Governor Kemp in GA already tried this with the Pathways to Coverage work requirement program for Medicaid. It failed. It restricted healthcare access. I care for a unique population of kids with disabilities who largely utilize Medicaid.Even those with private insurance have Medicaid as secondary through our Katie Beckett program. Private insurance doesn’t cover home nursing or much of the DME equipment or medications these kids need, but Medicaid does. We don’t have long term care facilities in GA for kids, so unless your child is hospitalized there’s no respite. Many families have one parent who can’t work, because their job is providing 24/7 care to a child who needs help with all activities of daily living. God forbid you’re a single parent. Then you really struggle to work a paying job and care for the child. Constantly torn to be in 2 places at once. The poor and disabled are not the problem. The problem is all of us paying more in taxes than a big corporation when the corporations benefit from the cheap labor and (what used to be) stability and laws of this country. I strongly believe healthcare access should be a right and not a privilege. We need to do better. The system is terribly broken. Most of us working in it don’t have time to fix it, because we are trying to keep our head above water to care for our patients. To overhaul it would mean leaving clinical care and abandoning our patients, because there’s not enough time in a day to do both.
Ugh, America. It used to be the haves and the have-nots. Now we have three categories: the haves, the have-nots and the have-yachts and because the have-yachts need more, we must take away healthcare for millions of people. Gabe doesn’t even mention that with Republicans letting Obamacare subsidies expire, many more people who weren’t even on Medicaid will be unable to afford healthcare. In the richest country on the planet.
"Able bodied men playing video games in their mom's basement" is clearly the new "welfare queen" - a convenient stereotype that justifies harsh policy without having to grapple with actual data. Can Republicans actually point to any research showing that a significant number of people on Medicaid are freeloaders in that exact situation, and will be the source of those saved dollars? Because the Kaiser Family Foundation data suggests this population barely exists, yet it's driving entire legislative packages. I wish the burden of proof were on them to show us that the majority effect of what they’re doing would mitigate fraud. Thanks to Gabe’s reporting, it’s easier to see that will not be the case here.
I have a friend who became disabled a little over a year ago through a brain injury, and the experience of trying to help him get benefits, even in deep blue California, goes to show how many hoops they want you to jump through. The system seems designed to hope that people will miss deadlines and miss a place to initial a form just so that people will get eliminated from consideration on pure technicalities. They’re being asked to call phone numbers where people don't pick up, going to voicemail boxes that are full, or if people do pick up, they'll often say things like "you were given bad information, I can't help you, but I know who can" and then give you another phone number that's the same deal. Despite him having me help him through this process while his vision and fine motor skills are deteriorating, it took almost a year to find someone whose full-time job it is to help him navigate this bureaucracy. And that only happened because he got desperate enough to contact his estranged parents who stepped in with funds to hire someone to do this. It’s exhausting even for me (an “able-bodied” man), so we have to imagine that a lot of the savings here will come from people who are so disabled that they lack the functionality and focus to prove they’re disabled. And I have to imagine it’s an easier process in California than in the states run by politicians who think this is all a good idea.
Preventing and rooting out fraud is absolutely important and should happen, but this isn’t that.
Let's also point out the injustice of dismissively categorizing people who "don't work because of caregiving responsibilities" - this should absolutely be considered work in itself, probably much harder work than what most of us do for a paycheck. The fact that we don't recognize caregiving as legitimate work while simultaneously expecting it to happen for free reveals how backwards our priorities are. At one point my friend was going to try to have me designated as a caregiver that could qualify for pay for this work, but 9 months later and we’re still in the application phase. At this point we’ve moved on to having him get appointed caregivers that will have already gone through the screening and approval process, we just hope that whoever it is ends up being a decent person.
Part of me wonders if there could be an easy way for politicians who champion medicare cuts to earn some good will from constituents: what if they turned down their government-provided health insurance and bought policies on the market instead? What would that look like? Perhaps it would be a lot easier to stomach the belt tightening that they say is necessary from us if their pants weren't constantly dropping to the floor. Like, to continue the belt metaphor, dude, nobody wants to see your saggy ass - stop showing it in public and utilize some of that "dignity" you keep prescribing for the rest of us.
I’m so sorry about your friend, and your story about the bureaucracy is so true, relatable, sad, and demoralizing. I have a hard time navigating things as a physician, and I know the system better than most non-medical people. I do think people give up, and if you can’t advocate for yourself or don’t have an advocate you will get left behind. Caregiving is one of THE hardest jobs. You do it for the people you love, but it comes at a cost to your health and finances. There’s too many competing priorities right now, and the patient - a human being - is lost in the shuffle. I felt more hopeful when Obama was at least trying to fix things. I have zero hope with this administration. In fact it’s only going to get worse with the cuts to science.
There's so many pieces of what I was talking about that are going to be impossible to expect in the future: the research that the government can rely on to make better decisions. The people who pick up phones at agencies tasked to help people. Rooting out legitimate fraud. Applying for aid for family caregivers. Training and background checks for hired caregivers. And then on top of all that, a strained medical system that is bombarded by people who lose their insurance and are forced to abuse hospital emergency rooms for non-emergencies.
I hate being in a mode of constant dread and negativity, but while this bill is being debated, it's important to list it all and be loud about it. Thank you for using your background as a physician to talk it out!
Thank you for this reporting. There has to be a better way. My Congressman sent out a letter that said the opposite of everything Gabe did here. I think he needs to read this article as well.
While I would love to agree with you, the letter that he sent out was in response to another letter he sent out praising the bill after he voted for it. When people wrote back with concerns he sent another basically saying Trump say's you're wrong. We're only going after fraud.
I am a middle aged, white woman with insurance through a decent enough job. I am in a network that is well organized and connected. I am incredibly lucky. As I type this I am trying to schedule an appointment for an ongoing issue that is quite painful. I need to have hand surgery. I went to the primary doctor and got a referral to a surgeon like I am supposed to. It has taken me 6 phone calls to get an appointment scheduled. 6 phone calls of being an absolute pain in the a@@. I can't imagine being really sick and trying to navigate a more hostile structure.
I wonder in the Arkansas example if they saw an uptick in uninsured people using the ER as a primary care health center. I am sure it happened. That drives up costs for everyone. That makes emergency care more difficult to access for everyone. It is less expensive and makes more sense to get people preventative care on the front end. I mean unless your goal is to make people sicker and less secure.
It seems that this administration is making policy not based on data or intellect, but based on the emotion of mutual hate. "Like who cares about the poors? Won't impact me." Oh, but it will when you have a heart attack and the ER is overrun with people in there for a simple cold because that is their only option.
4.5 months in and I have never felt more dispirited.
Excellent point, Jane. In the example of my friend, we've had to use the emergency room twice for non-emergencies because the standard process was going nowhere. It worked; he finally found a human to speak to after months of trying. But that's absolutely correct that it is SO much more expensive and wasteful to have emergency rooms as our safety net for underfunded regular health care.
It’s such a sad statement on how we feel about the citizens of this country. We are the only peer country who doesn’t provide healthcare for our citizens. We don’t provide higher education, child care, maternity/paternity leave or vacation time, but we provide more defense spending than the next 9 countries combined. That’s to a department that willing accepts it has lost track of billions of dollars. We also give billionaires massive tax cuts, when if they paid their fair share, would still be billionaires. We are a completely backwards country who thinks it is a world leader. Sad, pathetic and embarrassing.
This policy is yet another PR stunt to deny folks healthcare. It’s about justifying their gigantic increases in wealth at our expense. This plan increases bureaucracy- which is an increased expense- in order to make the system so onerous that workers lose their healthcare. Our business system has also become dependent on using short term contracts with entry level jobs- a 3 month contract that might get extended and then another and etc. These folks do not have healthcare thru their employment. The rather gigantic underground economy of folks using gig employment or non-licensed self employment because they just can’t afford to be above ground or because they have to have flexible schedules due to childcare or caregiving. Obamacare is a major reason our economy works at all for most of us.
The goal of the Arkansas program has become to just have an occupation. No hourly requirement, and a variety of programs are allowed. That seems like the right direction.
As the article says as about recipients before Arkansas enacted this program, "It turns out that most of the targeted Medicaid users were already meeting the eligibility requirements. And by “most,” I mean 97% of them." It seems like they were already doing fine.
As a society having people have access to healthcare is best for all. It means people don’t go into service jobs sick bc they have no insurance and no sick time. It means that if people with insurance have a medical emergency they can get access to ERs bc they are required to treat everyone regardless of insurance. It means pandemics can be cutoff closer to the source bc people will check with providers instead of just getting sicker.
As usual, Republicans find an example narrative that they repeat over and over, despite it not reflecting reality. They use that narrative to get their policy implemented, even though the policy affects many other people negatively. Like all safety-net programs, the costs are much easier to count than the benefits. Even the cost of enforcing the work requirement may be greater than the savings, except for the "savings" of suppressing legitimate access. Aren't Republicans against more bureaucracy?
There's not much "dignity of work" in a job with wages so low that you still have to use Medicaid. Such jobs are usually unsteady, so when the job disappears, so does your medical coverage. The effect of uninsured patient populations on local medical facilities and state and federal expenditures to cope with them is well known. But like the Mortgage Crisis, they will bail out the corporations while leaving individuals to suffer the consequences.
This is interesting. When you use the change in percentage could you report what that means in terms of number of people too at least an example for some state. The difference in percentage doesn’t have as much meaning as number of people.
"Instead of making state-by-state predictions, [the Congressional Budget Office] generates a national figure by estimating the percent of the affected population that lives in states with different anticipated types of policy responses. For example, different states might choose to implement a work requirement with reporting requirements that are easier or harder to comply with. In estimating the costs of the legislation, CBO assumes that in aggregate, states would replace half of reduced federal funds with their own resources in response to provisions that reduce the resources available to states, such as limits on provider taxes."
There’s this podcast I listened to a few years ago called The Uncertain Hour where they looked into work requirements to receive welfare benefits. They found that private companies would step in with work training programs that led to people having less time to even get jobs. They also pushed low income jobs like janitorial work which fundamentally just perpetuated the cycle. They also found some candidates had trouble reading or writing, but the program was not able to help with these skills that could pull them out of poverty.
This certainly affirms my experience as a Social Worker. I have searched my memory of my caseloads through the years and I can recall only one case where I thought the recipient could be working at SOMETHING.
A bigger opportunity for these waste fraud and abuse hunters would be the SSDI system. Social Security Disability. Now there’s a program ripe with opportunity to retrain recipients to re-enter the workforce. It will never happen as it is a way for states to avoid paying unemployment compensation by shifting the burden to the federal Government while ALSO letting corporations off the hook for massive layoffs. It is common practice for companies to facilitate mass applications to SSDI when closing a factory, sadly.
This is very sad. It really makes people who are truly disabled and need SSDI be side-eyed even more. It is also extremely frustrating that companies do that when for individuals the process is extremely difficult to navigate. They often, unless determined to be totally and completely disabled, have to recertify every few years. Which when you're doing it on your own, can be a stressful process.
I agree, Amber. This is a program people pay into, and a good safety net for those who need it. Sadly the process requires people to navigate a two year process, and the systems work together to immediately deny people. Upon denial, they are entitled to appeal. An appeal can only be handled by attorneys on a list of those certified to argue SSDI cases. At some Point a final decision is handed down, and the attorney gets a percentage of your back-dated benefits. To add insult to injury, those approved and deemed to be “disabled” are then required to complete a two year waiting period to enroll in Medicare. Why we would make people we have already decided are disabled wait for healthcare when we know they are not working and likely have no insurance boggles the mind.
Governor Kemp in GA already tried this with the Pathways to Coverage work requirement program for Medicaid. It failed. It restricted healthcare access. I care for a unique population of kids with disabilities who largely utilize Medicaid.Even those with private insurance have Medicaid as secondary through our Katie Beckett program. Private insurance doesn’t cover home nursing or much of the DME equipment or medications these kids need, but Medicaid does. We don’t have long term care facilities in GA for kids, so unless your child is hospitalized there’s no respite. Many families have one parent who can’t work, because their job is providing 24/7 care to a child who needs help with all activities of daily living. God forbid you’re a single parent. Then you really struggle to work a paying job and care for the child. Constantly torn to be in 2 places at once. The poor and disabled are not the problem. The problem is all of us paying more in taxes than a big corporation when the corporations benefit from the cheap labor and (what used to be) stability and laws of this country. I strongly believe healthcare access should be a right and not a privilege. We need to do better. The system is terribly broken. Most of us working in it don’t have time to fix it, because we are trying to keep our head above water to care for our patients. To overhaul it would mean leaving clinical care and abandoning our patients, because there’s not enough time in a day to do both.
A bit on the Ga program: https://www.cbpp.org/blog/georgias-medicaid-experiment-is-the-latest-to-show-work-requirements-restrict-health-care
Ugh, America. It used to be the haves and the have-nots. Now we have three categories: the haves, the have-nots and the have-yachts and because the have-yachts need more, we must take away healthcare for millions of people. Gabe doesn’t even mention that with Republicans letting Obamacare subsidies expire, many more people who weren’t even on Medicaid will be unable to afford healthcare. In the richest country on the planet.
"Able bodied men playing video games in their mom's basement" is clearly the new "welfare queen" - a convenient stereotype that justifies harsh policy without having to grapple with actual data. Can Republicans actually point to any research showing that a significant number of people on Medicaid are freeloaders in that exact situation, and will be the source of those saved dollars? Because the Kaiser Family Foundation data suggests this population barely exists, yet it's driving entire legislative packages. I wish the burden of proof were on them to show us that the majority effect of what they’re doing would mitigate fraud. Thanks to Gabe’s reporting, it’s easier to see that will not be the case here.
I have a friend who became disabled a little over a year ago through a brain injury, and the experience of trying to help him get benefits, even in deep blue California, goes to show how many hoops they want you to jump through. The system seems designed to hope that people will miss deadlines and miss a place to initial a form just so that people will get eliminated from consideration on pure technicalities. They’re being asked to call phone numbers where people don't pick up, going to voicemail boxes that are full, or if people do pick up, they'll often say things like "you were given bad information, I can't help you, but I know who can" and then give you another phone number that's the same deal. Despite him having me help him through this process while his vision and fine motor skills are deteriorating, it took almost a year to find someone whose full-time job it is to help him navigate this bureaucracy. And that only happened because he got desperate enough to contact his estranged parents who stepped in with funds to hire someone to do this. It’s exhausting even for me (an “able-bodied” man), so we have to imagine that a lot of the savings here will come from people who are so disabled that they lack the functionality and focus to prove they’re disabled. And I have to imagine it’s an easier process in California than in the states run by politicians who think this is all a good idea.
Preventing and rooting out fraud is absolutely important and should happen, but this isn’t that.
Let's also point out the injustice of dismissively categorizing people who "don't work because of caregiving responsibilities" - this should absolutely be considered work in itself, probably much harder work than what most of us do for a paycheck. The fact that we don't recognize caregiving as legitimate work while simultaneously expecting it to happen for free reveals how backwards our priorities are. At one point my friend was going to try to have me designated as a caregiver that could qualify for pay for this work, but 9 months later and we’re still in the application phase. At this point we’ve moved on to having him get appointed caregivers that will have already gone through the screening and approval process, we just hope that whoever it is ends up being a decent person.
Part of me wonders if there could be an easy way for politicians who champion medicare cuts to earn some good will from constituents: what if they turned down their government-provided health insurance and bought policies on the market instead? What would that look like? Perhaps it would be a lot easier to stomach the belt tightening that they say is necessary from us if their pants weren't constantly dropping to the floor. Like, to continue the belt metaphor, dude, nobody wants to see your saggy ass - stop showing it in public and utilize some of that "dignity" you keep prescribing for the rest of us.
I’m so sorry about your friend, and your story about the bureaucracy is so true, relatable, sad, and demoralizing. I have a hard time navigating things as a physician, and I know the system better than most non-medical people. I do think people give up, and if you can’t advocate for yourself or don’t have an advocate you will get left behind. Caregiving is one of THE hardest jobs. You do it for the people you love, but it comes at a cost to your health and finances. There’s too many competing priorities right now, and the patient - a human being - is lost in the shuffle. I felt more hopeful when Obama was at least trying to fix things. I have zero hope with this administration. In fact it’s only going to get worse with the cuts to science.
There's so many pieces of what I was talking about that are going to be impossible to expect in the future: the research that the government can rely on to make better decisions. The people who pick up phones at agencies tasked to help people. Rooting out legitimate fraud. Applying for aid for family caregivers. Training and background checks for hired caregivers. And then on top of all that, a strained medical system that is bombarded by people who lose their insurance and are forced to abuse hospital emergency rooms for non-emergencies.
I hate being in a mode of constant dread and negativity, but while this bill is being debated, it's important to list it all and be loud about it. Thank you for using your background as a physician to talk it out!
Thank you for this reporting. There has to be a better way. My Congressman sent out a letter that said the opposite of everything Gabe did here. I think he needs to read this article as well.
Have you considered replying to their letter point by point refuting their claims?? Maybe it could help!
While I would love to agree with you, the letter that he sent out was in response to another letter he sent out praising the bill after he voted for it. When people wrote back with concerns he sent another basically saying Trump say's you're wrong. We're only going after fraud.
I am a middle aged, white woman with insurance through a decent enough job. I am in a network that is well organized and connected. I am incredibly lucky. As I type this I am trying to schedule an appointment for an ongoing issue that is quite painful. I need to have hand surgery. I went to the primary doctor and got a referral to a surgeon like I am supposed to. It has taken me 6 phone calls to get an appointment scheduled. 6 phone calls of being an absolute pain in the a@@. I can't imagine being really sick and trying to navigate a more hostile structure.
I wonder in the Arkansas example if they saw an uptick in uninsured people using the ER as a primary care health center. I am sure it happened. That drives up costs for everyone. That makes emergency care more difficult to access for everyone. It is less expensive and makes more sense to get people preventative care on the front end. I mean unless your goal is to make people sicker and less secure.
It seems that this administration is making policy not based on data or intellect, but based on the emotion of mutual hate. "Like who cares about the poors? Won't impact me." Oh, but it will when you have a heart attack and the ER is overrun with people in there for a simple cold because that is their only option.
4.5 months in and I have never felt more dispirited.
Excellent point, Jane. In the example of my friend, we've had to use the emergency room twice for non-emergencies because the standard process was going nowhere. It worked; he finally found a human to speak to after months of trying. But that's absolutely correct that it is SO much more expensive and wasteful to have emergency rooms as our safety net for underfunded regular health care.
It’s such a sad statement on how we feel about the citizens of this country. We are the only peer country who doesn’t provide healthcare for our citizens. We don’t provide higher education, child care, maternity/paternity leave or vacation time, but we provide more defense spending than the next 9 countries combined. That’s to a department that willing accepts it has lost track of billions of dollars. We also give billionaires massive tax cuts, when if they paid their fair share, would still be billionaires. We are a completely backwards country who thinks it is a world leader. Sad, pathetic and embarrassing.
This policy is yet another PR stunt to deny folks healthcare. It’s about justifying their gigantic increases in wealth at our expense. This plan increases bureaucracy- which is an increased expense- in order to make the system so onerous that workers lose their healthcare. Our business system has also become dependent on using short term contracts with entry level jobs- a 3 month contract that might get extended and then another and etc. These folks do not have healthcare thru their employment. The rather gigantic underground economy of folks using gig employment or non-licensed self employment because they just can’t afford to be above ground or because they have to have flexible schedules due to childcare or caregiving. Obamacare is a major reason our economy works at all for most of us.
The goal of the Arkansas program has become to just have an occupation. No hourly requirement, and a variety of programs are allowed. That seems like the right direction.
As the article says as about recipients before Arkansas enacted this program, "It turns out that most of the targeted Medicaid users were already meeting the eligibility requirements. And by “most,” I mean 97% of them." It seems like they were already doing fine.
As a society having people have access to healthcare is best for all. It means people don’t go into service jobs sick bc they have no insurance and no sick time. It means that if people with insurance have a medical emergency they can get access to ERs bc they are required to treat everyone regardless of insurance. It means pandemics can be cutoff closer to the source bc people will check with providers instead of just getting sicker.
As usual, Republicans find an example narrative that they repeat over and over, despite it not reflecting reality. They use that narrative to get their policy implemented, even though the policy affects many other people negatively. Like all safety-net programs, the costs are much easier to count than the benefits. Even the cost of enforcing the work requirement may be greater than the savings, except for the "savings" of suppressing legitimate access. Aren't Republicans against more bureaucracy?
There's not much "dignity of work" in a job with wages so low that you still have to use Medicaid. Such jobs are usually unsteady, so when the job disappears, so does your medical coverage. The effect of uninsured patient populations on local medical facilities and state and federal expenditures to cope with them is well known. But like the Mortgage Crisis, they will bail out the corporations while leaving individuals to suffer the consequences.
I really appreciated reading this perspective. Thank you for sharing.
Thank you Gabe!
This is interesting. When you use the change in percentage could you report what that means in terms of number of people too at least an example for some state. The difference in percentage doesn’t have as much meaning as number of people.
The Kaiser Family Foundation gets into this a little bit: https://www.kff.org/medicaid/issue-brief/allocating-cbos-estimates-of-federal-medicaid-spending-reductions-and-enrollment-loss-across-the-states/ (they do have a map that shows the estimated percentage of enrollment lost from each state by 2034; my state, Maine, is estimated to lose 8%-12% of enrollees, which is roughly 29k-44k people who would lose coverage)
"Instead of making state-by-state predictions, [the Congressional Budget Office] generates a national figure by estimating the percent of the affected population that lives in states with different anticipated types of policy responses. For example, different states might choose to implement a work requirement with reporting requirements that are easier or harder to comply with. In estimating the costs of the legislation, CBO assumes that in aggregate, states would replace half of reduced federal funds with their own resources in response to provisions that reduce the resources available to states, such as limits on provider taxes."
There’s this podcast I listened to a few years ago called The Uncertain Hour where they looked into work requirements to receive welfare benefits. They found that private companies would step in with work training programs that led to people having less time to even get jobs. They also pushed low income jobs like janitorial work which fundamentally just perpetuated the cycle. They also found some candidates had trouble reading or writing, but the program was not able to help with these skills that could pull them out of poverty.
This certainly affirms my experience as a Social Worker. I have searched my memory of my caseloads through the years and I can recall only one case where I thought the recipient could be working at SOMETHING.
A bigger opportunity for these waste fraud and abuse hunters would be the SSDI system. Social Security Disability. Now there’s a program ripe with opportunity to retrain recipients to re-enter the workforce. It will never happen as it is a way for states to avoid paying unemployment compensation by shifting the burden to the federal Government while ALSO letting corporations off the hook for massive layoffs. It is common practice for companies to facilitate mass applications to SSDI when closing a factory, sadly.
This is very sad. It really makes people who are truly disabled and need SSDI be side-eyed even more. It is also extremely frustrating that companies do that when for individuals the process is extremely difficult to navigate. They often, unless determined to be totally and completely disabled, have to recertify every few years. Which when you're doing it on your own, can be a stressful process.
I agree, Amber. This is a program people pay into, and a good safety net for those who need it. Sadly the process requires people to navigate a two year process, and the systems work together to immediately deny people. Upon denial, they are entitled to appeal. An appeal can only be handled by attorneys on a list of those certified to argue SSDI cases. At some Point a final decision is handed down, and the attorney gets a percentage of your back-dated benefits. To add insult to injury, those approved and deemed to be “disabled” are then required to complete a two year waiting period to enroll in Medicare. Why we would make people we have already decided are disabled wait for healthcare when we know they are not working and likely have no insurance boggles the mind.
Much easier to nurse a stereotype of people on Medicaid.
Thank you Gabe for this information. It will be interesting to see what happens to this in the Senate.