Tag Archives: Medicaid

Medicaid Expansion & Hospital Closures

One aspect of Obamacare was the expansion of Medicaid in states that agreed to accept this expansion. Some states, such as my adopted state of Florida, declined the expansion. This provided researchers with an opportunity to study the effects of accepting or rejecting the expansion.

One study, conducted by <a href=”https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0976″>researchers at the University of Colorado Anschutz Medical Campus</a>, found that hospitals in states that expanded Medicaid were six times less likely to close than hospitals in states that declined the expansion. Hospitals in rural areas, which tend to rely more heavily on Medicaid and generally have less income relative to urban hospitals, were the hardest hit.

These results are hardly surprising. Hospitals are required by the <a href=”https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/”>1986 Emergency Medial Treatment and Labor Act</a>(EMTALA) “to ensure public access to emergency services regardless of ability to pay.” As such, unlike other businesses, they cannot turn away people who cannot pay for the services they provide. While Medicaid payments to hospitals are notoriously low, some payment is better than no payment. Because of this, hospitals in states that expanded Medicaid are less likely to need to provide unpaid services and this makes it more likely that they can remain profitable and stay open.

It is, of course, reasonable to consider alternative explanations. After all, mere correlation is not causation and it would be fallacious post hoc reasoning (to infer that because A happened after B, B must have caused A) to simply conclude that Medicaid is the cause. The states that expanded Medicaid might differ in other ways from states that did not—for example, they might have more robust economies or larger percentages of privately ensured patients. That said, the study does seem to support the connection between Medicaid and hospitals remaining open.

One moral and practical concern about hospital closings is that people who need care will be less able to receive it. While it would be hyperbole to claim that hospital closings would leave people in the area with no care, it does reduce their access to care. This is especially of concern in rural areas that already have few hospitals. While people can, of course, travel to get medical care, increased travel times would reduce the likelihood that people will seek care and would also impact outcomes. For example, rapid treatment is critical for stroke victims. Even if patients still have access to a local hospital, hospital closures will increase the time patients need to wait for treatment and this can have a negative impact on medical outcomes.

While health care does not operate within a free market of informed consumers and competitive prices, the closing of hospitals can result in increased costs for medical care. After all, the scarcer a commodity is, the more people tend to charge for it. Since medical care is already extremely expensive, an increase in costs would be even more of a burden on patients, especially those that are not affluent.

Because of the negative impact of not expanding Medicaid, states that have not expanded it should do so. This will decrease hospital closures and thus have a generally positive impact. From a moral standpoint, this would be the right thing to do—assuming that the state has an obligation to the well-being of its citizens.

One obvious counter to this view is to argue against such an obligation. This position is often taken by conservatives who favor limited government and oppose entitlements. There is also the obvious market-based argument here (although medical care is clearly not operating as a free market). The gist of this argument is that medical services are a business and that if a business cannot stay open on its own, then the state has no obligation to intervene. As such, Medicaid should not be expanded to address this problem: if the hospitals cannot stay open on their own, then the market should close them.

The easy and obvious reply to this is that, as noted above, the law requires hospitals to provide medical services even when patients cannot pay. By imposing this restriction, the state has taken a strong role in the market. Since the state imposes this requirement on hospitals, it seems reasonable that the state should take steps to offset this burden—in this case, by expanding Medicaid.

Alternatively, EMTALA could be repealed and hospitals could operate like other businesses in terms of being able to refuse services for those who cannot pay. In this case, there would not be a need to expand Medicaid to assist hospitals in remaining open—they would not lose money providing services to those who cannot pay. But, there would be a high cost in terms of sickness and death among those unable to afford medical care. There is also the possibility that even without the burden of EMTALA hospitals would still be more likely to close without a Medicaid expansion. After all, while hospitals would not be losing money on patients who cannot pay, they would also not have the financial benefit of the Medicaid expansion. As such, their closure rate would presumably be higher than hospitals in states that have expanded Medicaid.

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Adjuncts & Walmart Workers

A recently renovated Walmart store in Clinton,...

(Photo credit: Wikipedia)

The September, 2013 issue of the NEA Higher Education Advocate featured an infographic comparing working at Walmart with working as an adjunct/contingent faculty member.  Having worked as an adjunct, I can attest to the accuracy of the claims regarding the adjunct experience.

In the usual order of things, a college degree provides a higher earning potential. This is not, however, true for the typical adjuncts. In the United States, a retail cashier makes an average of $9.13 an hour, resulting in a yearly income of $20,410. By way of comparison, Goldman Sachs’ health  coverage for a higher end employee (such as Ted Cruz’s wife) amounts to almost twice that amount. An adjunct who is working 40 hours a week will make on average $16,200 a year (which is $7.78 per hour). Running a cash register sometimes requires a high school degree, but not always. Being an adjunct typically requires having a graduate degree and many of them have doctorates. I did and I made $16,000 my first year as an adjunct. That was teaching four classes a semester for two semesters. Adjuncts generally do not get any benefits, although some of them do get insurance coverage—as graduate students. I had health insurance as a graduate student (at a very low rate) but not as an adjunct—fortunately I had no serious injuries and only minor illnesses during my insurance free time. If I had had my quadriceps tendon tear when I was an adjunct, it would have cost me almost $12,000—leaving me only $4,000 for the year (less after taxes).

The typical workers for corporations like Walmart tend to be no better off—they do not get much (or any) benefits and hence often do not have health care coverage. It might be wondered how people survive on such low wages and with no benefits. In some cases, people simply do without. When I was an adjunct, I did not have a car, I bought only what food I could afford, I lived in a one bedroom apartment and did all I could to live frugally. I do admit that I splurged on luxuries like running shoes and race entry fees. Fortunately, I did make some extra money writing—which helped support my gaming hobby.

This approach can work for a person who has no dependents, can get by without a vehicle, and has no health issues. However, those who cannot do the obvious: they turn to the state for aid. In the case of Walmart, the taxpayers provide support to their employees. For example, in the state of Wisconsin Walmart employees cost the taxpayers $9.8 million a year in Medicaid benefits alone. Adjuncts would also often qualify for state support. Out of Yankee pride, I did not avail myself of any such aid—I could survive on what I was making, albeit at a relatively low quality of life in Western terms. However, many people do not have the luxury of pride—they need to care for their families or address health issues.

As might be imagined, these low salaries and lack of benefits are a point of concern. Laying aside concerns about fairness of wages (which actually should not be done), there is the fact that the low pay of many workers is subsidized by the taxpayers. That is, the taxpayers pick up the difference between what the employers pay and what people need to survive. As I have argued before, this is a form of corporate and university socialism: the state support allows schools and corporations to pay low wages and thus generate greater profits. Or, in the case of non-profit schools, funnel the money elsewhere—most likely to administration and things like bonuses for the university president. For example, the previous president of my university was guaranteed a yearly bonus that that was about twice the average yearly adjunct salary.

Obamacare is supposed to, in some degree, shift the burden of health care costs from the taxpayer to the employer. The idea is that larger employers will need to provide health care benefits to full time employees or pay a fine. This, as might be imagined, has caused some people to threaten dire consequences. To be specific, some employers, including universities, have stated that they will reduce employee hours so that they fall just under the line for full time employment. Some have even threatened to fire people on the grounds that they cannot afford to pay.

One stock counter to the idea that employers should provide such benefits is that the state has no right to impose such costs on businesses, especially when doing so will cause businesses to fire people and cut their hours. This does have some appeal. However, there is still the question of who will provide the workers with the resources they need to survive.

One view is that the employers have an obligation to provide a living wage to those who do their job and do it competently. Few would argue that an employer is obligated to just hand people money for not working or doing terrible work—after all, a person who can earn his way should do so. As might be imagined, many employers (including universities) would rather not do this. After all, increasing wages to an actual living wage would cut into profits. In the case of universities, such increases would mean cuts in other areas of the budget (but surely not presidential bonuses).

Another view is that private citizens or organizations of private citizens (such as church groups) have the obligation to provide assistance to others via charity. That is, individuals should voluntarily subsidize the employers by providing the employees with the resources they need to survive, such as food. Of course, if private citizens have this obligation, it would seem that the employers (being citizens as well) would also have this obligation. One clever way around this is to contend that corporations are people, just not the sort of people who have moral obligations. Obviously, people do provide such support—but it would certainly be a challenge for private citizens to adequately support all the working people whose wages are not adequate.

A third view is that the state has the obligation to provide the resources for people to survive. This is, for the most part, the current situation. However, since the state gets most of its income from the citizens, this is effectively having private citizens subsidizing the employers, only with the state organizing the charity. Once again, if the state is obligated to do this, this merely comes down to the citizens having this obligation.

A fourth option is that no one has an obligation to provide people with the resources they need to survive, even when those people are actually working full time and generating enough value to allow their employer to pay them living wages. One might make references to the morality nullifying powers of the free-market: while people might have moral obligations, these do not hold in economic relations. One might also reject the idea that people have any such moral obligations to others at all: people must make it on their own or perish, unless someone freely decides to provide assistance.

Overall, it comes down to the question of what, if anything, people owe to each other. My own view is that the market does not nullify morality and that we do have obligations to each other. These obligations include an obligation to not allow other people to suffer or die simply because others are unwilling to pay them a fair, living wage. To head off the usual attacks, I am not claiming that able and competent people should simply be handed resources earned by the toil of others for doing nothing. Rather, my view is about fair wages and ethical behavior. This is why I am against both just handing people stuff for nothing and for people profiting off the labor of others. Both are cases of people who are getting the value of others’ work and not earning the value themselves.

 

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Minimum Wage VI: Subsidizing

McDonalds-Brentwood

McDonalds-Brentwood (Photo credit: Wikipedia)

One common way to argue against not raising (or even just eliminating) the minimum wage is to build a case based on claims about those who work such jobs. For example, one approach is to argue that the people on minimum wage are mainly high school and college kids who are just earning spending money. As another example, it is often claimed that minimum wage jobs are temporary jobs for most workers—they will spend a little while at minimum wage and move up to better pay. While these claims are true in some cases, the reality is rather different in general. For example, the average age of fast food workers is almost thirty—they are not just school kids. Also, a significant number of people get stuck in minimum wage jobs because there is nothing else available.

As an aside, even if it were true that all those working such jobs were just earning spending money or were going to move on up, it would not follow that the minimum wage should be lower or eliminated. After all, the fairness of a wage is distinct from the motive of the person working for the job or what they might be doing next. For example, if I am selling my books to get money to buy running shoes rather than on survival necessities, it would seem odd to claim that I am thus obligated to lower my prices. Likewise, even if a kid is earning money to spend on video games rather than for putting food on the table, it would seem odd to say that she is thus entitled to less pay for the work she does.

Getting back to the main focus of this essay, the reality is that many of the folks who work minimum wage jobs are working the jobs primarily to pay for necessities and that many of them are stuck in such jobs (in large part to the current economic situation).  The reality also is that a minimum wage job will typically not provide adequate income to pay for the necessities. Interestingly, some corporations recognize this. McDonald’s, for example, generated a brief bit of controversy with its helpful guide for employees: the corporation advised employees in minimum wage jobs to have another job.

Given the gap between the actual cost of living and the pay of a minimum wage job, it is not surprising that quite a few of the folks who work for minimum wage avail themselves of state support programs, such as food stamps (which now goes by other names) and Medicaid. After all, they cannot earn enough to pay for necessities and certainly prefer not to starve or end up on the streets (although some are malnourished and struggling with housing). While one narrative about such people is that they are living easy on federal support, the reality is rather different—most especially for the working poor who have families, for those who are endeavoring to attend college or who hope to start a business.

Obviously enough, one large source for the funds for these programs is the taxpayer. That is, those who pay taxes are helping to subsidize those who received state support while working minimum wage jobs. However, there seems to be another equally plausible way of looking at the matter: the taxpayers are subsidizing those who pay minimum wage to their employees. That is, these employers can pay their employees less than what they need to survive because other people pick up the tab for this, thus allowing the employers to increase profits. If this is correct, those of us who pay taxes are involved in corporate socialism.

It could be countered that the taxpayers are not subsidizing the employers, such as McDonald’s. After all, the money for Medicaid and such are not going to the corporation, but to the workers. The obvious counter is that while this is technically true, the taxpayers are still contributing to sustaining the work forces for these employers, thus subsidizing them and allowing them to page sub-survival wages.

It could also be contended that the employer has no obligation to pay workers enough to survive on without the addition of state support. After all, there are plenty of poor people and if some cannot survive on minimum wage, then economic selection will weed them out so that those who can survive on less will take their place in the economic ecosystem. This, of course, seems rather harsh and morally dubious, at best.

Another counter is that the poor are to blame for their wages. If they had better skills, more talent, better connections and so on, then they would not be receiving that minimum wage but a better salary. As such, while it might be unfortunate that the poor are so badly paid, it is their own fault and hence their employers owe them nothing more. If the state wishes to help them out, that is hardly subsidizing the companies—they would, or so they might say, pay more for a better class of worker.

This has, obviously enough, all the moral appeal of a robber saying that it is the fault of her victims that they were not able to resist her crimes.

Overall, it does appear to be clear that the taxpayers are helping to subsidize those on minimum wage. While we could decide to let the poor slip deeper into poverty that would seem to be a wicked thing to do. It does seem to be reasonable to shift more of the cost to the employers who benefit from the work of the employees. After all, many corporations that are based on minimum wage workers have been making excellent profits—at the expense of the workers and the tax-payers.

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Health Care & Compulsion

President Barack Obama's signature on the heal...

President Barack Obama

The United States Supreme Court will soon be ruling on the constitutionality of the Affordable Care Act. This ruling will, of course, settle the legality of the matter-at least until it is challenged. While the constitutionality (or lack thereof) of the act is certainly interesting, my main interest as a philosopher is the ethics of the matter.

While the law is 2,400 pages long, I will just focus on the ethics of a key part, namely that the law requires people to purchase health care insurance. Opponents of the law assert that this is the first federal law that requires citizens to purchase a product and they typically assert  that this goes beyond the legitimate power of the state. Proponents of the law retort by arguing that the state is acting legitimately. As such, a key moral issue is whether or not the state has the right to compel citizens to buy a product in general and insurance in particular.

On the face of it, the idea that the state has a right to compel people to buy a product seems to be absurd-even when such a purchase would be a good idea. After all, buying and consuming fresh fruits and vegetables is a good idea, yet one would be hard pressed to present an argument in favor of compelling this by law (the Broccoli and Orange Act, perhaps).

To present a more substantial argument, I will begin by noting that I favor a a presumption in favor of liberty. That is, the burden of proof is upon the state to show that the intrusion on liberty is legitimately warranted. While spelling out the various conditions under which intrusion would be warranted goes beyond the scope of this essay, one obvious justification is that the intrusion prevents an individual or group from inflicting unjust harm onto others. Thus, the restrictions on murder, theft and defective products are warranted. Intrusion that are done merely for the good of a person would not be justified, at least if we follow John Stuart Mill’s classic arguments regarding liberty. After all, if I am sovereign over my self, then the state (and others) have no moral right to intrude on my actions when they impact only me. As such, while the state can justly prevent me from selling tainted broccoli, it would not seem warranted in compelling me to eat broccoli-despite the fact that doing so would be good for me. This line of reasoning, interestingly enough, would also forbid the state from making the use of marijuana illegal and would also make laws forbidding same sex marriage morally wrong since they impose on liberty solely to impose a specific religious/moral view rather than to prevent people from harming one another. In fact, the principle that the state cannot compel except to prevent harm would entail a host of libertarian positions on various issues-something that should be duly considered when using such a principle.

Of course, it could be argued that while the state has a right to compel people to not do various things even when they are not harmful to others, it does not have the right to compel people to take positive action. That is, the state can be justified in telling me what not to do, but it has no legitimate right to tell me what to do. As might be imagined, this approach is often taken by folks who want the state to compel people to not do various things (like smoke marijuana or marry someone of the same sex) but who are against this specific act.

While justifying specific acts of compulsion can be challenging, this approach does seem consistent. After all, the principle is that the state cannot compel taking action and can only compel people to not do things. As such, while the state can, for example, forbid abortion, it cannot morally  compel people to buy health insurance.

Naturally, if this principle is used to argue that forcing people to buy insurance is wrong, it must be applied consistently-namely that the state is wrong to compel action and it can only forbid. This would entail that compelling young men to sign up for selective service is wrong. It would also entail that compelling people to pay taxes is wrong. Forcing automakers to include seat belts, air bags, and brakes would also be wrong. Forcing women to undergo an ultrasound before getting an abortion would be wrong. So would forcing children to attend school. Compelling people to serve on a jury would also be wrong.  And so on. Naturally, this might have considerable appeal to some people, but this path would seem to take us into the realm of the absurd (although some, such as the anarchists, would say we are already there and doing this would take us out of the absurd).

The obvious counter is to insist on narrowing the principle from “the state has no moral right to compel” to “the state has no moral right to compel people to buy a specific product.” The challenge, of course, lies in justifying this principle. As might be imagined, the reply that “the state has not done this before, so doing it is wrong” is not a good argument. After all, the mere fact that something has not been done before is no indication of whether it is good, bad or indifferent. This sort of “reasoning” could be seen as a variant on the appeal to tradition fallacy, in that the idea is not that something is good because it is a tradition but that something is bad because it is not.

What, then, is needed is something that shows that the state lacks the legitimate authority to morally compel people to have health insurance while it does possess a right to compel people to do things. The challenge is to show a relevant difference between the insurance case and the other cases in which state compulsion is (allegedly) morally acceptable. The obvious thing to point to is that the state would be forcing people to buy a  product. However, the mere fact that this is different does not entail that it is a relevant difference that make this specific compulsion wrong. After all, the state does compel us to pay for Medicare, Medicaid and Social Security and is thus compelling us to buy what amounts to health and retirement insurance.

Naturally, it could be argued (as some have) that the state should not do this-that being forced to pay for Medicare, Medicaid and Social Security involves an unjust compulsion and thus the state should not do this. This view would allow someone to consistently oppose the Affordable Health Care Act’s compulsion to buy health insurance but at an obvious price-namely the need to be opposed to these three things.  As such, those who do not want to be rid of these things will need another line of attack.

The most fruitful one is that the the health care coverage is a private product rather than a state product. This, of course, does provide a significant difference between the state’s “products” and health care coverage. Of course, it does not provide an argument against the state compelling people to pay into a national health care insurance (as it does with the current national health care insurances, Medicare and Medicaid). As such, focusing on the fact that the product is a private one would seem to help shore up the view that the state should instead compel people to buy national health care-after all, this seems to be well within the legitimate power of the state (at least as it is currently conceived).

Nations other than the United States do, of course, have national health care. Of course, this sort of thing is presented as a worse demon than forcing people to buy private insurance. But this is a matter for another time.

 

 

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