How, then, are critics defining an acceptable level of anti-poverty spending versus one that is 'cruel and short-sighted,' to quote House Minority Leader Nancy Pelosi? The only guiding principle appears to be 'More.' If today’s spending were 10 percent higher and the GOP proposed a cut to the current levels that Democrats now defend, that would be 'cruel and short-sighted.' Conversely, had spending in the past two decades grown at 3 percent instead of 3.6 percent, leaving it 10 percent lower, staying the course would be a responsible choice.
But thanks to the roughly half of states that refused the ACA’s Medicaid expansion, a good control group exists. Surely the states that expanded Medicaid should at least perform better in this environment of rising mortality? Nope. Mortality in 2015 rose more than 50 percent faster in the 26 states (and Washington, D.C.) that expanded Medicaid during 2014 than in the 24 states that did not. Further, while two years is not enough time to evaluate a policy’s full effects, that is exactly the period over which the Massachusetts study found substantial mortality gains. Two years of gains from a different policy implemented by a single state a decade earlier can hardly be proof that the ACA saves lives when the ACA’s own two-year track record tells the opposite story.
The best statistical estimate for the number of lives saved each year by the Affordable Care Act (ACA) is zero. Certainly, there are individuals who have benefited from various of its provisions. But attempts to claim broader effects on public health or thousands of lives saved rely upon extrapolation from past studies that focus on the value of private health insurance. The ACA, however, has expanded coverage through Medicaid, a public program that, according to several studies, has failed to improve health outcomes for recipients. In fact, public health trends since the implementation of the ACA have worsened, with 80,000 more deaths in 2015 than had mortality continued declining during 2014–15 at the rate achieved during 2000–2013.
The 'long-term, holistic' studies that Carroll prefers show coverage for expectant mothers produced better health outcomes in their children and that children themselves receiving coverage had better health, educational, and financial outcomes. That's all great news, but there's one problem: Obamacare's Medicaid expansion does not target pregnant women or children.
Is Medicaid worthless?' is the quintessentially liberal battleground and a ridiculous lens through which to evaluate policy. Furman's defense, for instance, amounts to a claim that providing Medicaid is probably better than not providing Medicaid. The Oregon experiment tested the same question--Medicaid only had to defeat 'no Medicaid,' and even then it largely failed. But the right question to ask is whether this is a good allocation of scarce resources--not 'is Medicaid worthless?', but 'is Medicaid best?' The critical study is not the Oregon experiment, but one that gives Medicaid to Group A while offering Group B a wage subsidy, housing voucher, or used car of equal value. Good luck to Medicaid achieving superior outcomes in terms of health, upward mobility, or any other measure of well-being in that match-up.
Because of Medicaid, the safety net feels weaker as it grows heavier, exposing bigger gaps even as it spreads. Bad design and political pressure have allowed this one program to dominate our ever-expanding anti-poverty system. Medicaid now accounts for most of what we spend to aid the poor, even though the program aligns badly with the needs of low-income households and offers stunningly little value for its cost. The opportunity to improve support for the poor without increasing spending by reallocating funds from Medicaid to better uses is great.
America's safety net is thicker and wider than ever: antipoverty spending in real terms more than doubled between 1995 and 2015. True, Congress froze federal spending for the specific welfare cash-assistance program targeted by the 1996 welfare reform, causing its budget to decline in real terms; but that decline represented less than 1 percent of the safety net with total spending of more than $1 trillion in 2015.
The social safety net provides more than $1 trillion a year for low-income households. Yet no coherent antipoverty strategy allocates the spending. As the various programs have been created, their individual funding streams have pooled resources haphazardly and inefficiently. Medicaid, in particular, dominates the safety net. From 1975 to 2015, total safety-net spending per American in poverty doubled, in 2015 dollars, from $11,600 to $23,400. Of that increase, 91 percent was the result of higher health-care spending -- nearly all for Medicaid, whose costs rose tenfold to $568 billion.
The American social safety net's overwhelming emphasis on health care is the unintentional result of skewed incentives, leading to an ineffective antipoverty strategy poorly aligned with the needs and preferences of low-income Americans. Reforms that allow states to reroute substantial sums from Medicaid to other programs would better meet the needs of the poor at no additional cost to taxpayers, marking the first step toward a more flexible and effective safety net.
The federal government should package up the money it spends so ineffectively and send it back to states in proportion to their populations, to allocate as they see fit. Doing so will satisfy neither the Left's enthusiasm for expansive new programs nor the Right's appetite for shrinking government. But the American people would benefit enormously.