In 1965 Congress created the Medicaid program for families on welfare and low-income seniors. Medicaid is now the nation’s largest health insurance program covering roughly 1 in 5 Americans. The program is paid for by a combination of State and matching Federal funds with the Federal funds covering up to 83% of the total cost. In 2016 the cost of Medicaid to the federal government was $565 billion dollars. The cost of the Medicare and Medicaid programs combined was roughly $1.2 trillion dollars in 2016.
Recently the Trump administration announced it would allow Kentucky, and now Indiana, to require many of its Medicaid recipients to have a job or do volunteer work to receive benefits. Additionally under the new regulations Kentucky can charge monthly premiums, and if individuals fail to notify State officials of changes in employment they can be locked out of their coverage for six months. State officials expect that over the next five years the new rules will cause 95,000 people to lose Medicaid coverage. To put teeth behind this change, Gov. Matt Bevin (R) signed an executive order that will repeal the state’s Medicaid expansion if the inevitable court challenges result in the new rules being struck down. This Executive Order could result in a loss of coverage for an additional 400,000 Kentuckians. Graciously, the work requirement has a number of exemptions including an exemption for those that are medically frail.
Spending on healthcare in the US is roughly 18% of GDP, and while we spend twice as much per capita as other developed nations we provide care that is among the worst in the developed world. Current healthcare spending causes significant limitations on spending for the military, infrastructure, education and other national priorities. One area of agreement by all sides of the healthcare debate is that current spending is unsustainable. The economic argument for Kentucky’s new requirements is ostensibly to decrease the cost to the State, and the Federal government, of healthcare. This economic argument is both fallacious and overly simplistic. What is not stated is that the underlying argument for this this rule change is not economic, but rather moral. The moral argument being that the poor, ill and elderly are not worthy of healthcare.
Proponents of these changes are largely driven by the precepts of the prosperity gospel. A philosophy that promotes the idea that God provides wealth to the worthy and conversely a lack of wealth is evidence of a lack of God’s favor, Therefore, denying healthcare coverage or making recipients sing for their supper is justified. This is the moral subtext of Kentucky’s Medicaid rule wrapped in a cloak of fabricated fiscal responsibility. This same moral reasoning can be seen in words of Paul Ryan when upon passage of the recent tax bill he stated that the offset for the tax breaks that will greatly benefit the wealthiest 1% of Americans will be cuts to social programs, including Medicaid and Medicare. This ongoing moral assault on healthcare under the cover of economic responsibility is as mean spirited as it is counterproductive.
Requiring Medicaid recipients to work or volunteer to prove their worth will not decrease healthcare costs, but rather increase them. Kentucky’s Medicaid rules will increase barriers to access care for up to 95,000 people who will lose coverage in the next five years. An increase in Emergency Department visits and a failure to care for chronic conditions will cost more than any dollars saved or generated by requiring Medicaid recipients to work. Healthcare expenditures decrease when we invest in keeping people healthy and increase when we place barriers to care. Primary care serves to decrease the burden of disease and a lower disease burden results in lower costs. This change will make simple primary care unaccessible, and health maintenance and chronic disease management will be beyond the grasp of those who need it. The law is designed not to encourage work, but to punish those who have the temerity to be poor.
Part of the solution for the unsustainable cost of healthcare is to emphasize efforts that remove barriers and improve access to care. Simply put, investing in health costs less than fixing those that are ill. This moral assault on healthcare denies the fact that a nation’s health system is a reflection of its values, resources, policies and politics. Martin Luther King Jr. in a speech to the Medical Committee for Human Rights said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”