). No, actually. It’s just right with real cream cheese. But I gave up trying to convince her of such things many decades ago…
I once told my rheumatologist about a wealthy friend who had paid off his stepson’s student loans at Harvard Medical School, mentioning how lucky the kid was to hold such an esteemed piece of paper debt-free.
She quietly said that the University of Nebraska (her alma mater) was just fine. That shut me up. She’s an excellent physician.
Well put. An ex-pat living in Bangkok sprang for his mother’s complete face lift. Most of the work was good but the surgeon forgot to take out the drains around the eyes. That necessitated some procedures in the US when she got home and figured out what went wrong.
Medicaid will almost certainly shift to a per capita/block grant funding formula to justify Trump’s massive tax cuts. Republicans have tried to do this since the 1994 Contract with America, and this is probably their best chance to do it. I doubt they will try to repeal the ACA, either. They’ll just let the tax credits run out at the end of this year, which will significantly increase the costs of ACA coverage and essentially collapse it because it will become unaffordable.
Instead, they’ll be a return to pre-ACA, short-term coverage plans with essentially catastrophic-only coverage. They’ll be cheaper but with large deductibles, lifetime coverage dollar amounts, pre-existing condition exclusions, and frequent claims denials & recessions. Golden Rule (United Healthare’s short-term insurance subsidiary) was arguably the worst, and they used to aggressively use the medical history of applications to deny coverage/rescind coverage for high $$$ coverage cases, especially cancer cases. It’s even easier now, to a degree, with electronic medical records to gather this data, and it’s worth the insurer’s time if they can deny coverage on a claim that will be $150k+.
Not only another cost on the poor and aged but a great business ‘opportunity’ for those into Regulatory Compliance. I wonder which tech titan will get the contracts for monitoring these activities, report ‘violations’ and determine eligibility?
This reminds me that I need to verify that I am in compliance with Medi-Cal again as they mail me paperwork every year around this time, but I have not received it. Even if they screw up the paperwork, I don’t get a refund and I am in a multi month process of getting cataract surgery, which looks to be a six month process from the initial medical examination to getting my new glasses. The whole medical system seems to be getting much slower.
I know a fellow who is on Medicaid/Medicare, I’m not sure which. He’s just 52, and not rich by any standards, and while he’s on disability from a railroad accident a few years back, he’s not so disabled he can’t hitch his trailer and go to the lake, deploy his boat, park the truck with trailer 100 yards away, return to the ramp and scramble into his boat. He’ll then fish until noon, and reverse the process to get home. Once back, he’ll spend a half hour or so cleaning and gutting his catch, before calling it a day and settling in with a 12-pack of Natural Light to get buzzed whilst watching television until he goes to bed. And he does this almost every day. I know him because I stop and buy a few pounds of his fresh catch every now and then.
Point being, I’m working despite a lower back I could unquestionably find a doctor to sign off on for benefits. So it’s folks like these who work the system, and around here at least, there seems to be many, which DOGE is intent on doing something about. And note; these are many of the same people (the guy I know is an example) who have a handicap placard for their car or truck – yet – have no problem (whilst parking 50 feet closer than everybody else), traversing our Super Walmart (which has 5 acres under cover). And yes, I know all disabilities aren’t visible, but still, the system was put in place for those needing wheelchair access and then this system got gamed, also.
Anyway, I try hard not to think about those who have it figured out – but – I also won’t shed a tear if DOGE cleans out those who have worked the system for benefits they don’t really need by imposing a work requirement because either USD$32T accelerating toward USD$40T is genuinely unsustainable, or it’s a fiction. And note; this is true even if we confiscated 100% of the the wealth of lefty-hated figures like Musk, Gates, Bezos, et al.
Heck, simply type USAID into X and you’ll be astonished at learning which pet projects were getting millions. That the sum of this spending pales beside defense, medicare, SS, and debt payment is nevertheless, infuriating. So Musk and Company, at the behest of the President, have my full support.
Look, we have elections and they have consequences. So I say, let’s give them a chance to do what they promised. And in just under two years, we’ll get another vote, and in four the Democrats get another shot at the top job. Until then, let’s sit back and hope because the status quo ante isn’t viable – not by my math!
Sorry, this is one case. This is no proof at all of how often this happens. Yes, this is an abuse, but how frequent? And you act as if this can’t be remedied by tightening review requirements, particularly having independent doctors assess the condition of the allegedly disabled person.
Are you also yelling at the public companies whose shares you own about employees who game flight policies by getting doctors to write notes about their bad backs so they can fly business class for <8 hour flights? Most of those guys golf or engage in other physical exertion, in an analogue to your case.
With any large system you can find abusers. They have to rely on regularlized procedures and that results in some being able to game them. The only way to not have abuses is to have no social programs at all. That seems to be where you and DOGE are going.
I don't want to live in a society like that. The data shows overwhelmingly that highly unequal societies are sicker, more violent, and more unhappy. High levels of inequality impose health costs even on the very rich. So be careful what you wish for.
I actually agree with you in everything you say. But the system hasn’t cleaned out the gamers and I don’t see it ever doing so.
And as it happens, while I’m philosophically a Republican type (small, limited government) I also switched voter registration to Democrat expressly to support Bernie Sanders before the Democrats screwed him in SC and haven’t gotten around to switching back.
This, because I also happen to think Medicare for All is a splendid idea. Note, not because there would have been anything in it for me because, a) I could afford the $20k/year health insurance premium, and b) I would be on Medicare before any changes would have taken place . . . saying I switched party registration because I genuinely believe M4A is the smarter approach for the country.
Regardless, either $32T heading to $40T matters, or it doesn’t. And if Musk and company ever crunch the numbers, they may come to that conclusion since he’s not a stupid guy.
Assuming $40T matters, then we ‘need’ an overhaul. So I won’t shed a tear over what Musk is doing at the President’s direction. And, I also expect they’ll cut things I favor soon enough (meaning the crying-shoe will be on the other foot, and I’ll be screaming, eventually). After all, they’re going to set the dogs loose on the defense budget, so the wailing, rending of hair, and gnashing of teeth will be coming.
Meanwhile, I remain in wait and see mode.
The issue is not the level of spending. It is that the spending is not going anywhere enough for activities that will increase the productive capacity of the economy. The US ran absolutely massive budget deficits during WWII but that was for manufacturing that was enough general purpose that it could be converted to civilian use after the war.
Yes, most Trumpers are convinced that if we got rid of all welfare programs and returned prayer to the schools, all would be right with the world.
If I thought Doge would institute carefully thought out ways to cut out Medicaid fraud, I would be fine with that, although I know the real drain on our finances is a bloated Pentagon, and welfare shoveled to financiers, corporations, and oligarchs. But the poors are much easier to stomp on.
Doge is moving fast, breaking the wrong things, and playing with people’s lives like it’s all a video game. Yes we’ll all wait and see, see how much permanent damage they do. Good plan.
I wouldn’t mischaracterize half the country as ‘most Trumpers’ in those terms, but whatever. Nor would I disparage half the country who voted for Harris.
Ad to which, I happen to take into account those doing the wailing about, ‘all the wrong things’ quite likely are creatures working at the behest of those who favor spending millions for DEI in foreign countries. Like of ‘course’ they’re against everything the Trump team is doing, and they have the mainstream media at their beck and call despite the quiet firings that have been taking place (like I can’t wait for the despicable hypocrite, Rachel Maddow, to get her comeuppance). And I delight in the blinders coming off the joke CNN became. The left mobilized the power of the Times, Post, NBC, ABC, and CBS and still couldn’t sell Harris. They cheated with the laptop story and beat barely Trump four years ago and in the meantime, he’s had four years to mull his next move.
Anyway, since the election was fair and square this time, then if hater don’t like it they can decamp for another country.Think Ellen and Portia moving to the Cotswolds and stirring up trouble for them, now. I get a chuckle whenever I hear of the latest issue they have with how the English do things.
So riddle me this; doesn’t it resonate with you how $40M spending in MI would alleviate lead pipe problems? Like don’t we have enough of our own in genuine need to be spending millions on promoting DEI in the rest of the world? Honestly, In this regard, what the Vice President says about loving me and mine before loving strangers rings true to my ears.
Meanwhile, I suspect if USAID had stuck to vaccination programs and actual nation building we wouldn’t be in a position where there’s a risk of the baby being thrown out with the bathwater. But no, it became a grift for the left.
Yet all that said, I’m going to wait and see about this, also. Why? it’s because I don’t much like him, Sec State Rubio strikes me as anything but an idiot. Saying he and the State Department knows the genuine value of soft power. So give it time.
This is a fabrication and you need to stop it. You regularly dump uninformed right wing talking points into the comments section.
The DEI business abroad is a straw man.
And the right made plenty of use of the regime change ops at USAID. As Larry Johnson has documented, its two biggest increased in budget occurred under Bush and Trump. So cut the crap about it being on one team or another.
The lead pipe issue is state/local because they run waterworks, not the Feds.
And John, I know someone with heart disease and a deeply compromised respiratory system who doesn’t qualify for disability so he works. He lives frugally, he has had his apartment for years so by NYC standards it is deeply cheap, and he saves everything he can. Because at minimum wage he still has to avoid working at least two months a year to qualify for Medicaid. He does this because even with the subsidized health insurance available in NY, he would not be able to afford his care and necessary medications otherwise, even working the full twelve months. I know this for a fact because I was in the group who did a deep dive into what the plans would and would not cover if he had to leave Medicaid. My little group didn’t even want to think what his life wouldn’t be worth if the two valves his doctors are most worried about were to fail under the “great” special plan NY was offering at that time.
I would also tell you that if you were to meet him you wouldn’t realize for a moment what problems he faces.
Look, I know our system sucks and there are some not so desperate people taking advantage of what little relief it offers. I get that not being able to afford to go to a dentist when Medicaid will cover it and Medicare doesn’t frustrates a whole lot of Americans. But the problem is our tiered system. And the biggest gamers of the system aren’t the individuals but the United Healths, and the Pfizers, and the bigger players. It might be easy for Doge to kick off your fish source, but it isn’t going to fix it.
Thank Biden and the Dems for cutting about 20 million from Medicaid a year or so ago. Everyone thought this was just fine. I asked my local Dem reps in Congress, PA state and County if they would like to join a public effort with our single payer group to protest and demand national single payer and they all were silent. Even refused to acknowledge how many would lose coverage in their respective districts.
There are too many very wealthy and powerful people who benefit from the current “healthcare” system and they donate money to politicians at every level. If the politicians you talked to even just verbally acknowledged what you said as true, they would risk being primaried or having a very well funded challenger replace them.
I would like to point out UnFu*king the Republic’s newest and datafilled piece:
Understanding & Fighting for Medicare for All
Robert Allain
Very interesting article for Canadians, especially when Trump is threatening to turn our whole country into the 51st state using economic force if necessary to convince the naysayers.
Trading our medical and universal healthcare programs afforded to every citizen for the mishmash of government roadblocks to healthcare access to Americans as described in this article should be a warning to any Canadian foolish enough to contemplate Trump ‘s demands. Trump is playing with our Canadian sovereignty and we hold dearly to our independence. This would be much worse than 1812, this time Mar a Lago is the building going up in flames. So forget your 51st state and forget straddling us with your disfunctional system. We’re quite happy just as we are.