Little Evidence that Undocumented People Get Medicaid

Many posts have discussed federal deficits and the federal debt. Americans vastly overestimate the amount of waste in the budget

Phil Galewitz at KFF:

Last August, as part of the federal government’s crackdown on people in the country illegally, the Trump administration sent states the names of hundreds of thousands of Medicaid enrollees with orders to determine whether they were ineligible based on immigration status.

But seven months later, findings from five states shared with KFF Health News show that the reviews have uncovered little evidence of a widespread problem.

Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, which covers health care costs for people with low incomes and disabilities, and the closely related Children’s Health Insurance Program. Both programs are administered by states.

Spokespeople from Pennsylvania’s and Colorado’s Medicaid agencies said, as of March, the states had found no one who needed to be terminated from Medicaid. That was after checking a combined 79,000 names.

Texas has reviewed records of more than 28,000 Medicaid enrollees at the Trump administration’s request and terminated coverage for 77 of them, according to Jennifer Ruffcorn, a spokesperson for the Texas Department of Human Services.

Ohio has checked 65,000 Medicaid enrollees, of which 260 people were disenrolled from the program, said Stephanie O’Grady, a spokesperson for the Ohio Department of Medicaid.

In Utah, 42 of the 8,000 enrollees identified by the Trump administration had their Medicaid coverage terminated, said Becky Wickstrom, a spokesperson for the state’s Department of Workforce Services.

Federal Spending By Age

Many posts have discussed Social Security and Medicare.

Penn Wharton Budget Model:

• In Fiscal Year 2025, federal outlays totaled over $7 trillion across 52 general spending categories. Within each of these categories, we trace spending at the line item and subcategory level to assign a total of $4.4 trillion in spending across three age groups: retirees; working-age adults; children and young adults. We classify the remaining $2.6 trillion as “all ages” because they finance broad public goods.
• Retirees (ages 65 and older) receive $2.7 trillion, or 62 percent of the $4.4 trillion in age-assignable federal outlays, driven mainly by Social Security and Medicare.
• Working-age adults (ages 26–64) receive $1.2 trillion, or 28 percent of age-assignable outlays, spread across Medicaid, Social Security disability benefits, veterans benefits, and Marketplace subsidies.
• Children and young adults (under age 26) receive $449 billion, or 10 percent of age-assignable outlays, concentrated in Medicaid, SNAP, child nutrition, and education programs.
• The heavy expenditure share on retirees is consistent with a voting model from the field of political economy. The retiree share is predicted to increase even more with an aging population and fiscal strain.

Blowing Up the Federal Debt

 Many posts have discussed federal deficits and the federal debt.

Sahil Kapur at NBC:

President Donald Trump’s “big, beautiful bill,” which he signed into law this month, will add $3.4 trillion to the U.S. national debt over the next decade, according to a report the nonpartisan Congressional Budget Office published Monday.

The report found that the law, which Republicans passed along party lines, will also “increase by 10 million the number of people without health insurance” by 2034.

The budget office scrutinized the final version of the bill after Republicans made a series of last-minute changes to cobble together the votes needed in the Senate; it passed 51-50. That revised version subsequently passed the House on a vote of 218-214. Trump enacted it on July 4.

The package extends Trump’s 2017 tax cuts while providing tax deductions for tips and overtime pay for the next four years. It includes hundreds of billions of dollars in new spending for the military and to carry out Trump’s mass deportation agenda. And it pays for some of that with cuts to Medicaid, SNAP benefits (which help low-income families purchase groceries) and clean energy funding.

The analysis found that the law’s net spending cuts of $1.1 trillion are outstripped by the $4.5 trillion in decreased revenue, compared with if the measure had not passed.

Reliance on Government Support

Aaron Zitner, Jon Kamp and Brian McGill at WSJ:

Americans’ reliance on government support is soaring, driven by programs such as Social Security, Medicare and Medicaid.

That support is especially critical in economically stressed communities throughout the U.S., many of which lean Republican and are concentrated in swing states crucial in deciding the presidential election. Neither party has much incentive to dial back the spending.

The big reasons for this dramatic growth: A much larger share of Americans are seniors, and their healthcare costs have risen. At the same time, many communities have suffered from economic decline because of challenges including the loss of manufacturing, leaving government money as a larger share of people’s income in such places.

For its analysis of government spending, EIG used a government definition of income that includes spending on programs that Americans pay into, such as Medicare and Social Security. Another major government health program—Medicaid—is also counted.

The analysis also includes unemployment insurance, food stamps, the earned income tax credit, veterans benefits, Pell grants, Covid-era payments and other income support. States help pay for some of these programs, such as Medicaid, but the federal government covers roughly 70% of the total cost.

 

Americans are becoming more dependent on federal and state support. A revealing set of maps and analysis from @aaronzitner @jon_kamp @brian_mcgill --> https://t.co/68TtEJmxpg

— Tim Hanrahan (@TimJHanrahan) September 30, 2024

Texas v. Califoria, California v. Texas

Our colleague Kenneth Miller has a new book titled Texas vs. California (Oxford University Press, 2020)

Texas and California are the leaders of Red and Blue America. As the nation has polarized, its most populous and economically powerful states have taken charge of the opposing camps. These states now advance sharply contrasting political and policy agendas and view themselves as competitors for control of the nation's future. Kenneth P. Miller provides a detailed account of the rivalry's emergence, present state, and possible future. First, he explores why, despite their many similarities, the two states have become so deeply divided. As he shows, they experienced critical differences in their origins and in their later demographic, economic, cultural, and political development. Second, he describes how Texas and California have constructed opposing, comprehensive policy models--one conservative, the other progressive. Miller highlights the states' contrasting policies in five areas--tax, labor, energy and environment, poverty, and social issues--and also shows how Texas and California have led the red and blue state blocs in seeking to influence federal policy in these areas. The book concludes by assessing two models' strengths, vulnerabilities, and future prospects. The rivalry between the two states will likely continue for the foreseeable future, because California will surely stay blue and Texas will likely remain red. The challenge for the two states, and for the nation as a whole, is to view the competition in a positive light and turn it to productive ends. Exploring one of the primary rifts in American politics, Texas vs. California sheds light on virtually every aspect of the country's political system.

Fittingly, the two states are at odds in an important upcoming Supreme Court case. 

Oyez sums California v. Texas:

In 2012, the U.S. Supreme Court upheld the individual mandate of the Affordable Care Act (ACA) against a constitutional challenge by characterizing the penalty for not buying health insurance as a tax, which Congress has the power to impose. In 2017, the Republican-controlled Congress enacted an amendment to the ACA that set the penalty for not buying health insurance to zero, but it left the rest of the ACA in place. Texas and several other states and individuals filed a lawsuit in federal court challenging the individual mandate again, arguing that because the penalty was zero, it can no longer be characterized as a tax and is therefore unconstitutional. California and several other states joined the lawsuit to defend the individual mandate.

The federal district court held that the individual mandate is now unconstitutional and that as a result, the entire ACA is invalidated because the individual mandate cannot be “severed” from the rest of the Act. The U.S. Court of Appeals for the Fifth Circuit upheld the district court’s conclusion but remanded the case for reconsideration of whether any part of the ACA survives in the absence of the individual mandate. The Supreme Court granted California’s petition for review, as well as Texas’s cross-petition for review.

Retirement

Stef Kight at Axios reports that the 65+ number in the workforce has tripled in the past thirty years.

Why it matters: Delayed retirement is a sign of health and affluence for some and a continued life of hardship for others. As society ages and people live longer, a 21st century idea of retirement is needed, Steve Vernon of the Stanford Center on Longevity tells Axios.

The big picture: Americans are working longer — out of choice or necessity. And the trend has broad implications for people of all ages, from younger workers mapping out their futures to older people planning their legacies.

• 43% of Americans ages 45 years and older say they expect to outlive their savings, according to an Axios/SurveyMonkey poll.
• 31% of Americans ages 40-79 said they would continue working into retirement age even without a financial need, according to a recent Harris Poll for TD Ameritrade.

"[T]here is more and more incentive to work longer, because the more you work the more you're going to contribute to the [retirement] plan and the more you're going to get from the plan," Richard Johnson, Urban Institute's director for the Program on Retirement Policy, tells Axios.

The state of play:

• On one hand, the average retirement age is just 63 years old.
• Poverty rates among the 65 and older group have fallen.
• Since the 1980s, Social Security benefits have risen along with wages, Vernon said.

The other side:

• Pensions largely don't exist anymore, replaced by 401(k) style retirement plans.
• But many small and mid-sized employers don't offer retirement plans, according to the Bureau of Labor Statistics.
• Boomers today also have more debt than past generations — an average of $120,000 for those in debt, per the Stanford Center for Longevity.
• 30% of them had nothing saved in a retirement plan in 2014.
• There's a growing number of elderly Americans reliant on Medicare and Medicaid.

Reality check: The mechanisms that once ensured an easy retirement may be disappearing, but a small percentage of American workers ever really benefited from pension plans.

This image that we have that the prior generation of workers had generous pensions, is largely not right," Vernon said.

Americans Like Their Private Insurance

Daniel Dale at CNN:

If you ask people for their views on the cost of their health care, people on Medicare are much more likely to be satisfied than people on private insurance. In a Gallup poll in 2018, 51% of people on private insurance said they were satisfied with the total cost they paid. That was much lower than the 70% of satisfied people on Medicare or Medicaid.

If you ask people for their views on health insurance corporations, they tend to be negative. In a 2015 poll by the Kaiser Family Foundation, 44% said they had a favorable view of these companies, while 51% said they had an unfavorable view.

Sanders can point to figures like these to bolster his case.

But the story changes when you ask people for their views on their own private insurance plans rather than about insurance companies or costs. In poll after poll, for years, Americans using such plans have expressed positive opinions.
...

More than 155 million Americans received private coverage through employers in 2017, or about 58% of people under age 65.

Last year, the Kaiser Family Foundation asked people who have employer plans to give their coverage a grade. Twenty-five percent gave it an "A," or excellent; 43% said "B," or good. These results -- about two-thirds rating their employer coverage positively -- have been quite consistent dating back to 1997, according to data provided to CNN by Kaiser.

In a Gallup poll last year, 85% of people who used private insurance said the quality of their health care was "excellent" or "good," versus 79% of people on Medicare or Medicaid. (Gallup combined the Medicare and Medicaid groups in its report on the poll.) When people were asked about their coverage itself rather than the quality of care, 79% of people on Medicare or Medicaid said it was excellent or good, versus 70% of people on private insurance.

Pretty Much Everybody Hates Graham-Cassidy

There is a remarkable consensus against the Graham-Cassidy health bill.  Groups and interests that usually disagree are united in opposition. From America's Health Insurance Plans:

The following statement was jointly released on September 23, 2017 by the American Medical Association, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, America’s Health Insurance Plans, and the BlueCross BlueShield Association regarding the Graham-Cassidy-Heller-Johnson legislation.

We represent the nation’s doctors, hospitals, and health plans. Collectively, our organizations include hundreds of thousands individual physicians, thousands of hospitals, and hundreds of health plans that serve tens of millions of American patients, consumers, and employers every day across the United States.

While we sometimes disagree on important issues in health care, we are in total agreement that Americans deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all. The Graham-Cassidy-Heller-Johnson bill does not move us closer to that goal. The Senate should reject it.

We agree that the bill will cause patients and consumers to lose important protections, as
well as undermine safeguards for those with pre-existing conditions. Without these
guaranteed protections, people with significant medical conditions can be charged much
higher premiums and some may not be able to buy coverage at all.

We agree that the bill will result in dramatic cuts to Medicaid and a funding cliff in the
future, fundamentally changing the way that states provide coverage for some of our most vulnerable citizens. This means that millions of patients will lose their coverage and go without much-needed care.

We agree that the individual insurance market will be drastically weakened, making
coverage more expensive and jeopardizing Americans’ choice of health plans. By not
providing all states with sufficient funds to support working families who need help buying coverage, millions will go without it.

We agree that the bill’s current implementation timelines are not workable. State and
industry leaders will need to completely transform their individual insurance markets and
Medicaid programs in little more than a year – an impossible task.

Health care is too important to get wrong. Let’s take the time to get it right. Let’s agree to
find real, bipartisan solutions that make health care work for every American.

At The Washington Post, Christopher Ingraham provides a partial list of groups against the bill:

• Adult Congenital Heart Association
• ALS Association
• Alzheimer's Association
• Alzheimer's Impact Movement
• American Cancer Society
• American College of Emergency Physicians
• American College of Physicians
• American College of Preventive Medicine
• American Diabetes Association
• American Academy of Family Physicians
• American Academy of Pediatrics
• American Cancer Society
• American College of Emergency Physicians
• American College of Physicians
• American College of Preventive Medicine
• American Congress of Obstetricians and Gynecologists
• American Diabetes Association
• America's Essential Hospitals
• American Foundation for the Blind
• American Health Care Association
• America's Health Insurance Plans
• American Heart Association
• American Hospital Association
• American Liver Foundation
• American Lung Association
• American Medical Association
• American Nurses Association
• American Osteopathic Association
• American Occupational Therapy Association
• American Psychiatric Association
• American Psychological Association
• American Public Health Association
• American Society for Addiction Medicine
• American Speech-Language-Hearing Association
• Amputee Coalition
• The Arc
• Arthritis Foundation
• Association for Community Affiliated Plans
• 
  
• Association of American Medical Colleges
• Association of University Centers on Disabilities
• Asthma and Allergy Foundation of America
• Autism Society
• Autism Speaks
• Autistic Self Advocacy Network
• Big Cities Health Coalition
• Blue Cross Blue Shield Association
• Catholic Health Association
• Children's Hospital Association
• Center for Medicare Advocacy
• Coalition to Stop Opioid Overdose
• Consortium for Citizens with Disabilities
• COPD Foundation
• Cystic Fibrosis Foundation
• Family Voices
• Federation of American Hospitals
• HIV Medicine Association
• Infectious Diseases Society of America
• JDRF
• Lutheran Services in America
• Kaiser Permanente
• March of Dimes
• Medicare Rights Center
• National Association of Medicaid Directors
• National Association of Pediatric Nurse Practitioners
• National Association of School Nurses
• National Coalition for Cancer Survivorship
• National Down Syndrome Congress
• National Health Council
• National Institute for Reproductive Health
• National Kidney Foundation
• National Multiple Sclerosis Society
• National Organization for Rare Diseases
• Planned Parenthood
• Public Health Institute
• Robert Wood Johnson Foundation
• Trust for America's Health
• WomenHeart

Medicaid

Kate Zernike, Abby Goodnough, and Pam Belluck report at The New York Times that Medicaid survived the Trumpcare fiasco.

Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. The New York Times did not even mention Medicaid, conceived as a small program to cover poor people’s medical bills.

But over the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of one in five Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.

...
[L]ast week’s defeat reflected how hard it is to take away an entitlement. It also showed the broad and deep reach of Medicaid, which covers about six times as many people as the private marketplaces created under the A.C.A. but, perhaps because the markets are more strongly associated with President Barack Obama and his law, got less attention in this month’s contentious debate.

...

The program is so woven into the nation’s fabric that in 2015, almost two thirds of Americans in a poll by the Kaiser Family Foundation said they were either covered by Medicaid or had a family member or friend who was. The program not only pays for 16 percent of all personal health care spending nationwide, but also accounts for 9 percent of federal domestic spending.

Because it has always covered a patchwork of groups — and many of its beneficiaries are poor and relatively powerless — Medicaid lacks the unified, formidable political constituency that Social Security and Medicare have. States often have different names for the program, and many who rely on it don’t realize that MassHealth in Massachusetts or TennCare in Tennessee are just Medicaid by another name.

But in Kaiser’s polling since 2005, the percentage of people who support cutting Medicaid spending has never exceeded 13 percent. “The conventional wisdom that there’s a great deal of stigma attached to this program does not bear out in the public opinion data,” said Mollyann Brodie, who oversees polling for the foundation.

Affordable Care Act: Limited Access to Doctors

The New York Times reports:

Enrollment in Medicaid is surging as a result of the Affordable Care Act, but the Obama administration and state officials have done little to ensure that new beneficiaries have access to doctors after they get their Medicaid cards, federal investigators say in a new report.

The report, to be issued this week by the inspector general at the Department of Health and Human Services, says state standards for access to care vary widely and are rarely enforced. As a result, it says, Medicaid patients often find that they must wait for months or travel long distances to see a doctor.

The inspector general, Daniel R. Levinson, said federal and state officials must do more to protect beneficiaries’ access to care, in view of the program’s rapid growth. Just since October, the administration says, eight million people with low incomes have enrolled. By 2016, the Congressional Budget Office estimates, one in four Americans will be on Medicaid at some time during the year.

Twenty-seven states have expanded Medicaid eligibility since the passage of the health care law in 2010, and President Obama is urging other states to do so.

The Los Angeles Times reports:

Finding a doctor who takes Obamacare coverage could be just as frustrating for Californians in 2015 as the health-law expansion enters its second year.

The state's largest health insurers are sticking with their often-criticized narrow networks of doctors, and in some cases they are cutting the number of physicians even more, according to a Times analysis of company data. And the state's insurance exchange, Covered California, still has no comprehensive directory to help consumers match doctors with health plans.

This comes as insurers prepare to enroll hundreds of thousands of new patients this fall and get 1.2 million Californians to renew their policies under the Affordable Care Act.
Even as California's enrollment grows, many patients continue to complain about being offered fewer choices of doctors and having no easy way to find the ones that are available.

Some consumers have been saddled with huge medical bills after insurers refused to pay for care deemed out of network. These complaints have sparked a state investigation and consumer lawsuits against two big insurers.

Obamacare Context

The president announced that 7.1 million people had signed up on the health insurance exchanges.  At The Hill, Elise Viebeck and Jonathan Easley provide some context:

The central argument for ObamaCare’s passage was the need to cover the uninsured; 48 million people lacked coverage in 2012, according to the Census Bureau.

The administration last week said 6 million have signed up on the federal or state exchanges. Officials say they don’t know how many of these people previously lacked coverage, but independent estimates range as low as just 1 million, just 2 percent of those previously uncovered.

As many as 1.2 million may not have paid their first bill, which is a prerequisite for using a policy.

The law allows people up to the age of 26 to stay on their parents’ coverage, which a 2012 study by the Commonwealth Fund said added 6.6 million people to insurance rolls the previous year.

ObamaCare also expanded Medicaid, providing insurance to about 3 million additional people, according to Avalere Health.

If those totals were accurate, 
ObamaCare would be contributing to the insurance coverage of about 15.6 million people this year.

But because of ObamaCare, an estimated 4.7 million people have received cancellation notices for their existing policies.

Many were shifted to other plans or signed up for the exchanges, but some may have dropped health insurance for this year as they confronted higher-than-expected costs.

A Gallup survey released this month found the percentage of people who say they lack coverage fell in March to 15.9 percent — the lowest point in five years and more than two percentage points lower than the 18 percent recorded in mid-2013.

The Census Bureau’s annual report is usually published in September, so official insurance data for this year will probably not be available until after Labor Day of 2015.

Obamacare in California

 The Los Angeles Times reports:

Nearly half of callers to California's health insurance exchange in February and March couldn't get through and abandoned their call, state figures show.

Those service woes could worsen as more people try to beat the March 31 deadline to get Obamacare coverage under the Affordable Care Act.
Also Thursday, the Covered California exchange reported progress on another front: low enrollment among the state's large Latino population.

At its monthly board meeting, the exchange said 32% of health plan enrollees in the first two weeks of March described themselves as Latino. That was up from 18% during the first three months of enrollment that ended in December.

"That is a very substantial increase," said Peter Lee, executive director of Covered California.

Robert Ross, an exchange board member, applauded those gains with Latinos, but he expressed disappointment at the low sign-up rate among African Americans. It stood at less than 3% of health plan enrollment through mid-March.

California has led the nation with more than 1 million people enrolled in health plans through March 17, and it's a bellwether state for the national rollout of the healthcare law.

An additional 1.5 million Californians have enrolled or been deemed eligible for an expansion of Medi-Cal, the state's Medicaid program for the poor.

On the service front, Lee said the exchange has been able to reduce wait times on the phone from about 50 minutes to 30 minutes. The state has hired more call-center workers and added phone capacity in preparation for a last-minute rush.

Still, less than 5% of calls are answered within 30 seconds and about a third of callers get a busy signal, state data show. Overall, 40% of exchange customers surveyed said they found the enrollment process difficult.

Health Care: Coming Apart

At The Wall Street Journal, Michael Barone points to evidence undermining three assumptions behind Obamacare:  that the uninsured will get insurance once it's available, that insurance leads to better health, and that people with  Medicaid are less likely to seek primary care from emergency rooms.

[The] apparent discrepancies between what policy makers expected and how many of the intended beneficiaries of ObamaCare seem to be behaving reminds me of the divide described in Charles Murray's 2012 book "Coming Apart: The State of White America, 1960-2010." Mr. Murray, my colleague at the American Enterprise Institute, documents the sharp differences in behavior between the upper (in education and income) 20% and the bottom 30% of white Americans.

The upper group has low rates of divorce and single parenthood and high rates of what Harvard political scientist Robert Putnam calls social connectedness. They belong to voluntary associations and churches; they vote and follow public-policy debates. They tend to be connected, engaged and conscientious. The lower (income and education) group has high rates of divorce and single parenthood and low rates of social connectedness. They tend to be disconnected and disengaged, and sometimes heedless. It should not be surprising that they may not respond to the same health-care mandates, incentives and nudges that policy makers and others in the upper group do.

Liberal policy makers have long regarded Scandinavian policies as a model. If a welfare state can work there, they have long argued, it can work here. But the Scandinavian countries have homogeneous populations with high levels of trust, conscientiousness and social connectedness. It is not a coincidence that in the two states with the highest levels of the social connectedness Mr. Putnam described, North Dakota and Minnesota, most people are of Scandinavian or German descent. But policies that work well in Scandinavia or Minnesota and North Dakota won't necessarily work well in a wider United States, where a much larger proportion of people are socially disconnected.

President Obama and the War on Poverty

Last week, President Obama said:

As Americans, we believe that everyone who works hard deserves a chance at opportunity, and that all our citizens deserve some basic measure of security. And so, 50 years ago, President Johnson declared a War on Poverty to help each and every American fulfill his or her basic hopes. We created new avenues of opportunity through jobs and education, expanded access to health care for seniors, the poor, and Americans with disabilities, and helped working families make ends meet. Without Social Security, nearly half of seniors would be living in poverty. Today, fewer than one in seven do. Before Medicare, only half of seniors had some form of health insurance. Today, virtually all do. And because we expanded pro-work and pro-family programs like the Earned Income Tax Credit, a recent study found that the poverty rate has fallen by nearly 40% since the 1960s, and kept millions from falling into poverty during the Great Recession.

Lloyd Green writes:

Sadly, in his attempt to make all government programs equal and beneficiaries the same, Obama got sloppy with the facts, and worse, dismissive of working Americans. For the record, Social Security was FDR’s brainchild and has been around since 1935. It is not a Great Society legacy.

Furthermore, Obama forgot that he is the one calling for cuts to Social Security, over protests from Senate Democrats. As The Hill reports. “Obama proposed nearly $1 trillion in spending cuts in his budget, including a switch to using the Chained Consumer Price Index (CPI), which liberal policy experts estimate could cost seniors thousands of dollars in benefits over their lifetimes. 

Finally, Social Security and Medicare are the antithesis of food stamps and Medicaid. Unlike Medicaid and food stamps whose only criterion for eligibility is indigence, Social Security and Medicare are earned through a lifetime of work. Somehow, the notion that benefits must be earned may have been too much for the one-time community organizer

As for the other part of the war on poverty, Obama was more circumspect. He didn’t talk about how nearly 60 percent of births born in New York City are to households receiving Medicaid.

Nor did the president comment on the decoupling of reproduction from marriage, and its relationship to poverty. In his speech, Obama even ignored the question previously posed by Kay Hymowitz of the Manhattan Institute about the recent New York Times profile of Dasani Coates, “Did Inequality Make Dasani Homeless?”

Obamacare and Unanticipated Consequences

At Commentary, Peter Wehner writes of the finding that Obamacare may actually increase ER visits instead of decreasing them.

It might be worth calling attention, then, to a paper by the 20th century sociologist Robert K. Merton, who in 1936 published an essay in American Sociological Review, titled, “The Unanticipated Consequences of Purposive Social Action.” (Merton helped popularize the theory of unintended consequences.)

In citing some of the major factors of unexpected consequences, Merton listed ignorance and error. About the latter, he wrote the following:

Error may also be involved in instances where the actor attends to only one or some of the pertinent aspects of the situation which influence the outcome of the action. This may range from the case of simple neglect (lack of systematic thoroughness in examining the situation) to pathological obsession where there is a determined refusal or inability to consider certain elements of the problem… In cases of wish-fulfillment, emotional involvements lead to distortion of the objective situation and of the probably future course of events; such action predicated upon “imaginary” conditions must inevitably evoke unexpected consequences.

Medicaid and the ER

The New York Times reports:

Supporters of President Obama’s health care law had predicted that expanding insurance coverage for the poor would reduce costly emergency room visits because people would go to primary care doctors instead. But a rigorous new experiment in Oregon has raised questions about that assumption, finding that newly insured people actually went to the emergency room a good deal more often.

The study, published in the journal Science, compared thousands of low-income people in the Portland area who were randomly selected in a 2008 lottery to get Medicaid coverage with people who entered the lottery but remained uninsured. Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance.

The pattern was so strong that it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings.

The findings cast doubt on the hope that expanded insurance coverage will help rein in emergency room costs just as more than two million people are gaining coverage under the Affordable Care Act. And they go against one of the central arguments of the law’s supporters, that extending insurance to large numbers of Americans would reduce emergency room use, and eventually save money.

Participation in Government Programs

Previous posts have discussed trends in participation in government programs. The Census Bureau offers an infographic:

Mandatory Medicaid

At The Wall Street Journal, Nicole Hopkins writes of her mother, who had bought insurance on the individual market.  After the insurer told her that it was ending her old plan in favor of a more expensive one, she went to an exchange, which enrolled her in Medicaid.

Of course, Medicaid is not a new option for my mother; she knew that she was poor enough to qualify for cost-free health care. It was a deliberate choice on her part to pay that monthly $276 out of her own pocket. Clearly she had judged that she received a personal benefit from not being on Medicaid.

"I just don't expect anything positive out of getting free health care," she said. "I don't see why other people should have to pay for my care, whether it be through taxes or otherwise." In paying for health insurance herself—she won't accept help from her family, either—she was safeguarding her dignity and independence and her sense of being a fully functioning member of society.

Before ObamaCare, Medicaid was one option. Not the option. Before this, she had never been, in effect, ordered to take a handout. Now she has been forced to join the government-reliant poor, though she would prefer to contribute her two mites. The authorities behind "affordable care" had erased her right to calculate what she was willing to spend to preserve her dignity—to determine what she thinks is affordable.

That little contribution can mean the difference between dignity and despair.

For the truly poor, being institutionally forced to take welfare is demoralizing. The Affordable Care Act is at risk of systematizing learned helplessness by telling individuals like my mother that they cannot afford to care for themselves in the way they could before the law was enacted. "This makes me feel poorer than ever," she said.

Obamacare Remains Problematic

The New York Times reports on hospitals such as Memorial Health in Savannah:

Many of these patients were expected to gain health coverage under the Affordable Care Act through a major expansion of Medicaid, the medical insurance program for the poor. But after the Supreme Court in 2012 gave states the right to opt out, Georgia, like about half the states, almost all of them Republican-led, refused to broaden the program.

Now, in a perverse twist, many of the poor people who rely on safety-net hospitals like Memorial will be doubly unlucky. A government subsidy, little known outside health policy circles but critical to the hospitals’ survival, is being sharply reduced under the new health law.

The subsidy, which for years has helped defray the cost of uncompensated and undercompensated care, was cut substantially on the assumption that the hospitals would replace much of the lost income with payments for patients newly covered by Medicaid or private insurance. But now the hospitals in states like Georgia will get neither the new Medicaid patients nor most of the old subsidies, which many say are crucial to the mission of care for the poor.

“We were so thrilled when the law passed, but it has backfired,” said Lindsay Caulfield, senior vice president for planning and marketing at Grady Health in Atlanta, the largest safety-net hospital in Georgia.

Gallup reports:

In the midst of widespread news coverage of problems with the federal health exchange website, relatively few uninsured Americans (18%) -- the primary target population for the exchanges -- have so far attempted to visit an exchange website. The percentage is slightly higher, 22%, among uninsured Americans who say they plan to get insurance through the exchanges.

...
Gallup previously found that less than half of uninsured Americans (44%) who plan to get insurance say they will do so through an exchange, and about one in four say they are more likely to pay a fine instead of getting insurance. These findings help explain the low percentage of the uninsured who have attempted to access the exchange websites

Politico reports:

Only five people have fully completed the enrollment process in the D.C. insurance exchange, according to information compiled by lawmakers from four of the insurance companies participating in the exchange.

Two people enrolled in CareFirst BlueShield plans during October and three enrolled in Kaiser Permanente plans during the month. No enrollment data has been collected by UnitedHealthcare or Aetna as of Nov. 4 or Oct. 24, respectively, the companies said.

The information was collected by Sens. Chuck Grassley (R-Iowa) and Orrin Hatch (R-Utah). 

MediaIte reports:

“Thnx Mr. President.” That’s all former MSNBC host Dylan Ratigan had to say to President Barack Obama on Thursday when he announced that the health insurance plan he purchased on the individual market after leaving the news network was being cancelled. The new plan he was eligible would cost him 3.5 times more than his previous plan.

“I bought a catastrophic health policy for $170/mo when I left MSNBC,” Ratigan confessed. “Obamacare cancelled the policy. New rate $600/mo. Thnx Mr. President!”

Obamacare Losers

Politico reports:

Meet the new Soccer Mom: Obamacare losers.

Millions of married, older, white, college-educated, GOP-leaning Americans have quickly seen their political profile rise after their health insurance companies sent them cancellation letters with the launch of the giant new health care law.

It’s not a huge segment of the population — estimates show between 10 million to 19 million people bought health insurance from what Health and Human Services Secretary Kathleen Sebelius dubbed the “Wild West” individual marketplace.

But the ones who are making the most anti-Obamacare noise are part of this group (think of the self-employed, small business owners, freelance writers, musicians and taxi cab drivers) that share one politically pertinent common denominator. Their complaints — amplified in recent weeks by Republicans and reporters — demonstrate one of the first tangible stumbles of the Affordable Care Act.

“It’s not theoretical anymore,” said Virginia-based health industry consultant Robert Laszewski. “You can spin in the White House press room, but these are people who will be sitting down with their friends and families at Thanksgiving sharing stories about their cancellation letters. That’s going to be the only thing that counts.”

RNC is collecting Obamacare horror stories.

There are three reasons why the horror stories are a big problem for Democrats.

• First, as psychologist Daniel Kahneman has taught, losses loom larger than gains. Some people surely are benefiting from the law, but the downsides will get more attention and draw a louder reaction than the upsides.
• Second, the losses are concentrated, not diffuse.  They involve specific people -- and the cancellation letters make them highly tangible. As Kahneman says, "The explanatory stories that people find compelling are simple; are concrete rather than abstract."
• Third, the losers are relatively affluent people who are likely to vote.  The gainers -- especially people getting Medicaid benefits -- are less affluent and are less likely to vote. From the Census report on turnout in 2012, Reported Voting and Registration of Family Members, by Age and Family Income: November 2012

Total	63.6
Under $10,000	46.9
$10,000 to $14,999	45.8
$15,000 to $19,999	50.4
$20,000 to $29,999	55.8
$30,000 to $39,999	58.4
$40,000 to $49,999	63.0
$50,000 to $74,999	68.0
$75,000 to $99,999	73.8
$100,000 to $149,999	76.9
$150,000 and over	80.2
Income not reported	50.4