Home // 2011 // February

Sorry, Virginia, Santa Claus can’t pull money out of his ass to fund Medicaid

Medicaid is a big topic of conversation in my house. That’s not because we’re on it — it’s because my wife’s pediatric practice is up to its eyeballs in patients on AHCCCS, Arizona’s implementation of the program. Encouraged by federal matching dollars, Arizona, over the years, expanded the program to cover a big percentage of the states population. AHCCCS patients now constitute a majority of my wife’s patients.

Like most states in these less-flush times, Arizona is now scrambling to rein-in spending. There are a couple of ways that state legislators can do it, but given the degree to which expenditures have ballooned over the years, they’re all going to hurt. Depending on the choices that legislators make, my wife’s practice could very well go under.

But I’m preparing rather than complaining, because I can’t think of a painless alternative. States are hobbled by the federal government’s rules in the extent to which they can cut Medicaid costs. That means states are looking for federal waivers — and even considering dropping out of Medicaid.

To put things in perspective, here’s a history of Arizona’s tax revenues (PDF) over the past few years.

(All numbers in thousands of dollars)

Preliminary FY 2010

Actual FY 2009

Actual FY 2008


Actual FY 2007

Tax revenues have been shrinking, consistently, since 2007, though state number crunchers are (optimistically) predicting a small increase for 2011.

Total General Fund revenues are rather higher, given the sugar-daddy relationship of the federal government to the states. Once you add in such line items as “Net revenue enhancements/one-time adj.” — an item that has gone from zero in 2001 to over two billion dollars in 2010 — total General Fund revenues have still dropped from $9,625,786.0 in 2007 to $8,322,087.3 in 2010.

Which is to say, that even heavily subsidized by an itself-broke federal government, Arizona’s state government is … well … a bit tight.

Actual expenditures are way the hell higher, largely because of yet more federal money and because of borrowing. You can see what that means in terms of who cuts the checks in this chart (Source here):

And all that shrinking pool of money is pretty heavily committed to some specific programs.

That’s right. AHCCCS — Arizona’s implementation of Medicaid — consumes 26% of the original FY 2011 budget. It’s been growing steadily for years — from 17% of expenditures in 2007 to 30% of the latest figures (after cuts in other areas of the budget). That’s in budgets based largely on subsidies and fantasy. And a big chunk of those federal subsidies is scheduled to disappear this year. Reports the New York Times, “On July 1, the enhanced federal aid will disappear, causing an overnight increase of between one-fourth and one-third in each state’s share of Medicaid’s costs.”

Oh … Did I make explicit the fact that Arizona’s state government has been spending more than it takes in? Yeah. Except for a few flush years in the middle of the decade (real estate was very good to Arizona, for a while) Arizona has been purchasing red ink by the tanker truck. It’s really pretty impressive.

What makes this even sadder is that most of the people on Medicaid’s rolls are (relatively) blameless. Yes, there are scam artists here and there, but most of these people have limited means, and quite rationally took advantage of a program that offered them medical coverage at little cost to themselves. Few of us stop to look at  the meta picture when we sign up for attractive deals, and so a growing proportion of Arizona’s (and America’s) population has been growing dependent on a government program that has become increasingly economically non-viable.

And the medical practices that serve that population are also dependent on a program that is spending dollars that don’t exist.

Of course, it was easy to expand Medicaid by playing the compassion card, especially when it came to covering children. Who wants children to suffer, no matter what choices their parents have made? Wave a few photos of wide-eyed tots, make a few promises, and …

And millions of people have become dependent on programs that are unsustainable.

Here’s the thing. Forget about arguments over the proper role of government. If politicians and their enablers make promises that lead people to depend on government for things that it can’t possibly continue to provide, those oh-so-caring demagogues are not compassionate, they’re pricks.

I’ll admit that I knew better, and I’ve been sweating the arrival of the day of reckoning ever since learning the extent of my wife’s practice’s AHCCCS-dependency. We’re resilient though, and I expect my family to land on its feet.

But the people who will really suffer are those who have few means, and who could have made other arrangements and planned their lives differently if they hadn’t been led to depend on grandiose and unsustainable promises.

Outraged squawks over CPAC a good sign for libertarians

When you find yourself the target of a vigorous campaign of ostracism and marginalization, you can be pretty certain you’re getting under people’s skin.

Writing of the Conservative Political Action Conference, the Washington Post‘s Chris Cillizza insists that libertarian-leaning Rep. Ron Paul was a “loser” at the event, despite coming in first in the presidential straw poll with 30% of the vote. Why? Because “his speech – heavy on talk of defunding the wars in Afghanistan and Iraq as well as odd pronouncements such as ‘Government should never be able to do anything you can’t do’ – displayed the limits of his reach within the GOP.”

But New Jersey Governor Chris Christie, who pulled 6% in the same poll was a “winner.” And there was no mention of former New Mexico Governor Gary Johnson — the other libertarian in the race — who tied Christie and came in first among second-choice picks.

Young Americans for Freedom, the once-lively conservative campus organization that has become a bit of a footnote, promptly expelled Paul, who served on the organization’s board for two decades. The group cited Paul’s long-standing non-interventionist foreign policy views, saying they “border on treason.” In this, YAF replayed ancient history, since the four-decades-past split between libertarian and conservative elements in YAF, which culminated at a meeting in St. Louis amidst violent recriminations over war and the draft, largely gave rise to the modern, independent libertarian movement.

Almost at the same moment, a talk radio/Fox New pundit accused “disrespectful libertarians” of “hijack[ing]” the CPAC poll. He added that “libertarians are the worst form of political affiliation in the nation. Combining the desire of economic greed, with the amoral desire to promote any behavior regardless of its cost to our culture.” And a Forbes columnist penned a borderline-incoherent piece denouncing Paul and libertarians (in fairness, all of his pieces seem to dance at the outer limits of rational thought).

It’s clear that most mainstream journalists are flat-out uncomfortable with libertarians and libertarian ideas. I think this stems as much from an ideological discomfort with criticism of state power as it does with lazy inertia — covering Team Red and Team Blue is easy; covering different shades of political opinion and a rising movement driven by ideas that fall outside the traditional mainstream and therefore require some actual thought is hard. This explains the eagerness of Cillizza and many of his colleagues to dismiss a political rockstar like Ron Paul, an emerging figure like Gary Johnson, and their apparently inexplicable appeal (without some actual effort that might lead to understanding) to enthusiastic supporters, many of them young. If there’s an actual political shift underway, some reporters are going to have to get off their asses and do some reporting; much simpler to write it all off as an aberration and hope for the best.

As for YAF and company … Many conservatives seem wedded to the idea that their movement is necessarily one of grouchy old white people who like to blow things up and hate on gays. I don’t understand the attraction of militarism and social intolerance, but then I never did — that’s why I’m not a conservative. As the political “right” (really free-marketeers and fans of limited government) shows a bit of life and the Republican Party recaptures the House of Representatives, authoritarian conservatives want to control the brand and push non-interventionists, anti-statists, the socially tolerant and civil libertarians to the fringes or out of the conversation altogether.

Well … Why not let them? That is, why not make explicit (again) the break between libertarians (and the libertarian-leaning) on the one hand, and the bigoted hawks on the other? Is there really that much to lose? After all, CPAC has become more libertarian in recent years, and welcomed gay groups this year, because that’s what the attendees want. The attendees pushing for this ideological shift are mainly young people driven by a desire for smaller government, individual liberty and peace. These “disrespectful” young people (have young people ever been anything else?) ticking off the murderous old homophobes are mostly supporters of Ron Paul — and now Gary Johnson — because those men speak their language.

If there was comparable energy among the intolerant warmongers, they wouldn’t be bitching that their meet-and-greet, which achieved record attendance this year, was hijacked.

But instead of being pushed away, how about doing the pushing? It’s time to marginalize the bigots and warmongers and celebrate the fact that momentum is, at least for the moment, with supporters of peace and freedom.

Out of Left Field

I know what you were thinking. You were saying to yourself, “Hmm, self, it’s been a while since any of my progressive friends have proposed anything insanely totalitarian. They’ve maybe been a little nanny-ish, but I haven’t heard a hint of secret police or absolute control in a while. I wonder if they’ve lost the faith and loosened up?”

Oh no, dear readers. Fear not. There’s no reason to suspect a loss of faith. Or loosening. Absolutely no loosening.

Actual Facebook wall posts below, initiated by an acquaintance of recent eastern-European extraction whose employment in American academia may be exacerbating her nostalgia for pre-Glasnost days.

Natasha (not her real name): People, stop working! Your productivity is killing the planet.

[Skipped reply]

Natasha (not her real name): What I meant was that “productivity” leads to production of useless products and services (and sometimes absolutely no products and services), that in a long run cost us more than the monetary reward we get. The problem is that nobody deals with that qualitative output of the economy. It’s all about transactions.

Academic with a cat as his profile photo (not his real name): If there were one-fourth the number of people on the planet as currently exist, we’d have a hell of a lot more leeway on every major problem, as well as time to figure out reasonable paths forward. But the human population shot past the carrying capacity of the biosphere years ago. By way of comparison, pretty much everything else is just rearranging deck chairs on the Titanic.

“Productivity” is not a problem, but a symptom of a deeper and more serious societal rot.

[Skipped reply, followed by a post by an American sociology professor at a different university]

Distaff Mao (not her real name): Here’s something for BOTH [cat person] & [other guy]: Every person gets a 0.5-share Reproduction Credit that they may choose to use or trade on the Reproduction Market. Good for the environment, good for the marketeers!

Distaff Mao (not her real name): And then a 35-hour-max work week. Nothing creates jobs like decreasing absolute surplus value!

Yeah, yeah, yeah. It’s just a couple of off-the-cuff comments cribbed from a social-networking site. But these were folks talking among friends, so it really is a peek at what they believe.

I mean, honestly, when was the last time you heard anybody seriously proposing legally enforceable limits on reproduction?

Oh .. and it’s a long story as to how I ended up connected to so many Stalinists on Facebook. I’ll try to balance this out with some loony theocratic posts, but I’m not really tapped in to that crew. Do they even use computers?