I did not plan to write as much about Medicaid as I have done recently, but the issue keeps popping up. One reason, of course, is that it is a major cost item for us the taxpayers; another is that Medicaid is being used for ideological purposes by the left, in their unrelenting quest for single-payer health care.
When the left says they want Medicare for all, in reality what they want is Medicaid for all. This is why it is so important for the left to push Medicaid Expansion - and also why it is so surprising to see many conservatives considering the issue. As I explained just yesterday, our outgoing governor Matt Mead is a big fan of the expansion, and he is not alone among conservatives.
Since this issue is unlikely to go away any time soon, we might as well take the opportunity and look at Medicaid from a more systemic perspective. What do we really want with Medicaid, and why? Should we even keep Medicaid as it is, or redesign it - or even abolish it altogether?
The recent court cases against Planned Parenthood provide a good vehicle for this discussion. Reports NBC News:
The U.S. Supreme Court on Monday left lower court victories intact for Planned Parenthood in a legal battle with states over access by Medicaid patients to the group's services. The dispute did not involve abortion, but the action by the justices keeps a hot-button political issue off the docket. Three of the court's conservatives said the court should have taken the case.
It is, of course, unreasonable to suggest that this has nothing to do with abortions. As LifeNews.com explains,
On Monday, six of the nine justices refused to take two cases out of Kansas and Louisiana where lower courts refused to allow the states to defund the nation’s biggest abortion business. Both states, and several others, moved to revoke taxpayer funding of Planned Parenthood after videos exposed the abortion giant allegedly selling the body parts of aborted babies. Planned Parenthood sued the states, and the 10th Circuit Court of Appeals ruled that Kansas cannot defund Planned Parenthood, despite an investigation by the U.S. Department of Justice into its aborted baby body parts trade. Then, the 8th Circuit Court of Appeals upheld a similar effort by Arkansas to defund the abortion chain in 2017. Because of the circuit split, pro-life groups thought Supreme Court would take up the case.
In other words, there would not have been a case if Planned Parenthood had not been in the abortion business in the first place - and been partly funded by Medicaid.
Which brings us to the core of this problem. It goes without saying that abortions are immoral, and it is certainly not a form of health care. Health care treats injuries and cures diseases. Pregnancy is neither an injury nor a disease. The battle against abortions is a separate cause, and a worthy one, but the heart of this legal case against Planned Parenthood is different.
President Lyndon Johnson signed Medicaid into law as part of his War on Poverty. Since then, Democrat and Republican Congressional majorities, as well as Democrat and Republican presidents, have consistently decided to keep Medicaid. They have also expanded it in several steps - even President Reagan signed bills to grow Medicaid and expand eligibility - which is only natural given that this is an entitlement program under the welfare state.
And right there, you have it: a welfare state is a system of entitlement programs, paid for with progressive taxation, for the purposes of economic redistribution. This redistribution takes two forms:
1. Redistribution of income. Jack makes $1000 per year while Joe makes $800. Government decides to redistribute income, forcing Jack to pay $100 in taxes while paying Joe a cash entitlement of $100. The two now have $900 per year in income.
2. Redistribution of consumption. Jack makes $1000 per year while Joe makes $800. Jack buys health care for $100 per year out of his own pocket. Government thinks Joe deserves to get the same health care, but without having to pay for it. They tax Jack for $100, then spends it on a government program worth $100, which Joe gets to use for free. Technically, Joe still only has $800 in income, but since he gets $100 worth of health care for free, while Jack has to pay for the same services, the two men de facto have the same standard of living.
These are stylized cases, but they illustrate the ideological design behind the welfare state, and behind Medicaid (which, of course, falls into the second category above). A welfare state is an ideological product, created and maintained to reconfigure society in the image of egalitarianism and social justice. Therefore, all the entitlement programs that are created under its umbrella, are also redistributive for the purposes of eliminating economic differences between individuals.
For this reason, if we accept the existence of an entitlement program that falls under the second redistributive category - redistribution of consumption - we are going to have to accept that the consumption provided under the program (health care) is going to be no more, no less than what is available in the open market. If we restrict what health care can be provided under Medicaid, we violate the egalitarian principle that the program is built upon.
As a libertarian, I have no problem with getting egalitarianism out of government spending altogether. The problem is not to oppose egalitarianism on principle - it is to try to combine the egalitarian ideology with other ideological values. In the case of abortions, this means combining pro-life values with the utilitarian, entirely instrumental values that constitute egalitarianism.
Medicaid is a perfect example of this conflict. On the one hand, the program is supposed to redistribute health care precisely as the egalitarian ideology prescribes; on the other hand, the program is supposed to deny services that some people consider immoral.
For clarity: I do not want my tax money to go toward abortions. Nor do I want them to go toward euthanasia, "gender reassignment" surgery, non-restorative cosmetic surgery or medical conditions resulting from a deliberately risky lifestyle. However, if at the same time I decide that it is OK to redistribute health care through government, I surrender the right to have a say in what that program provides; anything short of what I myself would have access to in the free market, would violate the egalitarian principles upon which the redistributive program is built.
If you, like me, are pro-life and don't want your tax dollars to pay for abortions or anything else you find immoral, then you only have two options:
1) Redesign Medicaid. Remove the redistributive element from the program; rewrite it specifically so that it becomes a last-resort program that provides only basic, catastrophic health care. Include a firmly written ban on elective procedures; if we cannot exclude abortions by explaining that it is not a health-care procedure, at least a ban on elective medical services would rule it out.
2) End the welfare state. I am not going to go into the details on this, as I just signed a contract with a publisher for my new book where I explain precisely what it means to end the welfare state. However, for those who are interested in the practical side of this, a few years ago I did put a small sample of essays together under the title Ending the Welfare State: A Path to Limited Government That Won't Leave the Poor Behind.
The first option - a Medicaid redesign - is actually possible here in Wyoming. We could choose to opt out of the federally sponsored program and replace it with an in-state program instead. If we did, we could redesign it however we want to, as a state. We might even get it done as an experiment in entitlement reform, an alternative that is more realistic than many people think.