Why Paul Krugman is Wrong to Push Medicaid as the Remedy to Health Care Costs

Lambert here: Krugman should go on Medicaid himself for a year before he presumes to make recommendations. As any quick survey of the literature would show, the political class is almost completely insulated from the human effects of the policies they so freely propose.

By weldon, a long-time poster at Corrente. Originally published at Corrente.

Paul Krugman suggests in his New York Times column today that continuing the expansion of Medicaid is the answer to the outlandish cost of health care in the United States. He’s wrong. Medicaid is a lifeline for the impoverished, but the program would have to be reformed to the point that it would no longer be recognizable as Medicaid to be satisfactory for most Americans.

The reason Krugman likes Medicaid is the program’s success at controlling costs. He says that of all the health care delivery systems in the country, Medicaid is the one most like those in Europe, which have much lower costs than ours. If that’s true, it’s only because most of the rest of our fragmented system is completely fucked up.

Among the primary aims of European systems is health care equity — providing everybody with the same access to high-quality health care regardless of income or station. Medicaid does not come close to doing that. Krugman says that care from Medicaid providers is good and that lack of access is greatly exaggerated. In my experience the former is sometimes true and the latter, never.

The level of care and access to it varies wildly from state to state and even from county to county within states. In some locations the government’s role is only to determine eligibility, and the program itself is run in whole or part by for-profit managed care organizations with extremely narrow choices of providers. In others, it remains a government-administered program in which the choice of doctors is limited only by the number of them who choose to accept Medicaid patients — but that number is typically a small percentage of the doctors in the area.

I’ve been a Medicaid recipient in three counties and two states. In Los Angeles, Medicaid was administered entirely by the county government. I received my primary care from a satellite clinic of a highly regarded university-affiliated hospital system. The clinic itself was well appointed, and waiting times were only occasionally excessive. Care, however, was inconsistent. I didn’t know from visit to visit which doctor I would see. The clinic took months to retrieve my records from the low-income clinic (also affiliated with the university hospital system) where I went before I got Medicaid; a mistaken diagnosis at the Medicaid clinic led to several extraneous X-rays that put me over the limit considered safe, and that would have been avoided had my chart been promptly retrieved. And there were other issues that don’t warrant relating but that would almost certainly not have occurred had I been a patient of higher social status attended by a physician in private practice.

Medicaid in San Diego county was run by for-profit managed care organizations with few provider options. Because Medicaid is administered at the county level in California, I had to register with the San Diego office in order to get referrals to specialists, a process that was the earthly embodiment of Catch-22. I ultimately chose the plan with the clinic closest to me. The clinic was perpetually swamped. Waits were usually long and reception areas were sometimes standing room only. I have no quarrel with the care, other than that the staff seemed perpetually exhausted.

It’s no secret to regular readers of my blog that I’ve had my share of mental health issues; that’s how I wound up on Medicaid. I didn’t have a problem with access to mental health providers in Los Angeles, although I did get saddled with a couple of shrinks who were in serious need of shrinks. In San Diego, though, it took months to get a referral and more months to get an actual appointment. This was in part because of the difficulty registering with the county, and in part because the number of providers was so small. Ultimately I saw a psychiatrist once in the year I was a Medicaid patient there, toward the end of my tenure. Prior to that I had to press the nurse practitioner at my clinic to ask her supervising physician to prescribe my psych medications.

Now I’m back in Honolulu, which also uses managed care groups to run its Medicaid program. None of the doctors I had when I lived here before accept patients from either of the managed care groups, and none of the doctors near me do so either. I’m back in a clinic. It’s not the most comfortable environment, crowded and often with long waits, but the staff are dedicated, there’s a pharmacy on the premises and I get to see the same doctor each time. He has referred me to a couple of specialists for non-emergency exams or treatment; three months later in one case and one month in the other, I still don’t have an appointment with either because so many specialists don’t accept Medicaid patients that the ones who do are seriously backlogged.

Other problems exist in addition to the access problems and the issue of drastic inequalities across the system nationally and within states. Among the most serious of these is the provision under which Medicaid agencies can attempt to recover costs from the estates of beneficiaries who are more than 55 years old. This is something that would be unimaginable in any other developed country.

Another problem, the proliferation of for-profit managed care companies within the system, may well destroy Medicaid in all but name. This is a process that began in the 1980s under Reagan, continued under Clinton and accelerated under the second Bush. 28 states now use for-profit companies in at least some locales. The Obama administration recently granted a waiver to Arkansas allowing the state to steer Medicaid expansion-eligible residents into plans sold on the insurance exchange there — a practice other states, particularly the ones that spurned the expansion but will eventually join in, are certain to emulate. What this means is that Medicaid is in the process of being privatized, with government money subsidizing insurance companies and managed care companies. It begins to approximate a voucherless version of the voucher system that Republicans hold so dear, laundering money through consumers to the corporate gatekeepers.

This is not the system Krugman imagines. He’s not alone; most Democrats and many people who describe themselves as progressive are celebrating the Medicaid expansion under Obamacare as an extraordinary advance. In terms of coverage, they’re right. In terms of steering the country toward health care equity, they’re wrong. Medicaid patients are too often treated as second-class citizens, and the problem is likely to worsen without the kind of drastic reform I mentioned earlier.

There are at present about 150 million Americans being served by at least a half-dozen single-payer systems. We need to take the most popular of those systems and expand it to provide cradle-to-grave coverage for everyone in the country, and improve it to achieve the health care equity that Americans deserve and that President Obama has described as a basic human right. We need Medicare for all.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


    1. Alexa

      Ditto, excellent post.

      What we also need to address, is the fact that the Democratic Party through the ACA, is setting us up for “managed care” under the Medicare Program.

      The sixth state has already been granted a “waiver” to being a test or pilot program to put their sickest , poorest, and most vulnerable senior and disabled beneficiaries–“dual eligibles”–into managed care, in lieu of fee for service (like traditional Medicare).

      I’ll continue to post on this, in hopes that the progressive community was start pushing back on this trend. I have seen no sign of this, thus far.

      When developing their demonstration projects, states can theoretically choose between managed care, called the capitated model, or a managed fee-for-service model in which the state handles the integration of Medicare and Medicaid benefits and receives a performance payment from CMS if it meets certain targets. But managed care is winning out — four of the five approved states proposed managed-care programs; Washington state opted for managed fee-for-service. Of the 21 other states that have proposed a duals demonstration, 14 chose managed care. Five decided to try managed fee-for-service, and two are testing both models. . . .

      The stakes are high. The nation’s 9 million dual eligibles account for 15 percent of Medicaid’s enrollment, but nearly 40 percent of its spending.

      As conversations in Washington, D.C., focus on deficit reduction and entitlement reform, health officials know that the duals demonstration could play a significant role in getting government health care spending on a sustainable path.

      If this trend is not stopped soon, it is very possible that in a relatively short time the entire Medicare Program could become a “managed care” program.

      I think there’s a term for this: “The Camel’s Nose Under The Tent!”

      [So, thanks for bringing up this topic, Lambert and weldon.]

      Here’s link to a piece about Virginia’s “Demonstration Project” which began on January 1, 2014.


  1. bob goodwin

    Controlling costs is the driver of the entire debate. Chronic illnesses represent 85% of all healthcare costs, and many people in this category don’t have a cure available. Costs are controlled by slowing down treatment and creating obstacles. Even in treatable diseases (Lyme is my pet project right now) very sick people are very expensive to treat. Europe has lower costs because they treat chronic diseases more slowly. Obstacles are aplenty in our insurance reimbursement system as well.

    I wish Weldon well with his difficult issues.

    1. bob goodwin

      “Europe has lower costs because they treat chronic diseases more slowly. ”
      Slowly is not always the right word. Perhaps frugally, or measured, and fewer medications.

      1. Yves Smith

        Europeans and Australians (I have direct experience with Australian health care) seem to try to avoid Hail Mary pass costly treatments, particularly ones that also result in low quality of life. A friend’s cat got cancer, and he took it to the Animal Medical Center, which is the equivalent of a teaching hospital for animal treatment. He said he’d rather go to the AMC if he ever got cancer than Sloan Kettering (NYC’s premier oncology center). The AMC gave his cat low dose chemotherapy, to reduce the symptoms and give him some modest life extension, rather than try to “cure” the cancer while making him acutely miserable in the process.

        My perception with Australians is they were much more cautious about recommending surgery, and more attuned to the success rate of procedures and possible downsides.

        Similarly, everywhere but the US bargains hard on drug prices and is more skeptical of “new” drugs, which in over 85% of the cases are modest reformulations to extend patent life, with accompanying 2-3X price increases. So drug costs are way lower.

        1. vlade

          From what I know (some of it being second hand experience, but still having direct knowledge of about 5 different health systems), US overdiagnoses (and overmedicates), Europe underdiagnoses (and undermedicates).

          So in US quite a few non-issues that would disapper on their own with time get expensive medical treatment (a good example is psychology, where often a good psychologist is way better treatment than any amount of medication), but on the other hand, in Europe it’s sometimes hard to get a real medical condition recognised. A good example of that is lyme borreliosis, which hardly any UK GP can diagnose (and usually misdiagnose) or even knows about (despite the fact it’s a reportable disease).

          So pick your poison.

          TBH, I like the French system the most (maybe because I wasn’t exposed to it enough) – it has the freedom of choice while the costs are the same, which means they do have to compete on quality, not cost.

        2. DakotabornKansan

          “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.” – Voltaire

          Siddhartha Mukherjee, The Emperor of All Maladies A Biography of Cancer, writes:

          “Between 1891 and 1981, in the nearly one hundred years of the radical mastectomy, and estimated five hundred thousand women underwent the procedure to “extirpate” cancer. Many chose the procedure. Many were forced into it. Many others did not even realize that it was a choice. Many were permanently disfigured; many perceived the surgery as a benediction; many suffered its punishing penalties bravely, hoping that they had treated their cancer as aggressively and as definitively as possible. Halsted’s “cancer storehouse” grew far beyond its original walls at Hopkins. His ideas entered oncology, then permeated its vocabulary, then its psychology, its ethos, and its self-image. When radical surgery fell, an entire culture of surgery thus collapsed with it. The radical mastectomy is rarely, if ever, performed by surgeons today.”

          “The ominous topping of radical surgery off its pedestal may have given cancer chemotherapists some pause for reckoning. But they had their own fantasy of radicalism to fulfill, their own radical arsenal to launch against cancer. Surgery, the traditional battle-ax against cancer, was considered too primitive, too indiscriminate, and too weary. A “large-scale chemotherapeutic attack,” as one doctor put it, was needed to obliterate cancer.”

          “Hexamethophosphacil with Vinplatin to potentiate. Hex at three hundred mg per meter squared. Vin at one hundred. Today is cycle two, day three. Both cycles at the full dose.” – Margaret Edson, W;t

          “The smiling oncologist does not know whether his patients vomit or not…Few doctors in this country seem to be involved with the non-life threatening side effects of cancer therapy. In the United State, nausea and vomiting and diarrhea, baldness and body image and loss of self-esteem, loss of libido, broken marriages, financial problems, and disturbed children are nurses’ turf.” – Rose Kushner, National Cancer Advisory Board, warning against the growing disconnect between doctors and their patients

          1. Banger

            Beautiful comment! Modern medicine still function with the industrial mindset. Human beings are units to work on not deep and profound beings. Medicine itself is often an exercise in political domination that Ivan Illich wrote about decades ago. That’s not to say that there are not many virtues to modern medicine but, even to this day after heaps of scientific evidence, the psychic part of healing is more or less ignored by most doctors and hospitals.

          2. Dave of Maryland

            One good quote deserves another:

            Take a handful of the inner rind of limewood, let this boil in 2 cups water until slimy, then add 2 teaspoons old butter, 1 teaspoon medicinal soap [green soap?] and enough wheat flour to make not too thick a paste. Apply this to the ulcerated breast. The pain will swiftly subside, but will return after a few hours. Apply a fresh poultice and the breast will soon open up. When it has opened, apply the following mixture: Take 2 egg yolks with 2 teaspoons sweet butter. Part of this mixture should be smeared on the ulcer, after which the poultice may again be applied. When the ulcer is no longer burning, 1/2 teaspoon of Peruvian balsam may be added to the mixture of egg yolks and sweet butter.

            This remedy cured within a few weeks a woman who had seven holes in her breast and was threatened with removal of the breast. That was thirty years ago [1882, apparently] and the woman is still healthy. – from page 25 of Comfort to the Sick, by Brother Aloysius, 1912

            Permit me to unpack a bit of this.

            There is a modern belief that medicine did not exist before, say 1900. A moment’s thought will reveal this to be absurd. Medicine comes right after food, clothing and shelter. There has always been medicine, there will always be medicine.

            What did happen about a century ago is that older systems of medicine were suddenly swept away by the current version, based on a mal-formed understanding of “science.”

            Which traces back to a movement in German universities around 1870 or so. Which quickly infected American universities, among them, Johns Hopkins in nearby (to me) Baltimore. Teachers and students were convinced that microscopes and dissection and The Scientific Method would quickly uncover all the secrets of the human body and cure all ills. They blithely dismissed the past (more than 2000 years of well-preserved experience), believing they had a superior system.

            Regrettably, when the first graduates attempted to practice, they found the public in general rejected their work. This angered them, as they had worked long and hard and spent a great deal of money to get their certificates. The public clung to their traditional doctors, which were largely herbal-based. Many of them had been trained in the Eclectic School (that’s the actual name), so-called as they would use whatever worked. At the time they were based in New York or Philly, though they ended up in Cleveland or Cinncy, I forget which. Where their library can still be found.

            Spurned, various efforts were made to convince the public of the error of their ways. Which, as they all failed, ultimately resulted in the AMA and the Carnegie Foundation commissioning Abraham Flexner to write his famous report of 1910, which you can read on-line. The Carnegie people wanted to do to medicine what they had done to libraries. Which was a noble idea. It meant they needed someone to donate to. Universities, with their university medical departments, were the logical choice, despite the fact that no one wanted their doctors.

            In his report, Flexner, a graduate of Johns Hopkins, but writing as an educator, not a doctor, essentially repeated a formula that said, “science good – not-science bad.” In the entire report, not a single case was given of the superiority of the new scientific medicine over the generally accepted herbal remedies of the time. Flexner merely stated, over and over again, that the existing system was bad and that science would save us.

            With the weight of science, and Johns Hopkins, and the AMA and Carnegie behind them, state legislators saw the error of their ways and mandated that henceforth all doctors should be university-trained.

            Which hit our Brother square between the eyes. A Dutch monk, he had cured himself of consumption as a young man by means of the famous (cold) water cure (1891) and then found himself compelled to minister to the sick in his parish, requiring him to abandon his cloistered life. By 1912, the year of the second edition of his book, he was famous throughout Europe, having personally treated many thousands of patients. But Holland was no different than the US and many other western countries. In 1917 he was assigned a university trained doctor. Whom he probably ran roughshod over. In 1923 he was reassigned by his diocese to a nearby town, to deliberately hide him. I found a picture of him as an old man, eyes bulging out, exactly as Spencer Tracey made his bulge out as Mr. Hyde, in the famous movie. By forcibly removing him from his patients, his government rendered him insane. He died in 1942.

            Looking at his treatment for breast cancer, we can see that it involves poultices and salves. On pgs. 29-32 of this same book are not one, not two, not three or four, but twenty-two recipes for cancer. All but about four of them involving plasters, poultices, salves or ointments. All but a couple of them requiring two or more ingredients. (One required eleven). Only four of which were teas. None of which involved surgery.

            I am out of time. My apologies for the length. Suffice to say that modern medicine dates from the era of Prohibition, of early Communism, of the belief that Jesus Christ would shortly return to save us all. All of them fanatics, as it turned out. The actions of members of the American medical community are rather similar to that of the Communist Party under Joseph Stalin, of Pravda. We need to change laws.

            Myself, it will do to find one firebrand preacher who will use the First Amendment to establish a religious right to the medicine of his choice, as originally pioneered by the Christian Scientists. If he should head a mega-church, then he will already have herbalists, attorneys and local politicians among his congregation. He will need all of them. A friend of mine, Ema, sells simple herbal teas from her shop in California. On Facebook she currently has 43,882 likes, 3317 talking about this, and 1236 who were here. She is literally being crushed by the demand for real medicine, which is why I dare not link to her. Any preacher brave enough to get out in front of this could very well find himself the next president. There is that much need already out there.

            1. TimR

              Fascinating, thanks. What do you think of the Medical history Pilkington recommended yesterday? (Roy Porter, “The Greatest Benefit…”)
              I don’t quite understand why, we’ve had pages and pages of analysis on NC (and in comments) of Obamacare — detailed picking over, much concern and consternation — and hardly any of these brilliant minds pause to look at the system that (even it were executed brilliantly!) they’re shunting everybody into.
              It’s almost always useful, IMHO, to go back to the initial establishment of whatever system one is analyzing. How many people are really aware of the political/economic forces that shaped our current system, the propaganda required, the flagrant bad faith with which these men acted, as you describe (or perhaps they were sincere but delusional, either way.) Why can’t we unleash our intellectual firepower to some serious ends, such as establishing a truly useful medical industry? Rather than carping over some side-issue of a fundamentally flawed paradigm?
              Meanwhile the same powerful interests that established this nightmare system in the first place, are constantly scheming to shut down all alternative options, such as your friend’s business. And everybody here is worried that the tickets to this amusement park of terrors won’t be affordably priced.

            2. F. Beard

              Cartels, cartels, cartels. Sigh. The US is a huge collection of government backed/enabled cartels.

              My own alternative medicine witness is to water fasting, walking and weight lifting. The water fasting cures so many chronic diseases including mental ones that it would quickly eliminate the need for many physicians.

            3. bob goodwin

              I will add my humble story to that list and my current obsession. I had a 20 year painful UT problem that was being treated with STEROIDS by doctors, and I discovered that this problem had been linked to chronic Lyme by 3 studies, and Johns Hopkins says chronic disease does not exist and tried to get doctors to lose their licenses if they disagreed. I gave up on medicine and started self experimentation (kids at home: baaad idea). But ended up coming up with a combination which not only self cured the problem, but it was later discovered that I had a major cancer in my UT from reviewing an 8 year old tissue sample that resulted in having almost immediate surgery. There was no cancer left. My surgeon was impressed by the case because the disease and cancer had been so pronounced and medically documented, and now clearly absent.

              That shattered a lot of beliefs I had. Medicine knew that treating Lyme with Steroids was very dangerous, and yet chose a different path based on ego’s, not science. And now I am doing deep research into what went so terribly wrong with our Lyme research. The disease was discovered 40 years ago, 4M people have been infected, 10% treated, and there are at least tens-of-thousands of people who are disabled today because of it. It is not pretty.

    2. PaulArt

      “…Costs are controlled by slowing down treatment and creating obstacles.” Interesting. All over Europe old people are left to die in neglect due to poor and inadequate health care.

      Thanks for contributing this gem to our discussions. We would have never known. Obviously the right way to go is to follow the American Medical Association Specialty Physician Cartel fleecing and the insurance company looting. Yep we have a great system and the European model is bogus.

    3. trish anderson

      I disagree that controlling costs is the driver of the whole debate. obviously some of it, but I think corporate profits are the bigger overall driver, easy. Pseudo-liberals like obama have to DO SOMETHING for the poor who can’t afford to shell out to the insurance companies, so medicaid expansion, where controlling costs through inhumane treatment like denial of access is the driver.
      Then, of course, the insurance companies spend a huge amt of healthcare dollars trying to deny access for those who can shell out. The driver is controlling costs but obviously the ultimate driver is corporate profit.
      Everywhere I look it is.
      And of course there’s the patent, copyright protections for the drug companies along w/ the admins refusal to negotiate prices, etc.

  2. JGordon

    Healthcare ought to be a universal human right. As I only later in life came to realize, in most places in the world it’s quite unnatural having to fear bankruptcy every time you visit an emergency room.

    I wonder when the point of having a society stopped being about making people (uh “consumers”, for those of you who only listen to corporate media/government propaganda and are therefore out of touch with reality, can be equated to “people” or “human beings”. Although I suppose Google will start creating robot “consumers” soon to pick up the consumption slack if those human “consumers” keep uncouthly slacking on their duty–so that might not be true in the future) healthy and happy and started being about making “The Economy” grow at any and all costs. It’s like people are confusing the end and the means here.

    You all should ask yourselves: is this kind of a delusional, heartless society really worth trying to reform or save? Especially when most people in it (especially the elites) would be annoyed at you for even (futilely) trying? Charles Hugh Smith had an insightful post a while ago that said the solution to all our corruption problems was sit back, take it easy, and pick up the pieces after everything collapsed. After the Supreme Court upheld Obamacare I realized he had the right of it all along.

    1. F. Beard

      You all should ask yourselves: is this kind of a delusional, heartless society really worth trying to reform or save? JGordon

      I more and more think the US is Babylon the Great. And think about it: the people who moved here, for better or worse, are pretty much self-selected (exception: black slaves).

      Still, it irks me that an idealistic country like the US would tolerate a government backed banking cartel.

  3. PaulArt

    You get what you deserve. You keep electing f**d up GOPers in Red States who then do everything possible to deny and dilute Medicaid then that is what you deserve. Take West Virginia. I have no sympathy for the people who are sucking up contaminated water there. Every citizen recognizes the importance of public services ONLY when they have a need for it and they are DENIED it. Joe the Plumber will never understand medical bankruptcy unless a truck runs over him or he comes down with some terrible illness. As long he is healthy and makes it past 65 into Medicare, he will NEVER know the pain of Doctors and Insurance companies fleecing him. I personally experienced this circa 1994-98 when my daughter went through two major surgeries. This is exactly the reason why the Specialty Physician cartel and the Insurance cartel are able to plunder so much. Unless you walk through a major illness or a family member does and you are sitting in the Hospital Cafeteria sifting through the bills you have paid and have been re-billed for and bills you were sent in error etc OR you suck up polluted water, you will never learn. I have zero sympathy for White t**sh in the rural countryside suffering for lack of medical care. They had it coming. It is also my most sincere wish and prayer that the Red states suffer the most grievous forms of environmental degradation that comes about due to climate change. They have it coming there too.

    1. Klassy

      Why would you want anyone to suffer the most grievous forms of environmental degradation? So, you think it is the “White t**sh in the rural countryside” that are responsible for our out of control health care costs? Don’t see too many of them working as lobbyists for the various components of the medical industrial complex. I don’t think they are the ones shutting down hospitals in rural areas or consolidating. I am most certain that they don’t comprise the class of well paid insurance executives or hospital administrators, or physician specialists. I bet some of these people I just listed listen to NPR and read the NYT!

    2. marym

      West Virginia has a Democratic governor, Democratic majorities in the state Senate and House, and 2 Democratic Senators.

      1. NotTimothyGeithner

        Democrats suffer from the same tribal identity crisis as the GOP. Any problems will be the fault of the other side or a handful of Senators who are constantly defended by their own Senators.

        Since the Democrats have behaved just awfully, including not getting anything for their voters for passing the most recent budget proposal which is a GOP wet dream (stunning negotiating, snark), Democratic partisans have to make up fantasies or obsess over state politics (Christie; its useful as an example, but the NJ media seems to be on this) and retired individuals. Two MSNBC hosts have had to apologize for remarks about Palin and Romney in the last three months; one was fired. Why on Earth were they even discussing people who will never achieve political power at this point? Their stars have passed, but the answer is to deflect from Democratic failures by reminding us of GOP clowns.

    3. Banger

      We are better of having compassion for all. If you really listen to people in red states and get to know them they all have stories and lives and are easily swayed by calculated appeals to cultural prejudice, vanity and so on as are all sectors of the population none of which have a monopoly on wisdom. I’ve lived in red areas and blue areas and levels of ignorance seem about the same from my POV (I would define ignorance differently, I suspect, than you or many reading this).

      Since I know mountain people I know that they tend toward a fatalistic view of life. The powerful are the powerful and there’s not much anyone can do about that–you live your life the best you can and avoid fretting over the oligarchs. Others, like in the DC suburbs where I lived most of my life believe that we can challenge the oligarchs and many try but almost always fail and end up either bitter and frustrated or live in delusional constructs.

      In the end, Washington failed. In the end the American liberal class failed as Chris Hedges cogently has pointed out. It is the job of intellectuals to stand up and in almost every sense that class in the United States has laid down and spread its legs for the oligarchs every time far more than the poor and middle-class in flyover country who have a narrative few on the left care to listen to with compassion.

      1. F. Beard

        I suppose I was a bit jealous of you at first but you make more and more sense to me. One or both of us has changed.

        Delusional constructs? At least mine, should it turn out to be so (but I’ll never know it) has been shared by millions and faith, iirc, has been found to be good for one’s health.

        My poor, intelligent, hardworking, clean living, hot (to me at least), single* mother laundry lady is currently fretting over her health and I wish I could transfuse my faith as easily as I could transfuse my blood should she ever need any.

    4. Phil Perspective

      You do realize that WV has had a Democratic Governor since before 9/11, right? Yes, that 9/11, so going on 12 1/2 years straight now. Also, Democrats have controlled the WV House of Delegates since the 1930’s. Yes, you read that correct. So the whole West Virginia Water Crisis isn’t the fault of the GOP only.

  4. LucyLulu

    When evaluating costs and outcomes of a nation’s healthcare policy, it’s important not to overlook the impact of non-medical, or social factors on an individual’s health. For example, factors such as family income, education, housing, employment status, stress levels, and available social support directly impact health on both a short and long term basis through a number of paths. Lack of housing or access to heating fuel during cold winter months will affect the success of treatment. The presence of mold or local environmental pollutants lead to higher rates of asthma (which is growing problem). A diabetic needs to be able to purchase nutritious and balanced foods to optimally control his blood sugar. High rates of violent crime or accidents in unsafe neighborhoods lead to poorer health. Lack of access to transportation limiting access to healthcare services can lead to disastrous results in some, such as somebody who requires dialysis three times weekly to avoid costly hospitalizations (or death). High quality early childcare reduces stress and illness in both children and parents. Living in one neighborhood can yield a life expectancy that is 14 years longer than living in another just a few miles away. The reduction of inequities in healthcare delivery requires interventions beyond what is typically considered the purview of healthcare. Undoubtedly a portion of the savings achieved by other developed nations is achieved by the presence of lower levels of inequity on a broader social basis. These same factors affect US educational outcomes as well (which are very competitive globally IF one excludes those living in poverty and blighted neighborhoods).

    When I worked in community health with low income clients, almost all on Medicaid, sometimes the needed resources were available in the community but the client was unaware of them
    or didn’t have the necessary skills to access them. Tracking them down and completion of the referral to the limited available resources, whether reduced rent through Section 8 or assistance with the necessary paperwork for a successful disability claim or a free medication program through the drug company, is beyond the knowledge and know-how of the client and typically deemed by healthcare providers, focused on secondary and tertiary treatment of disease, as being beyond their scope. As US healthcare (hopefully) realigns towards prevention, and supporting healthy life choices, as opposed to treating disease, it needs to also begin addressing the broader psychosocial measures that can have critical effects on health outcomes.

    1. F. Beard

      Very good points!

      Stress is certainly unnecessary; no one should have to worry about food, clothing or shelter in the US yet many do.

  5. John F. Opie

    Just one comment: there is no “European” health system. Instead, there are as many as there are countries in Europe. I live in Germany and pay quite a bit (€1500/m including employer’s portion for family coverage) for relatively basic coverage (no dental, no eye, group room in hospitals, etc), within the general public health system. I subsidize the grandmothers and single moms with kids: they don’t pay nearly as much, if anything. It’s hooked to your income.

    Systems aren’t really comparable as well. The waiting times for the NHS are legendary (and largely true); in Germany, I’ll wait 4 or 5 months for an appointment with a specialist, and many don’t take “public” patients any more for the same reason that doctors in the US won’t see MediCare patients as well. Each country in Europe has its own system, some better, some worse. Can’t put them all into one basket when comparing.

  6. trish anderson

    This is exactly right. I developed an autoimmune illness shortly following my (bitter) divorce. Together, both essentially impoverished me. I had at the time managed to get into the library system but part time, no benefits, so I went on medicaid. I had a young son still home with me- with high functioning autism- and in NC an adult can only get medicaid if they have a child in the home. So I guess that was lucky in that regard.
    I go to a clinic…same issues- crowded, random docs- and long waits for appts with your particular doc. The doctors are kind and respectful but harried with so many poor to see. And finding specialists willing to see you is hard, often impossible for ones within the city. Many don’t take medicaid patients. I have to drive way out to see an autoimmune doc, and it took 9 months just to find and get in to see that one initially, and he’s pretty mediocre. I have found that some specialists seem dismissive of medicaid patients, but that’s only my perception (could be just basic arrogance). And every couple months I had to go through the whole paperwork process of “proving” my low income and I would sweat it out because my sub job meant some weeks I made “too much.”
    And now I am going to take a more “permanent” part time library position which is more stable than my sub job but gives me steady 20 hrs a week so I will lose my medicaid because I make too much. Pathetic. Can barely live with that and my child support. And I am frankly scared.

    1. jonboinAR

      I’m sorry for your difficulties. I think most of us feel ourselves close to the precipice you’ve fallen off of. Somehow we have to get ourselves collectively organized to do something about this. One of the basic problems with getting going is figuring out what to do. I think one of the first order of business is to try to do something to “reverse” Citizen’s United, and then continue in that direction toward some kind of comprehensive election reform.

      I hope your health and financial issues get resolved soon.

    2. Doro Reeves

      This system is dehumanizing, sadistic and cruel. What you and others have described, I would not wish on my worst enemy.

  7. Fred

    Let me be very straightforward and simple to understand: the problem with Medicaid and the reason more private physicians won’t accept Medicaid is that you can’t run a remotely viable medical practice accepting Medicaid. Unless of course, you’ll do shady things like bill for visits or treatments not provided. Here’s a real life example.

    A relative of mine works as an internist in an inner city hospital in NY where greater than 90% of the patient population is on Medicaid. My relative is salaried by the hospital so he doesn’t have to deal with billing or overhead. Let’s say my relative wanted to run a private practice. For each patient visit, Medicaid pays about $35. Assume you’ve got 25 patients per day, 5 days per week, you’re pulling in ($35 x 5 x 25) = $4,375 per week. Now assume you work 48 weeks per year, you’re pulling in ($4,375 x 48) = $210,000. But this $210,000 is GROSS. If you’re talking Medicaid you’re probably going to need 1-2 staff people to bill. Then there’s rent. And malpractice insurance. You’re net salary is probably going to be less than the salary of a NYC public school teacher.

    After hearing the economics, I’m convinced the only way doctors can run a private practice that have a high proportion of Medicaid patients is by doing shady stuff. Alternatively, you’ve got to work for a city hospital, clinic, or some other organization that pays your overhead.

  8. PaulArt

    I am getting a strong whiff of Medical-Industry complex trolling going on here. All with anecdotal experiences that all sound pretty self-serving along the lines of ‘oh the poor Doctors and Hospitals’.

  9. LAS

    I don’t like Medicaid because the benefits/terms of who qualifies are always changing due to politics.

    It makes no difference whether we hear about Medicaid or Personalized Medicine solutions, health care is seriously class-based or inequitable, with no sign of improving. Within country inequities are bad, but global inequities are even worse. Where poor people really suffer is having to work and live in communities with dangerous unregulated professions: mining, welding, smelting, chemical production, tanneries, etc. These exposures and poor pay really shorten lives dramatically. Poor children suffer in having their communities contaminated with air pollution and run off from unregulated factories/industries using mercury, lead, chromium and chemicals, etc.

    The New York Times and Wikileaks is this morning reporting that the Pacific Rim trade deal that Obama has been working on (and this blog has already objected to) is getting even uglier as the administration retreats from its previous demands for environmental provisions. The scale of that sell out to humanity is growing.

  10. marym

    Medicaid is a for-profit business.

    Below are links to data as of 2011 showing the percentage by state of Medicaid recipients enrolled in managed care organizations; and data as of 2012 indicating that about half of these were for-profit, and also showing that only 11 states had a mandated medical loss ratio for Medicaid.

    A commenter pointed out on correntewire that those legally classified have corporate features in their financial practices like high executive pay and privileges.

    If Paul Krugman were interested in providing healthcare he wouldn’t recommend either a for-profit system or a system in which he never expects to be a patient.


    1. Yves Smith

      Oh, he actually wrote a NYT op ed repeating his unresearched opinion after he said he needed to do research. I saw it too late to go after him. Shameless but no surprise.

  11. F. Beard

    I haven’t said much about health care but in general I’m in favor of as much socialism as is necessary to counter the injustice of the current money system.

    But IDEALLY, almost all Americans should be able to pay their medical expenses out-of-pocket or from a slight to moderate diminution of their assets (self-insured). That was often the case before WWII, iirc.

    But by all means, let’s continue the endless strife between fascists and socialists because neither really believe in justice, just that they be in charge of the looting. It’s just so much fun! /sarc

    1. Doro Reeves

      Beard- your assessment of the fascist mentality is spot-on. But you don’t know squat about socialism.

      1. Robert Sadin

        I noticed after I commented.

        An apropos story….Miles Davis classic album “Kind of Blue” featured Bill Evans on piano except for one song which was played by Wynton Kelly. Evans was very excited about how the album had turned out and brought it to the great Milt Jackson to play it for him.
        Jackson listened intently…when the album got to Freddie the Freeloader (the cut with Wynton Kelly), he said,
        “Bill, that’s the best you’ve ever played.”

        Thanks for keeping the heat on health care.

      2. bob goodwin

        It is a very well constructed article with good balance of feelings, observations, humility and perspective. It is very hard to write in that frame and very effective. It is also a gift from a writer to expose a part of themselves like that that we tend not to appreciate enough.

        Thanks for sharing.

  12. TarheelDem

    “Medicaid is a lifeline for the impoverished, but the program would have to be reformed to the point that it would no longer be recognizable as Medicaid to be satisfactory for most Americans.”

    But most middle class Americans who receive Medicaid receive it after “spending down” in order to get long-term care and long-term care subsidies are missing from Medicare.

    Moreover the biggest issue with Medicaid is the involvement of the states in funding it. Upping the federal subsidy and requiring states to participate with 100% federal funding is legislatively a bill of a few pages or an amendment that is a rider even in a budget. The federal funding would set the base level (even for Mississippi) and states with higher cost structures (like California) could supplement the program with state funds. Getting a sufficient base-level of funding is the issue.

    Where single-payer (Medicare-for-all) ends up is Medicare/Medicaid for All with Long Term Care Support.

    The issue is not as cut-and-dried as you make it out to be.

    But given the current Congress, Krugman’s proposal is hypothetical anyway.

  13. Klassy

    Krugman’s post is silly. How does Medicaid control costs better than medicare? Does it negotiate prices better than medicare or is it just medicare with less services covered/narrower networks? I assume it is the latter. So, how about medicare for all?

  14. Sisko systems

    Nearly all the comments above are true, including the comments that appear to in opposition to each other. It just goes to show how deep and complex the problems of our medical care system. Nobody has figured out the perfect solution. Yet.

    1. F. Beard

      There is no perfect solution since if the Lord wishes one to remain sick, then there’s no getting around Him. Otoh, in the spirit of witness and not proselytizing:

      Isaiah 40:31
      Psalm 91:16
      Proverbs 3:16
      Psalm 38:3
      Psalm 41:3
      Proverbs 4:22
      Isaiah 38:16
      Jeremiah 33:6
      Luke 7:10
      Acts 3:16
      Acts 4:10
      3 John 1:2

      Feel free to ignore since a control group is useful too.

  15. Splashoil

    Princeton University should embrace the opportunity to emulate Europe as Professor Krugman advocates by adopting Medicaid for all faculty and staff. The uniquely American features of Medicaid apartheid such as the lack of medical cost ratios for the mostly for profit administrative “partnerships” who actually run the program in most states should be retained in this great experiment. Most especially, the clawback at death of estates from beneficiaries older than 55 years of age. Cost control indeed. No country in Europe claws back the costs of medical care from the estates of the deceased. “Medicaid for thee but not for me” is a waste of a valuable educational experience I hope the Professor can try out.

  16. JimZ

    The writer is no doubt correct. However, the placement of US health care into the hands of the private providers was ordained at the starting blocks. I predict that our health care system will go through two phases before it gets to where the writer thinks it ought to go (as do I). First, get (almost) everyone coverd somehow. Then, reform the system to move it closer to a universal (Medicare for all – type) system. As Churchill said, The US always does the right thing, after trying all of the alternatives.

  17. MaroonBulldog

    If I interpret Mr. Krugman’s post correctly, he is making the point that Medicaid programs keep costs low by saying “no” to treatments, which is to say by “rationing”. The NC commenters who have experienced long waits and delays are also informing us that Medicaid rations care, by showing us one way that Medicaid goes about it. To them, rationing is something to complain about. To Krugman, rationing is a positive feature.

    Like it or not, rationing of access to medical services is likely to be in your future; medical service providers are not in a position to cut prices and make it up on volume. Cutting their prices will not induce them to make the any new investments or do any additional work that would be necessary to increase the supply of the services they offer.

    Krugman’s column is just an apologist’s effort–not very successful, based on the commentary–to add the spoonful of sugar that will make the rationing medicine go down more easily.

  18. Hugh

    Krugman’s job is to sell whatever the current Democratic line is to a particular set of rubes. Of course, it is contradictory and doesn’t make a lot of sense. Propaganda seldom does. This is a class thing. If those of Krugman’s class had to live under Medicaid, they would see it as a kind of unjust punishment. The idea that they could not get good and timely care whenever they wanted it is against the laws of nature. But for the undeserving poor, inadequate, inconvenient, and delayed treatment is perfectly fine for them. Indeed it is necessary. If their care wasn’t heavily rationed, they would just abuse the system. We all know how the poor are.

    It’s all about class. We would not have Medicaid at all if we didn’t also have a class system. As soon as Krugman starts championing Medicaid, he is also championing the class system which spawned it. But what else would we expect from the conscience of a liberal? We need to understand that liberalism as practised, not as it is sold to us, is perfectly at home in a class system, –as is Krugman.

  19. Jess

    “We need Medicare for all.”

    With all due respect, no, we need universal single payer health care that covers the costs of treating injuries and illnesses. Here’s a real-life example of Medicare’s shortcomings:

    Medicare is financed by taking a $138 per month out of the recipient’s Social Security check. In return, Medicare pays 80% of “covered costs”, and some doctors accept the Medicare payment at full payment. The theory behind the Medicare Advantage Supplemental Insurance is that it pays a signicant portion of the other 20%, the actual amount varying according to whether or not you use an in-network provider, if the charges are within “R & C” (regular and customary for your area, as determined by the insurance company), etc.

    I live in the Los Angeles area where there are 26 Medicare Advantage provider plans available. However, the only PPO plan is Anthem Blue Crucifix Medicare Preferred Standard. All the rest are HMO’s, so if you want a real choice in your doctors and issues of office/clinic/facility location are important, you’re pretty much stuck with the BC plan.
    In 2013 Blue Crucifix starting charging an additional $28 per month on top of the $138 which Medicare already deducted and gave to BC. This year BC raised that from $28 to $80, along with raising co-pays and imposing some additional restrictions on coverage, drug exclusions, etc. For 2014 I got a 1.5% COLA adjustment in my SS check. However, once the additional $52 BC premium is subtracted, my actual net SS check is $29 LESS than last year’s.

    Here’s how that relates to an actual medical situation: Last June I suffered a herniated disc. (Evidently on area of the disc had been degenerating for many years and finally gave out from sleeping on a crappy sofa bed while visiting friends.) After rehab and a steroid epidural failed to solve the problem, in early Dec I had a micro-discectomy procedure performed by doctors at the UCLA Spine Institute. The UCLA center, the UCLA hospital where the surgery was performed, and all the medical personnel, labs, etc, are IN-NETWORK, and my deductible for the year had already been reached. To date the portion I must pay is over $1.400 and that doesn’t count the cost for follow up office visits, of which I’ve had one and the next is the 28th of this month. Once I’ve recovered enough there will still my co-pays and uncovered portions for physical therapy. Plus, one of my pain and muscle relaxant post-op meds is not covered by my BC Part D coverage and that’s $55 every two weeks. And oh, did I mention, that because of the meds I was already taking for other conditions and for injury pain relief that last year I feel into the Part D coverage gap?

    My net SS payment this year is $1,380 per month, and I will be facing probably $2,500 or more in out-of-pocket medical expenses not covered by Medicare — for a “relatively” minor one-day out-patient surgery. Fortunately, I have supplemental income from renting out the old family home I grew up in. But I cannot imagine how people who depend solely on SS, even couples with two SS checks coming in, handle the expenses for any kind of major medical conditions.

    Universal, government-paid, government-administered single payer is the only true solution.

    1. lambert strether

      Thanks for reminding us of how the neo-liberals are infesting and corrupting Medicare, which is shorthand for universal single payer but sadly no longer lives up to that standard.

      As far as not being able to afford Medicare on Social Security, that’s not a bug. It’s a feature. IMNSHO, a fall in life expectancy is an elite policy goal, exactly as permanently high disemployment is an elite policy goal.

      1. F. Beard

        a fall in life expectancy is an elite policy goal, LS

        Progressives should rejoice since that’ll help save the planet. “Save it for what” should be the question because “Nature is red in tooth and claw” with or without man and arguably less so with man.

        exactly as permanently high disemployment is an elite policy goal. LS

        Workers have been disemployed with their own stolen purchasing power via the banking cartel. No explicit goal is necessary; the drive for profit alone drives it.

      2. bob goodwin

        “a fall in life expectancy is an elite policy goal, exactly as permanently high disemployment is an elite policy goal”

        I think to assume bad intent weakens your power even if it strengthens your argument. You have much greater power to attack “a system that intends well but achieves bad” than attacking an “evil and competent system”.

        The reason is that competency is more easily measured than intent.

    2. marym

      The bill that’s usually referenced for Medicare for All – HR 676 – is actually called “Expanded and Improved Medicare for All.” It addresses the kinds of problems you describe with existing Medicare. The bill is for comprehensive coverage (including things like vision and dental). There are no out-of-pocket costs (no co-pays, premiums, supplemental insurance, etc.). Funding proposals are for a series of progressive taxes, including taxes on stock and bond transactions, and unearned income.

      1. Jess

        Are you by any chance the MaryM who posts on FDL? If so, I used to post there (before I got banned) as Beach Populist and just want to say “hi”.

  20. Hugo Stiglitz

    Excellent observations, as usual, thank you.

    “the political class is almost completely insulated from the human effects of the policies they so freely propose”

    This should be engraved in marble on a large monument prominently on the Mall in Versailles on the Potomac. It applies to pretty much everything they do and say. When it comes to the day-to-day realities of ordinary people, the disconnect between “ruled” and the rulers has never been greater in the US. Something has to give.

  21. tar, etc.

    Lambert, I just wanted to follow up on Medicaid in Oregon. I last posted here that Oregon had waived the asset recovery requirement. I had read an article in the Oregonian that had quoted OHA officials on that. And Cover Oregon went to considerable trouble to convince people this was this case.

    However, I have just seen the updated application guide for coverage, and it first states how asset recovery will not apply to Oregon Medicaid, but then says “except under the very limited circumstances listed below”:

    “Estate recovery rules are different for individuals receiving benefits, including their OHP benefits, to help pay for care in the following circumstances:

    “Individuals who were over 55 years of age when benefits were paid.”

    In other words, the policy remains the same for those over 55, yet the State appears to have engaged in a misinformation campaign to get people to sign up. If so, that’s a new low, and seems illegal to me.

    Weldon, nice article. You mention visiting a clinic that was “well appointed.” Where I live the build-out in clinics and medical facilities of all manner is extraordinary. You’d think we were Dubai. It’s another inequity that there is lots of money to build posh facilities but diminishing ability for patients to afford to walk in the front door.

    1. Lambert Strether Post author

      Well, that’s appalling. Got a link on that guide?

      So, we get the Democrat bait and switch vs. the Republican boot in the ribs, and it all comes to the same thing.

      1. tar, etc.

        Here’s another link from the Oregon Health Authority

        It’s titled, “Estate Recovery and the Oregon Health Plan
        The Oregon Health Authority will no longer implement estate recovery for OHP clients”
        That seems clear. Got my hopes up. But near the bottom there is this:
        If I sign up for the Oregon Health Plan, will the state recover from my estate after I pass
        No. If you sign up for the Oregon Health Plan, the state will not recover any assets from you. The state has changed the policy. Effective October 1, 2013, estate recovery is done only for people receiving long-term care services and/or for people over 55 or who have been in an institutional setting.

        Note the “and/or for people over 55…”

  22. tar, etc.


    Estate recovery is on page 9 of the Application Guide and reads the same on the Cover Oregon website.

    Nothing specific about asset recovery is written where you sign the application, but the section just above says, “I have read the Application Guide and agree to all sections.”

    I’m no lawyer, but that is ambiguous at best. I haven’t been able to get anyone to respond on the record, and I’m not sure who to ask. I wrote Dr. Alan Bates, my state senator, but heard nothing back. I’ve asked the Oregonian to follow through. I’ll let you know if I learn anything further.

    1. lambert strether

      That’s great, thanks. If you don’t get a response, consider writing a letter to the editor. Staffers actually pay attention to them.

  23. Nathanael

    In New York, Medicaid is getting kind of unrecognizable compared to what it was before. There seems to be a conscious effort to expand it to a universal program.

    So it could happen. We’re getting serious state-by-state breakup, though, where it’s vital to live in the correct state. So much for the Union.

Comments are closed.