Secretary of Defense Jim Mattis claimed Wednesday that the Syrian government backed down after the White House said that Syrian President Bashar al-Assad’s forces were preparing for another possible chemical attack. “They didn’t do it,” Mattis said.
I would like to formally announce that if Russia kills my mother in a nuclear attack, there will be grave consequences. If my mother is still alive tomorrow, that will show that they’ve backed down. I’ll let you know.
In a piece yesterday, Cosmopolitan senior writer Rebecca Nelson highlighted seven women who are supposedly “generating 2020 buzz,” and every single woman on her list is either a Democratic politician or a public figure committed to the left-wing cause.
The list doesn’t mention Republican Susan Collins, who has been a GOP senator from Maine for over two decades. It also disregards the GOP’s remaining four female senators, several of whom have been in office longer than the Democratic senators Nelson names.
Likewise ignored are female Republican governors across the country who outnumber their Democratic counterparts four to two. Nelson snubs U.N. ambassador Nikki Haley, who served a successful six years as governor of South Carolina and who is widely considered one of the GOP’s rising stars.
I dunno. The article is specifically about people who “could be our first female president,” and I guess Cosmo is assuming that Donald Trump will run for reelection in 2020. This means that no one, male or female, is generating “2020 buzz” on the Republican side of the aisle. Am I missing something here?
California’s assisted suicide act went into effect last year, and today the Department of Public Health released statistics for 2016. A total of 191 people requested prescriptions for aid-in-dying drugs, and 111 used them. However, because the program is very new, and only covered half the year, these numbers are certain to go up significantly in future years.
Unsurprisingly, the initial statistics confirm what we know from other states that have similar laws: assisted suicide is barely used at all among non-whites.
The reasons for this are not entirely clear. Among Hispanics, it’s probably partly related to religion, since the majority of Hispanics are Catholics and the church forbids suicide. More generally, it’s probably also related to a distrust of doctors among minority groups. Beyond that, I’m not sure anyone really has a persuasive explanation.
Generally speaking, though, the main demographic for assisted suicide is professional, college-educated white folks who are used to being in charge and dislike the idea of losing control over their lives. This was true in the 90s and aughts, when it was illegal and done under the table, and I believe it’s true in every state that’s legalized assisted suicide since then.
Last night a reader emailed to ask what I thought about the death of California’s single-payer health care bill. Is Assembly Speaker Anthony Rendon a progressive traitor because he tabled the bill for this legislative year? For you non-Californians out there, here are a few things to know:
History. Don’t make the mistake of thinking that SB562 was some brand new, Bernie-esque health care reform. California Democrats have been introducing universal health care bills of one sort or another for decades. This is California’s seventh attempt, following the introduction of single-payer bills and ballot initiatives in 1992, 1994, 1998, 2003, 2005, and 2009.
Funding. Single-payer would cost something like $200 billion, give or take a few billions. This is nearly double the entire state budget, but SB562 blithely ignored it. It included no funding mechanism at all, and simply passed that reponsibility to the state Assembly. It’s not surprising that Rendon was reluctant to shoulder this on his own over the course of the next few months.
Prop 98. Like it or not, California has a school funding law put in place years ago by Proposition 98. It’s insanely complicated, but basically requires that 40 percent of the state budget go to K-12 schools. Using round numbers, if the state budget is $100 billion, school spending has to be at least $40 billion. If state spending goes up to $300 billion, school spending has to be at least $120 billion. Aside from being ridiculous, it also leaves only $120 billion for the health care bill. Oops.
As far as I know, there is no tricky way to get around this. It would have to be dealt with by a ballot initiative. That’s obviously not going to happen in this legislative session.
Waivers. This is the issue nobody pays attention to, but is probably the most important of all. To implement single-payer, California would need $200 billion in new funding plus $200 billion in federal money that currently goes to Medicare, Medicaid, veterans health care, and so forth. Without federal waivers to give California access to that money, the plan can’t go anywhere. As Duke University researcher David Anderson puts it, “If there aren’t waivers, this plan is vaporware.” What do you think are the odds that the Trump administration will grant all those waivers? Zero is a pretty good guess.
Along the same lines, Michael Hiltzik points out that self-funded health care plans are governed exclusively by federal law. That means California would need an exemption from the law. What do you think are the odds that a Republican Congress will grant that exemption? Zero again?
Two-thirds. This bill requires a two-thirds vote to pass. Democrats control exactly two-thirds of both houses of the legislature. They can afford to lose one vote in the Assembly and no votes in the Senate. This means the bill needs to be very, very carefully crafted.
State plans. This is not about California in particular, but it’s worth remembering Ezra Klein’s Washington Monthly piece in 2007 about the history of state attempts to set up universal health care plans. As he concluded, “the results are pretty clear: states are no good at delivering universal health care.” Who knows? Maybe a better plan could succeed where others have failed. But it better be a pretty good plan.
Single-payer at the state level is enormously complicated, extremely expensive, difficult to set up properly, and politically fraught. Developing a workable policy will not take months, it will take years. Bottom line: Rendon could have kept the bill alive, but it would have been a charade. It was going nowhere this legislative session and he knew it. At a policy level, this needs a lot more work before it’s ready for prime time.
A senator who supports the bill left the meeting at the White House with a sense that the president did not have a grasp of some basic elements of the Senate plan — and seemed especially confused when a moderate Republican complained that opponents of the bill would cast it as a massive tax break for the wealthy, according to an aide who received a detailed readout of the exchange.
Mr. Trump said he planned to tackle tax reform later, ignoring the repeal’s tax implications, the staff member added.
The eternal question is: evil or stupid? Does Trump really not know that the health care bill is a huge tax cut for the rich? Or does he just not want anyone to mention it in his presence? The problem here is that Trump would have to be really, really stupid not to understand that the central provision of both the House and Senate bills is a huge tax cut for the rich. I mean, nobody is that stupid. Right?
Mitch McConnell may have a dark and twisted soul, but he’s a pretty good legislative tactician. That’s why he’s basically told Donald Trump to stay out of health care negotiations in the Senate, since he’d probably just screw things up. But Trump couldn’t help himself. After Sen. Dean Heller of Nevada announced that he would vote against the bill, Trump gave the OK to a Super PAC to run ads against Heller. According to the New York Times, McConnell was pissed:
Over the weekend, Mr. McConnell made clear his unhappiness to the White House after a “super PAC” aligned with Mr. Trump started an ad campaign against Senator Dean Heller, Republican of Nevada, after he said last week that he opposed the health care bill.
The majority leader — already rankled by Mr. Trump’s tweets goading him to change Senate rules to scuttle Democratic filibusters — called the White House chief of staff, Reince Priebus, to complain that the attacks were “beyond stupid,” according to two Republicans with knowledge of the tense exchange.
….The move against Mr. Heller had the blessing of the White House, according to an official with America First, because Mr. Trump’s allies were furious that the senator would side with Nevada’s governor, Brian Sandoval, a Republican who accepted the Medicaid expansion under the health law and opposes the Republican overhaul, in criticizing the bill.
As near as I can tell, the biggest tailwind Democrats have going for them right now is that Trump is such a cretin. I don’t know how likely it is that Republicans can pass a health care bill anyway, but there’s not much question that Trump is making it harder thanks to his bottomless ignorance of both policy and politics. Trump’s only tool is a wrecking ball, and that means he views every problem as a building to be razed. This is very definitely not how US senators like to be viewed, but Trump is too stupid to understand this.
And who knows? In the end, that might be the thing that saves Obamacare.
GARCIA-NAVARRO: We’re talking about male players, but there [are] of course wonderful female players. Let’s talk about Serena Williams. You say she is the best female player in the world in the book.
MCENROE: Best female player ever — no question.
GARCIA-NAVARRO: Some wouldn’t qualify it; some would say she’s the best player in the world. Why qualify it?
MCENROE: Oh! Uh, she’s not, you mean, the best player in the world, period?
GARCIA-NAVARRO: Yeah, the best tennis player in the world. You know, why say female player?
MCENROE: Well, because if she was in, if she played the men’s circuit, she’d be, like, 700 in the world.
McEnroe is getting slagged for insulting Serena Williams by saying she’d rank #700 on the men’s circuit. Also for the sin of thinking that female athletes have to be compared to men. And for being an idiot. Etc.
This is ridiculous. McEnroe can run his mouth with the best of them, but in this case he’s completely innocent. Just read the interview:
McEnroe says Serena William is the best female tennis player in history, full stop. This is something he’s said many times before.
The interviewer then sloppily changes the subject to whether Williams is the best player in the world. Not the best woman in history, but the best in the world right now among all tennis players. This is laughably ignorant.
McEnroe is obviously taken aback, but then answers accurately: If we’re talking about the quality of all tennis players on the planet right now, Williams isn’t even close. This is completely noncontroversial, and it’s something Williams herself has said herself.
McEnroe didn’t bring this up out of nowhere. He wasn’t trying to say anything about Serena Williams or women’s tennis in general. He wasn’t trying to generate controversy. He was responding to a dumb question from an interviewer. I suppose he could have told the interviewer he didn’t understand what she was saying, and then asked for a clarification, but instead he just answered and moved on—or would have, anyway, except that the interviewer just wouldn’t let it go.
Since then, half the sports writers in America have proved they have too much free time on their hands by going after McEnroe. And everyone else is now chiming in too.
This piece at Vox is what finally sent me over the edge. Alex Abad-Santos obviously understands that this whole thing is baseless. He acknowledges that Serena Williams has said the same thing McEnroe did. He acknowledges that McEnroe’s past history clearly demonstrates his appreciation of both Williams and women’s tennis in general. He acknowledges that McEnroe is innocent of racism and sexism. He acknowledges that the interview was sloppy, but then turns this into a weird kind of praise: “Garcia-Navarro does a good job of getting McEnroe to talk himself into a bit of trouble.” But even after acknowledging all this, he claims the whole thing is McEnroe’s fault: he’s just “courting controversy” and is being stubborn and bullheaded for declining to apologize.
This is so, so tedious. Everyone knows how dominant Serena Williams has been. Everyone knows that men play a stronger game than women. It’s a matter of opinion whether Serena is the most dominant tennis player of all time. And McEnroe only mentioned this because an interviewer asked a stupid question.
Why do we have to pretend to be outraged over trivia like this? Just give it a rest, folks. There’s nothing here.
POSTSCRIPT: If you’re not mad enough at me already, here’s one more thing. In addition to everything else, Abad-Santos tweaks McEnroe for “the 700 number he seems to have pulled out of nowhere.” No he didn’t. In fact, he was probably being nice. I’d guess that the real number is more like 2000. I’d offer to argue about this with anyone who’s interested, but honestly, who cares? This is one of the dumbest “controversies” ever. If you really need an excuse to show how woke you are, pick something else.
This is a western tiger swallowtail butterfly. They’re pretty common around here, but I didn’t take this in our garden. This is the last of my pictures from my trek to Silverado Canyon a couple of months ago. I should probably go out again. This particular spot, with its shady, distant background, was really great for taking pictures of various flying critters.
Facing resistance from their own party, Senate Republican leaders said Tuesday they would postpone a vote on their healthcare bill until after the July 4th recess, according to two sources familiar with their thinking….Senate Majority Leader Mitch McConnell wants to provide more time to try to convince reluctant GOP senators to vote for the measure.
Conventional wisdom says that time is not McConnell’s friend. In fact, it turns out that even a week was too much time. I’d like to say that the Senate bill was just too appalling even for Republicans to take, but I’m not sure that’s quite right. After all, a lot of the pushback has been from tea-party types who think the bill isn’t brutal enough.
In any case, the summer recess will now be an opportunity for Republican senators to find out just how dangerous a Yes vote really is. The progressive community needs to make sure they find out. And don’t forget to recruit your moderate conservative friends too. They probably have more influence with your local GOP senator than you do.
Jonah Goldberg suggests today that no one can say what they really believe about health care. Republicans refuse to admit that they don’t really want to repeal Obamacare after all. As for Democrats:
Meanwhile, the Democrats know that Obamacare has been a huge albatross for their party and understand that the best thing that could happen for them is if the Republicans agreed to keep Obamacare in name (i.e., abandon the rhetoric of “repeal”) but do whatever is necessary to make the thing work. But the GOP is doing the opposite. It’s largely keeping Obamacare in terms of policy (at least the really popular parts) but rhetorically it’s claiming to destroy Obamacare utterly. So, both the Democrats and the Republicans end up claiming this is a repeal of Obamacare when it’s not. It’s all a war for the best spin, not the best policy.
Wait a second. “Keep Obamacare but fix it” is practically the Democratic rallying cry these days. There’s hardly a Democrat alive who doesn’t loudly and publicly support this position. A couple of months ago all 48 Democratic senators signed a letter promising, “If repeal is abandoned, we stand ready to work with you to help all Americans get the affordable health care they need.” Every liberal rally and march includes people carrying “Don’t repeal it, fix it!” signs. I’ve personally written multiple times about this, most recently two days ago: “Obamacare’s modest problems could be fixed with nothing more than a few minor changes and additional funding of $5-10 billion or so.” Those minor changes include, possibly, a higher mandate penalty and continuing to fund the CSR subsidies. Nothing all that hard.
Would Democrats be willing to support some conservative priorities—tort reform, HSAs, block granting Medicaid—in return for this? Beats me. But Democrats have sure made it clear that keeping Obamacare and fixing it is what they want. If Republicans truly have any interest in this, they shouldn’t have any trouble finding willing listeners.
I ask Rice why she thinks she became a target. She laughs, sort of. “I’ve spent a lot of time thinking about this. What do you think?”
I mention Benghazi, the moment when much of the right’s base became aware of Rice’s existence. “Does it start there?” she asks. She is not a person given to agitation, but here, Rice’s focus sharpens — she looks at me more directly, with heightened intensity. “And why me? Why not Jay Carney, for example, who was then our press secretary, who stood up more?”
Carney isn’t an African-American woman, of course….I point out that she has a reputation for being tough, and a strong-willed woman who seems sure of herself makes a certain kind of man nervous.
“Let me just put it this way,” she says. “I do not leap to the simple explanation that it’s only about race and gender. I’m trying to keep my theories to myself until I’m ready to come out with them. It’s not because I don’t have any.”
Well, I for one will be eager to hear her theories once Rice decides she’s ready. Rice is certainly the most unfairly maligned public servant of the past few years, all because she went on TV and told the truth about Benghazi. That was her real sin, of course.³
And as long as we’re on the subject, I’ll just take this opportunity to add that progressives didn’t exactly cover themselves in glory while Rice was being endlessly slandered by conservatives over Benghazi. For weeks they mostly held their tongues or damned her with faint praise (“she probably shouldn’t have mentioned the video….”). But Rice literally did nothing wrong. Zero. On her infamous Sunday show appearances, she told the absolute truth as it was then understood by the intelligence community. This was, unfortunately, a precursor to progressives also failing to aggressively defend Hillary Clinton over her emails. Why? I suppose because lots of progressives were afraid there might be a smoking gun somewhere and didn’t want to risk coming strongly to her defense and then looking foolish. Cowards. In the end, of course, we eventually learned that Clinton had also done literally nothing wrong and the FBI never had even a weak case against her.
¹As opposed to favorite longtime punching bags Hillary Clinton and Nancy Pelosi.²
²Both of whom are also women. Kinda makes you think, doesn’t it?
Let’s start the day off with some good news. You never know: it might be the last we get today. Here’s the latest on same-sex marriage from Pew Research:
Everyone is getting more comfortable with gay marriage: all ages, all races, all religions, and all parties. On the other hand, I guess we still have to sort out whether a Christian bakery can refuse to make a wedding cake for a same-sex couple. That’s going to seem pretty quaint a few years from now.
Need a quick couple of quickie graphics to summarize the Senate health care bill? I’m here to help. First, the basics:
Next, a comparison of premiums. It’s true that the Republican bill generates lower premiums than Obamacare, but that’s only because its coverage is so skimpy and its deductibles and copays are so high. It’s like bragging that a gas-guzzling old jalopy is cheaper than a new Prius. However, Kaiser has crunched the numbers to come up with average premiums under BCRA and Obamacare for similar policies. Here they are. These estimates are for a current average silver plan after all tax credits have been applied:
By 2026, spending on Medicaid will be slashed $772 billion. (Page 5)
As a result, there will be 15 million fewer people on Medicaid. (Page 16)
By 2026, spending on subsidies for private insurance will be slashed $408 billion. (Page 5)
As a result, there will be 7 million fewer people with private insurance. (Page 17)
This sums to a total of 22 million more uninsured people by 2026, compared to 23 million under the House version of the bill.
Revenue would be reduced about $750 billion, mostly via tax cuts on corporations and the wealthy. (Tables 2 and 3)
Obamacare is not in a death spiral: “The subsidies to purchase coverage, combined with the effects of the individual mandate…are anticipated to cause sufficient demand for the market to be stable in most areas.” (Page 6)
BCRA would also be stable. However: “A small fraction of the population resides in areas in which—because of this legislation, at least for some of the years after 2019—no insurers would participate in the nongroup market or insurance would be offered only with very high premiums. Some sparsely populated areas might have no nongroup insurance offered….In addition, the agencies anticipate that all insurance in the nongroup market would become very expensive for at least a short period of time for a small fraction of the population residing in areas in which states’ implementation of waivers with major changes caused market disruption.” (Page 7)
Deductibles for silver plans will increase from about $3,600 to about $6,000. (Page 8)
The actuarial value of health care plans will be reduced to 58 percent. This means that even after buying insurance, consumers are responsible for 42 percent of their total health care expenses. “As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.” (Page 8)
“Because nongroup insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law.” (Page 9)
Because of the reduced value of health care policies under BCRA, premiums will go down. (Page 9) However, net premiums after accounting for subsidies will go up for most people. Among those with modest incomes, net premiums for silver plans would go up $500 for 21-year-olds; $1,300 for 40-year-olds; and $4,800 for 64-year-olds. Among those with higher incomes, net premiums would go down except for 64-year-olds, who would face increases as high as $13,000. (Table 5)
The share of uninsured older folks with low incomes would skyrocket from about 11 percent to 26 percent. (Page 16)
Caps on Medicaid spending will likely cause some states to reduce already low reimbursement rates for doctors. If this happens, “fewer providers might be willing to accept Medicaid patients….If states reduced payments to Medicaid’s managed care plans, some plans might shrink their provider networks, curtail quality assurance, or drop out of the managed care program altogether.” (Page 30)
Reading the CBO report in its entirety, it’s hard to see that BCRA offers any improvements over Obamacare aside from cutting taxes for the rich. Net premiums go up for most people—quite massively in the case of older consumers; deductibles go up; out-of-pocket expenses go up; the working poor are virtually shut out of the insurance market; the quality of coverage gets worse; and 22 million people lose insurance.
The only plausible path for any improvement is the increased flexibility states would have to run their own health care progams. Historically, this has accomplished little except to allow conservative states to cut back on health services to the poor, so you’d need to be mighty starry-eyed to think that it will produce amazing innovations this time around. But that’s about it: believing in the power of states to innovate because they have less money is the only path for defenders of BCRA.
Last week I put up a picture of a guy cycling and texting at Santa Monica beach. That’s kid stuff. Here’s a guy cycling, texting, and holding a beer¹ in his teeth. That’s how we roll in Huntington Beach, my friends.
Can they get away with this under reconciliation rules? I’d say no, since it doesn’t have a direct effect on government spending or outlays. But I assume they already ran this by the parliamentarian, and she approved it. So that’s that: if you don’t maintain continuous coverage, you have to wait six months before you can buy insurance.
There’s nothing inherently wrong with this. It’s a way of coaxing people into buying health insurance, just like the individual mandate penalties in Obamacare. But I wonder what the point is? Obamacare already restricts new signups to an open enrollment period at the beginning of each year, so for most people there’s already a waiting period if they don’t have continuous coverage. That’s still around in the Senate bill, so I guess this is just a way of tightening things up. Everyone who lacks continuous coverage has a minimum 6-month waiting period, even if they sign up during open enrollment.
However, there’s an exception! There is no waiting period for “a newborn who is enrolled in such coverage within 30 days of the date of birth.” All heart, these guys.
If Democrats manage to defeat Trumpcare, that’s hardly the end of the battle. If Obamacare remains the law, Republicans will do everything in their power to ensure that it does indeed “crash & burn.” They will stop funding the CSR subsidies, which will devastate the poor. They will stop enforcing the individual mandate. They will do everything legally possible to issue damaging insurance regulations. And they will make it crystal clear to insurance companies that there is nothing they can count on, and they might as well just exit the Obamacare exchange market now.
This is not me being pessimistic. This is just the reality of what Republicans will do. Their goal is to repeal Obamacare, not to provide medical care to the poor and working class. That’s what we’re up against.
By chance, another study of Seattle’s $15 minimum wage has just come out. It’s from the University of Washington group that’s been issuing periodic reports, and it comes to a different conclusion than last week’s study. Among jobs paying less than $19 per hour:
We estimate statistically insignificant hours reductions between 0.9% and 3.4% (averaging 1.9%) during the three quarters when the minimum wage was $11 per hour. By contrast, the subsequent minimum wage increase to $13 associates with larger, significant hours reductions between 7.9% and 10.6% (averaging 9.4%)
The authors suggest that Seattle lost about 10,000 low-wage jobs when the minimum wage increased from $11 to $13. If this is confirmed in subsequent studies, it suggests that a minimum wage of, say, $12 per hour, has a minimal effect on low-skill employment. But $15 will have a significant effect.
The effect on hours worked is similar. At $11, the reduction in low-wage jobs is small and probably illusory anyway: “It appears that any ‘loss’ in hours at lower thresholds is likely to reflect a cascade of workers to higher wage levels.” But at $13 it looks like this:
The key thing in this chart is that the solid line never reaches zero: “Thus, there is no evidence to suggest that the estimated employment losses associated with the second phase-in reflect a similar cascading phenomenon.”
This study is more pessimistic than previous studies, but it’s well done and scrupulously honest. Nor should it necessarily be a surprise. There’s a mountain of evidence that modest increases in the minimum wage have little effect on low-wage jobs, but the key word here is modest. We’ve never tested how high the minimum wage can go before it starts to have a serious impact on low-wage jobs, because no one has ever raised the minimum wage more than modestly. This means that the question of how high the minimum wage can go is an empirical one—and there’s no special reason to think it’s $15. It could be higher or lower. And if this study holds up, the answer at the moment is around $12.
One other thing worth noting: Among other rich countries, the minimum wage is roughly 50 percent of the median wage. Depending on how you measure it, that comes to $11-$13 in the United States. So if the ideal minimum wage turns out to be $12 per hour—roughly the same as it was in the 60s—no one should be taken aback.
UPDATE:EPI has released a critique of the new UW study: “The authors’ analysis…suffers from a number of data and methodological problems that bias the study in the direction of finding job loss, even where there may have been no job loss at all.” I won’t try to arbitrate this, since I don’t have the econometric chops to do it. Eventually this will all get sorted out, but it’s likely to take a few years.
The Supreme Court handed President Trump a victory Monday by reviving part of his disputed ban on foreign travelers from six Muslim-majority nations….The justices said the travel ban may go into effect, except for “foreign nationals who have a credible claim of a bona fide relationship with a person or entity in the United States,” such as a spouse or close relative.
….”The student from the designated countries who have been admitted to the University of Hawaii have such a relationship with an American entity,” the court said. “So too would a worker who accepted an offer of employment from an American company or a lecturer invited to address an American audience.” But this would not extend to other foreigners who lack this connection.
Despite the fact that tightening up visa requirements was supposedly a critical national security concern, Trump dropped the whole thing after his travel ban was stayed by several lower courts. He’s had plenty of time to craft new vetting rules—which were supposed to take 90-120 days from February—but he’s done nothing.
The official excuse is that the courts prevented this, which is ridiculous in the way Trump’s statements are always ridiculous. There was nothing stopping him from working on new, permanent rules. But he didn’t, presumably because personal pique was more important than the supposedly porous borders that he inherited from President Obama.
With the Supreme Court rules now in place, even this thin excuse is gone. So will he restart work on new rules so he’ll be ready to go as soon as the Supreme Court gives the OK? That’s what he’d do if he really thought this was important. Let’s wait and see.
With the Senate health care bill finally out in the open, a tediously familiar game is unfolding once again. The game is to defend massive Medicaid cuts by claiming that Medicaid is useless anyway. In fact, maybe worse than useless. You see, people on Medicaid don’t have mortality rates any better than people with no insurance at all.
This is tiresome, especially since it invariably comes from folks who have private insurance and would sooner cut off their big toes than give it up. My guess is that if they were suddenly poverty stricken, not a single one of them would choose to go uninsured rather than accept Medicaid.
But that’s just my frustration talking. Instead, let’s talk facts. There are two big reasons why I find this nonsense so annoying.
First, improving mortality is hardly the only goal of medical care. For most of us, it’s not even the main goal: the vast majority of doctor visits aren’t for life-threatening conditions. So even if it were true that Medicaid did nothing to extend lives, it still does plenty. If you get a toothache fixed, or your migraine headaches treated, or a meniscus repaired, it doesn’t affect your lifespan at all. But it sure makes you feel better. And if, in addition, it does this without subjecting you to $10,000 in debt and a horde of bill collectors on your ass 24/7, that’s pretty damn helpful too. Unless you’re explicitly looking for a cynical reason to claim that Medicaid is useless, you just can’t pretend that this stuff doesn’t matter.
Second, the average age of adult Medicaid recipients is 38. At that age, there isn’t much mortality in the first place: less than 2 per thousand each year. To meaningfully distinguish mortality rates given such a low baseline you’d need a huge study. And it better be a pretty good one. General mortality (as opposed to mortality for, say, a chemotherapy drug) only makes sense if you follow a population for five or ten years. So it needs to be a long-term study. And it needs to account for the fact that the Medicaid population is different from the general population: poorer, sicker,¹ more stressed, more disabled, etc. I don’t know if any studies have ever been done that meet these criteria.
However, there have been studies. Warts and all, they’re the best we have. The most famous is the Oregon Experiment, which is especially useful because it used genuinely identical treatment and control groups. However, each group consisted of only 10,000 people, which means the expected mortality in each group was 18 per year. That’s so low that the authors of the study couldn’t reach any conclusions at all about whether Medicaid had any effect on mortality. They did, however, draw null conclusions about other health indicators like blood pressure and cholesterol. The problem, again, is that the treatment group was so small that it’s hard to put much stock in this, especially since the study only lasted two years. However, if you nonetheless take their null conclusions about blood pressure and cholesterol seriously, you also have to take seriously their extremely positive results about depression, self-reported health, decrease in pain, and lack of financial catastrophe.
Either way, that’s only one study. There have been others. A trio of researchers reviewed Medicaid studies recently in the New England Journal of Medicine, and came to these conclusions:
The Oregon experiment found…significant increases in the rate of diagnosis of diabetes…along with a near-doubling of use of diabetes medications…. Meanwhile, the Oregon study found…a 30% relative reduction in rates of depressive symptoms.
….Multiple analyses have found improved self-reported health after the ACA’s coverage expansion, either in broad national trends or Medicaid expansion studies….Self-reported health is a validated measure of the risk of death….One study compared three states implementing large Medicaid expansions in the early 2000s to neighboring states that didn’t expand Medicaid, finding a significant 6% decrease in mortality over 5 years of follow-up….A more recent analysis of Medicaid’s mortality effects was one life saved for every 239 to 316 adults gaining coverage.
….One head-to-head quasi-experimental study of Medicaid versus private insurance, based on Arkansas’s decision to use ACA dollars to buy private coverage for low-income adults, found minimal differences. [That is, Medicaid was as effective as private insurance.]
That’s pretty impressive, and it doesn’t even count aching teeth, repaired cartilage, treated migraines, or any of the hundreds of other routine things that don’t show up in studies of chronic conditions. Nor does it validate the frequent claim that Medicaid is useless because doctors won’t see Medicaid patients: most studies show that Medicaid patients did indeed see doctors when they needed to and were generally pleased with their treatment.
That said, there’s a pretty obvious reason that Medicaid might not always produce dramatic differences compared to people with no insurance: by hook or by crook, the uninsured do get treatment for serious conditions. The main difference is that they have to pay for it. Here are the results of the Oregon experiment on the finances of the folks who received Medicaid:
Adults on Medicaid had 81 percent fewer catastrophic expenses. And in this case, the methodology of the Oregon Experiment is fine. A sample of 10,000 is plenty big and a timeframe of two years is plenty long. These are not things that affect only a tiny percentage of people, or that need years to show an effect. In addition to its medical benefits, Medicaid is a financial godsend for poor people.
One final thing: the folks who claim that Medicaid is useless never provide any feasible mechanism for this. Statistical studies are fine, but if they really do show null results for Medicaid coverage, there has to be some plausible reason why it produces no results. If we assume that medical care in general has positive results, why wouldn’t Medicaid? It may not provide the quality of care of private insurance, but it’s hardly the domain of quacks and shysters. It pays for care by real doctors and real hospitals, and it would be remarkable if that care really did no one any good. So what’s the theory here?
None of this means that Medicaid is perfect. It reimburses too little and really does seem to fail on some measures. It’s a serious drain on state budgets. And it has other problems as well that we ought to address. Liberals and conservatives alike should be dedicated to continually improving it.
Of course, speaking for myself, I’d love to eliminate Medicaid. And Medicare. And Obamacare. And employer insurance. A simpleminded national health care system would cover more people, almost certainly cost less than our current hodgepodge, and produce better results than what we get now. But that’s pie in the sky in this particular political moment. Given the reality of what we have, Medicaid is a critical part of our health care hodgepodge. Slashing it in order to give a big tax cut to the rich is obscene.
¹You may be surprised to learn that low reimbursement rates aren’t the only reason doctors are reluctant to see Medicaid patients. It’s a big factor, but nearly as important is that Medicaid patients take up so much time. This is because they’re generally sicker than other patients. So doctors are getting paid half as much for patients who have much more complex medical needs than average. The general stress of being poor accounts for most of this, but lack of consistent health care over their lifetime probably accounts for some of it too.