Medicaid is on the table again. This is good, and in principle so are the discussions related to costs and policy intentions. Nevertheless, my view is that too much of the conversation has been at the 20,000 foot level, kept aloft by ideologies. Here are my impressions of what’s being said: We will not go along with a massive increase of the Medicaid program, especially under Obamacare, and furthermore such entitlement programs weaken us as a people. Meanwhile different voices assert: There is a need for Medicaid, cutting it back will hurt our most vulnerable populations. Expansive commentary about Medicaid has been elevated since the Supreme Court ruled on the Affordable Care Act in late June and boosted again beginning early September by Bill Clinton’s speech at the Democratic National Convention.
Let’s drop down a few thousand feet. Using data freely available on the Internet, the accompanying chart gives a more detailed view. The chart’s three plots all share the same horizontal axis, the percentage of people in each state that self-identify as politically conservative. The vertical axes represent child poverty, coronary heart disease, and Medicaid expenditures. The average trend lines are highly significant. In one sentence, the chart shows health needs increasing while providing for those needs through Medicaid deceases, all as the concentration of conservatism deepens.
Here is the context. Child poverty is both about children’s current health and a determinant of future health. It is the human-society equivalent of a canary in the coal mine. Children raised in poverty, on average, have more health problems both as children and as adults. And poor children are more likely to grow up to be poor, almost one-half become poor adults. As for heart disease, over the past 30 years there’s been a marked reduction in mortality rates. This is a major health-care success story. Nevertheless, coronary heart disease is still the leading cause of death in the United States and the most expensive to treat. Poor children, and adults with coronary heart disease, are a large part of the Medicaid caseload and budget. Nationally children make up about two-thirds of Medicaid beneficiaries while adults account for over two-thirds of the costs, a good part surely due to heart disease.
The prevalence of child poverty and coronary heart disease changes with the sway of conservatism as it moves across the states. Additionally, the chart provides a glimpse of the nation’s vigor. Not shown is that the two health outcomes correlate with other impairments of health, such as diabetes and poor health status. Thus child poverty and coronary heart disease can also be viewed as population-health indicators, not just isolated outcomes.
So what’s driving the strong relationship with conservatism? I submit it is the dual ideologies—which have elevated status in the United States—of unregulated markets and individualism. The belief that the market rules and everything has a price, that competition is the wherewithal, that we’re totally self-reliant, and all that’s worthwhile derives from great men so that an unequal society is a good society. I use conservatism as a proxy. If direct measures had existed, the horizontal axis of the chart would have been more accurately labeled “neoliberalism and extreme individualism.”
The average trend lines over the 50 states show that relative to conservatism there is less provision for health as the need increases. It is the lack of resources that weakens us. We would not expect to have a thriving garden without good soil, favorable climate, and attentive care. Are we less than a garden? We also require supportive conditions to flourish. People who think otherwise have their head in the clouds.
Note: A PDF version of this post is here.