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Questions about Medicaid that Are Never Asked


One of the problems that Democrats had with the feeble (and now failed) Republican efforts to repeal and replace Obamacare was that the Republican plans “cut” Medicaid spending.

This is almost a mirror image of what happened in 2010 when the Democratic-controlled Congress passed Obamacare in the first place. After the Patient Protection and Affordable Care Act “cut” Medicare spending (i.e., it slowed the rate at which spending was increased), some Republicans accused Democrats of cutting a vital health-care program for the elderly.

Medicaid is government-funded health care for poor Americans of any age and people with certain disabilities. It is the third-largest federal domestic program (after Social Security and Medicare) and the primary source of health-insurance coverage for low-income populations and nursing-home long-term care. Medicaid is a means-tested welfare program jointly financed by the federal government and the states, but designed and administered by the states within federal guidelines. The federal government pays states a specified percentage of program expenditures that ranges from 50 percent to 79 percent of the program’s cost, depending on the states’ per capita incomes. Total Medicaid spending for fiscal year 2016 was $574.2 billion.

According to the Kaiser Family Foundation, Medicaid provides health-insurance coverage to 33 million children and 19 million adults in low-income families and 16 million elderly and disabled persons, assists 21 percent of elderly and disabled Medicare beneficiaries, and provides long-term care assistance to 1.5 million institutional residents and 2.9 million community-based residents. Medicaid finances about 16 percent of total personal health spending in the United States and half of all long-term care spending. Obamacare expanded both Medicaid eligibility and federal funding.

The Congressional Budget Office (CBO) estimated that under current law, from 2018 through 2026, the federal government would spend about $4.62 trillion dollars on Medicaid. Under the Republicans’ Senate plan to repeal and replace Obamacare, the Better Care Reconciliation Act of 2017 (the Senate version of H.R.1628), the CBO estimated that total Medicaid spending would be about $770 billion less over the same period. Medicaid spending would not be cut; it would just increase at a slower rate.

But the Senate plan also rolled back who was eligible for Medicaid, reduced federal payments to states that expanded Medicaid, and shifted the program from covering a certain percentage of a state’s costs to a fixed amount. Those are things that Democrats, and some Republicans, were upset about.

Because Medicaid has been in the news of late, NPR’s Morning Edition recently had a segment on Medicaid featuring NPR senior news analyst and commentator Cokie Roberts.

In “Cokie Roberts Answers Your Questions about Medicaid,” the NPR host, David Greene, explained that the show had been taking listeners’ questions about the Medicaid program and was now “ready to put them to Cokie Roberts in our regular segment ‘Ask Cokie.’”

There followed five questions from four listeners by telephone or Twitter:

  • “What percentage of Americans rely on Medicaid, especially in rural America?”
  • “I would like to hear more about EPSDT, the EPSDT benefit, and why it was added.”
  • “How many students, K-12, in the U.S. receive Medicaid assistance?”
  • “Why do beneficiaries struggle to find providers willing to accept Medicaid payment?”
  • “Why do Medicaid-funded services vary so wildly across states?”

There was no problem with the way Roberts answered the questions. The problem is the questions themselves. Here are some far more important questions about Medicaid that were never, and are never, asked.

  1. Who actually pays for Medicaid?

Unlike Social Security, which is mostly funded by a payroll tax of 6.2 percent on both employers and employees, and Medicare, which is partially funded by a payroll tax of 1.45 percent on both employers and employees, there is no special tax that funds Medicaid. Funding comes out of the general federal budget that is funded by income taxes. But recipients of Medicaid aren’t the ones who pay for it with their income taxes. Since Medicaid is a means-tested program limited to low-income persons who are usually not paying any income tax in the first place, it is the taxpayers who are not on Medicaid who are actually paying for it. And since someone else is paying the bill, Medicaid recipients are more likely to use the health-care system than Americans who have to pay out of pocket.

  1. Is Medicaid constitutional?

I’m afraid not. And not only is there nothing in the Constitution that authorizes the federal government to have a Medicaid program, there is nothing in the Constitution that authorizes the federal government to have a Medicare program, a Children’s Health Insurance Program (CHIP), a Basic Health Program (BHP), the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), federal laboratories, the Food and Drug Administration (FDA), the Affordable Care Act (ACA), the Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), the Center for Medicaid and CHIP Services (CMCS), federal databases of Americans’ medical records, or federal insurance exchanges, or to provide subsidies for any American’s health insurance.

  1. Is providing Medicaid a legitimate purpose of government?

Unfortunately not. The only legitimate purpose of government is to protect life, liberty, and property from aggression and violence. That means defense, judicial, and policing activities that keep the peace, prosecute and punish those who initiate violence against person or property, provide a forum for dispute resolution, and constrain those who would attempt to interfere with people’s peaceful actions. It is not the proper role of government to fund, regulate, or have anything to do with health care or health insurance.

  1. Is anyone entitled to receive Medicaid?

Health care is not a right; it is a service that can and should be provided on the free market just like any other service. No American is entitled to health care provided at the expense of another American. No American should be forced to pay for the health care of any other American — regardless of how poor, old, sick, or disabled that other American is.

  1. How would low-income Americans receive health care without Medicaid?

Since it is not the job of government to provide a safety net or transfer income from the “rich” to the “poor,” all charity should be private and voluntary. All welfare programs should be eliminated in their entirety. Charity would be up to individuals, corporations, and organizations. Physicians, like lawyers, would no doubt do pro bono work, just as doctors did before Medicaid was enacted in 1965. Americans weren’t dying in the streets for lack of medical treatment before then. The federal government increased demand for health care with the passage of Medicare and Medicaid while restricting the supply of doctors and hospitals. That is what led to large increases in the price of health care. Less government intervention in health care will result in health care’s being more affordable for low-income Americans.

Don’t look for any of those questions about Medicaid to be asked by NPR or any other mainstream media outlet.