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[Entitlements] and ethics
Atomika
Live fast and get fucked or whateverRegistered User regular
Live fast and get fucked or whateverRegistered User regular
A case I had at work recently gave me pause to think upon the nature of entitlements such as Medicaid and Social Security and whatnot, and the practical and moral ramifications for altering those systems.
To wit, a woman checked herself and two of her children into the Emergency Room tonight, all for the same symptoms: coughing and a low-grade fever. Each had had the symptoms for multiple days, yet had not gone to a clinic or called a family practice doctor before coming into the ER. They came into the ER at approximately 1:30 AM for treatment, despite being ill for at least over 3 calendar dates, and the mother herself for almost two weeks. In triage, none of their vital signs or presentations indicated an urgent illness.
The mother was a homemaker, and she was 31 years old. She had eight children, all her own. Due to their family's combined income, she easily qualified for Medicaid, as did all of her children. As well, she was currently pregnant with her ninth child, and her twelfth pregnancy overall.
So here we have a case where a woman and her children are entirely subsisting on tax dollars, and will do so for the foreseeable next two decades (if not more, if she keeps having kids). She is billing the taxpayers emergency rates for illness that need little or no medical intervention, yet hospitals are obligated to see these patients due to their low risk for tort action and a small-but-guaranteed return on services rendered. Anecdotally, Medicaid recipients use the ER far more frequently than privately-insured patients, many having seen the ER a dozen times before their 10th birthday for matters as benign as the common cold.
This costs the taxpayers untold billions of dollars every year, as well as increasing ER wait times and raising the costs of healthcare. Yet no contingency is in place or even being currently debated as to curbing this phenomenon. You can't really remove the children from the benefits program, no matter how irresponsible their parents may be, as doing so only prevents them from getting care in the instances they need to.
I ask you, Penny Arcade forumers, what should be done?
To wit, a woman checked herself and two of her children into the Emergency Room tonight, all for the same symptoms: coughing and a low-grade fever. Each had had the symptoms for multiple days, yet had not gone to a clinic or called a family practice doctor before coming into the ER. They came into the ER at approximately 1:30 AM for treatment, despite being ill for at least over 3 calendar dates, and the mother herself for almost two weeks. In triage, none of their vital signs or presentations indicated an urgent illness.
The mother was a homemaker, and she was 31 years old. She had eight children, all her own. Due to their family's combined income, she easily qualified for Medicaid, as did all of her children. As well, she was currently pregnant with her ninth child, and her twelfth pregnancy overall.
So here we have a case where a woman and her children are entirely subsisting on tax dollars, and will do so for the foreseeable next two decades (if not more, if she keeps having kids). She is billing the taxpayers emergency rates for illness that need little or no medical intervention, yet hospitals are obligated to see these patients due to their low risk for tort action and a small-but-guaranteed return on services rendered. Anecdotally, Medicaid recipients use the ER far more frequently than privately-insured patients, many having seen the ER a dozen times before their 10th birthday for matters as benign as the common cold.
This costs the taxpayers untold billions of dollars every year, as well as increasing ER wait times and raising the costs of healthcare. Yet no contingency is in place or even being currently debated as to curbing this phenomenon. You can't really remove the children from the benefits program, no matter how irresponsible their parents may be, as doing so only prevents them from getting care in the instances they need to.
I ask you, Penny Arcade forumers, what should be done?
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Accept that so long as we seek to care for the "virtuous" poor that we will also care for those whose actions do not meet our standard of conduct.
Answer the second: any system implemented on the 300-million person scale is going to result in sub-optimal efficiency for at least some individual people. It's no big thing if a few people overuse, especially given that we have to balance that against rule shifts which will, inevitably, produce their own potentially disastrous inefficiencies.
Public hospitals that will treat anyone with a file, you can open a file with a passport for none saudies or an ID if you are, these have heavily populated ERs and a wait list of weeks to see speacilists.
Private hospitals that will only see people who'd pay or have insurance, ERs will still see random people, but they are under orders to send them off as soon as they are able to walk. Speacilists wait lists are in the hours.
This seems like a very capital/social hybrid, standard of care isn't diffrent aside from better food, both hospitals hire from the same pool of doctors and other care givers, the waiting times and the time per visit are greatly improved in the private sector.
Isn't that the case state side?
Nope.
In the US the first category of hospital doesn't exist.
Do you have any data on how much this costs? Even a rough estimate? If it's on the order of 1 billion dollars, I'd say just let it slide. There are bigger fish to fry. If this is really a significant cost for medicaid, then we do need to implement some sort of incentive so that people with medicaid will go to a clinic or family doctor instead.
Well, there's no hard-and-fast rule governing it, and it depends on if the hospital's status is "public funded," "private non-profit," and "private for-profit."
EMTALA is the only rule that all hospitals in the US have to follow, and it basically states that no care facility can refuse treatment to anyone in immediate risk to life or limb. Now, that classification only constitutes probably less than 1% of all patients, however many hospitals will treat uninsured patients regardless because of their financial structure, which may allow for losses to be offset by write-offs (like big private systems, like Baylor), or which might be partially or fully funded by county taxes (such as Parkland).
Still, neither of those options actually makes anything better, and it's one of the parts of the greater healthcare problem I take most issue with; hospitals really just want to make money, end of line. All this shit you hear about "patient satisfaction" and "top blabbity blah" means next to nothing and is only there to get your business. Most studies even show that county-funded and military hospitals (the poorest types of care systems) have as good if not better physical outcomes than all but the tiniest fraction of private-pay hospitals, but studies also show that people care more about how the hospital food tastes than if their care was successful at treating their illness.
@DevoutlyApathetic:
I think what I'm trying to ask in that particular case is, should there be a mechanism against child-farming? Doesn't "(combined family poverty) + 1" at some point become child abuse in and of itself?
It varies state to state, but most sources agree that the taxpayer burden is anywhere from $2000-$5000/year per family of four. I don't know if that number was came by from taking the total state medicaid expenditures and dividing it per family, or dividing it per family of non-medicaid recipients. If it's the latter, you can expect that value to likely be much higher.
The big disincentive for Medicaid is that it's not federally mandated, and it's not adequately provided for. The pay out is quite poor for those who take it, so very few private doctors do. That means that even big cities will often only have a small number of offices and clinics that take Medicaid, and none of them are open at night. The current set up of Medicaid actually incentivizes ER abuse; the weeks-long waits for appointments and short hours for the public clinics make the ER the best choice for quick access to care. Why would a Medicaid recipient care if they're not using the system properly? It doesn't hurt them a bit.
Mental Health Care and regular Health Care are fairly different, with the first seemingly always under funded and under staffed.
MWO: Adamski
Slightly off-topic, but I hate obligate as a verb. It makes me wince
total budge of medicaid. But anyway, for arguments sake let's just assume that this is a significant extra cost to the program.
Honestly my first reaction is to say that universal health care would completely solve this problem. But since that's not going to happen any time soon, why can't the ER just refuse to treat people that have nonserious problems? If the person really just has a cold, send them to a clinic. Maybe you're right that we need more offices and clinics to take medicaid, but that's a separate issue.
I do think what I've bolded here is a related, but ultimately separate issue from the other issues you've raised.
Addressing your original issue: I live in Canada, where we have what the GOP fearfully calls socialized medicine.
I am a person of poor physical (and mental!) health who has grown up in poverty. I'm actually mentally disabled, and my meager minimum-wage income is supplemented by a government disability support check each month.
Now, as far as most people would measure, I'm one of the "virtuous poor". I work to the capacity my disability allows, I try to improve my life situation, I go to walk-in clinics instead of the ER unless it's actually an emergency (I don't have a family doctor, which is a big problem in this country), I don't defraud the disability support system and report all of my income fairly, etc.
But, I am not everyone. I wouldn't even hazard to say I am representative most of the people in the social safety-net. There are people who actively and knowingly defraud our social safety-nets, and there's many, many more who abuse it through irresponsibility and ignorance.
That's... unfortunate. However, alterations to the system to "buckle down" on fraud and abusive use of the system fucks me over. Me. Not some mythical person we can discuss as an archetype, me personally. Someone many of you have spoken to through the internet over the years and some of you have met personally.
I have been screwed over pretty bad by changes to these government systems (which I need in order to survive), changes designed exclusively not to target me, but to target fraudsters and wastoids who jerk the system around.
Invariably, the "virtuous poor" who don't jerk the system around and are good examples of how the system is supposed to work become the casualties of the war on fraud and abuse. We are the ones who get fucked over the most.
You know why? Because the fraudsters and abusers will find a way to do it anyway. If your social catch-net system is open enough to actually be useful to those who legitimately need it, it will always be vulnerable to the unscrupulous and self-centered who will abuse it. There's no way to "fix" that problem without ultimately fucking over the people who use it legitimately and need it, because the only way to make the system "secure" enough is to make it practically useless and inaccessible to everyone.
This is especially true when you consider that those who need the system most (the poor, the disabled, and the severely uneducated) are the least adept at actually navigating, understanding, and appropriately utilizing the bureaucracy and complex systems that they require in order to continue to be alive.
Let me tell you a little story. This is not a story that I pulled from some website, or something I heard from a friend of a friend. This is about me, personally, speaking from something I personally experienced.
I had a stroke two years ago. This is pretty well-known to most people who talk to me, since it was sort of a big deal when it happened and it's struck me with some pretty awful mental and physical disabilities. It's not visibly noticeable most of the time (especially on the internet) but it's a shitty set of problems to deal with.
When I had the stroke, I got a pretty good standard of care from the Canadian healthcare system. I was promptly taken into the emergency room, given priority status for treatment, and admitted to the stroke recovery ward when the immediate danger was passed. From there, I was given treatment sufficient to ascertain it was safe for me to be released into the care of my family and I could attend outpatient physio/cognitive/speech therapy services.
Now, the problem was: I couldn't work. I was not able to return to my old job, in fact while I was undergoing recovery and therapy it was impossible for me to work any job, a recovery process that took nearly a year.
In that time, I needed to pay rent and eat food. My family could not afford to financially support me any more than they already were. Because my stroke had left me with brain damage, it was suggested by doctors that I apply for the provincial disability support program, which would give me money at least sufficient enough to allow me to survive.
Now, applying for that disability support is a lengthy, complex process that fortunately I had the help of my family to get through (I would not have been capable of doing it on my own). It involved visiting multiple doctors and having them fill out forms validating my disabled status and supporting my claim for disability support.
Even when the process of applying is completed, because the disability support program has to sift through a massive amount of applications and claims, and then validate each and every one individually with a thorough process to ensure nobody is defrauding the system, the wait time to even have a decision rendered on your claim is 3-4 months.
Additionally, in the majority of disability claims, the government intentionally rejects the first claim, forcing the applicant to go through a second, lengthy appeal process. Why? Because the government believes that the majority of fraudsters and abusers will give up after the initial rejection, or that their falsified claims/documents/bullshit they feed their doctors will not hold muster to a second review via the appeal process. The appeal process, once completed, still takes another 2-3 months to have a decision rendered on it.
So, 3-4 months to have your application decided on, and then possibly another 2-3 months to have your appeal decided on if the government rejects your first application even though they figure you are probably legit, they play on the "safe side" of rejecting more than 75% of initial applications.
This is completely putting aside that the process of filling out those applications/appeals requires visits to doctors and specialists in order to have them validate that you are disabled on government documents. This requires getting an appointment to see those specialists, which in and of itself can take over a month or two to happen.
I found all this out while going through the disability support application process, and realized that while the odds of me ultimately acquiring the disability support I was entitled to were very high, the odds of it taking almost a year were also very high.
In that time, I still needed to eat and pay rent. So, I had to go to Employment Insurance first. For those of you who live in countries that don't have it, EI is a system distinct from welfare where people who have been working but are between jobs can get temporary assistance until they get back on their feet. Now, as someone who prior to this had paid into EI since I was 15 years old, I figured it'd be pretty easy for me to get EI support to pay my rent and food until disability support could take over.
I mean, after all, I have a pretty legitimate reason for not being employed and it's a temporary situation until disability support kicks in, right?
Yeah, uh,
Nope.
EI determined that because I had lost my job due to an injury/illness that I had declared made me unfit to work for an indeterminate amount of time and was in the process of applying for disability support, EI told me I did not qualify.
Why? Because apparently a fairly standard abuse of the EI system prior to "closing this loophole" was for people to fake an injury or illness, begin the lengthy disability support application/appeal process, and the whole time do fuck all, don't work, and sit at home collecting EI. When they eventually would go through their second and third appeal through the disability support system only to be finally rejected(which could take years), EI would cut the person off, but they'd have already ridden that horse till it was dead anyway.
So, because EI was trying to "close loopholes" and "prevent abuses of the system", I got told to basically go fuck off and die. I paid for ten years into a government safety-net system that, when I needed it, wasn't there for me.
From there, I went to welfare. Now, the welfare system in my province underwent an "overhaul" a few years prior in order to "prevent fraud". What it meant is that getting welfare was made more labyrinthine, difficult, and demeaning than before in order to basically discourage people from using it. It's become more difficult to get, more difficult to keep, and had its funding for its operations viciously slashed by a Conservative provincial government overly concerned with "welfare moms" exploiting it.
However, "I need welfare until disability support kicks in" was fortunately still considered a valid use of the system, and I was able to get welfare before my next rent was due. This was also with the understanding that if disability support gave me any "back-pay" to the date of my becoming disabled (which they typically do) I would have to pay welfare back for the time they supported me while I waited.
So it wasn't even a real welfare system, it was basically just an interest-free loan that I'd be convicted of fraud if I didn't pay off as soon as I could.
Because welfare is primarily concerned with supporting children (and, only incidentally, their parents), single-parents and other people with children on welfare get a pretty decent slice of pie to survive off of. It's not much, but often it's enough, especially if it's just an in-between jobs type thing. My mom had to go on welfare when we were kids, it was hard but survivable.
However, because of "closing loopholes" and "preventing abuses", single men with no children get buttfucked by welfare. Welfare basically looked at my costs of rent, living expenses, bills, etc. (which I had to submit to them) and came to the conclusion I qualified for $560 a month.
My rent at the time was $485 a month, so welfare thought it was reasonable that I could pay my bills and eat off of $75 a month.
Why? "Because you don't have children, and you could utilize the foodbank and other private charities in order to assist yourself, and you have familial support". The welfare agent literally told me to go beg for food from my family and whatever charity would help me. Oh, and my family wasn't allowed to give me any money, because I'd have to report that as income and my "living costs would be adjusted accordingly" (ie, they'd give me less money).
I had to live like this for five months until I was approved for disability support. I'm doing okay now, but jesus fuck those were some grim fucking times.
This is what happens when you emphasize "preventing fraud/abuse" and "closing loopholes" in your social safety-net over actually helping people who need it. The more you try to crack down on the people abusing it, the more you are going to fuck over the people who need it. Period.
That would be logical, right? Except both hospitals and doctors work under this constant specter of fear of being sued for malpractice, and since Medicaid patients are at least minimally-guaranteed reimbursements, neither wants to risk it. A big part of this is that, aside from disabled patients, the lion's share of Medicaid patients are children and pregnant women, and juries love children and pregnant women. Legally, hospitals can turn away Medicaid patients, but I can count on one hand the number of times I've seen it happen.
My idea for the solution? Mandate at least one 24-hour Medicaid clinic per county, then fine ERs that don't refer their patients out to it. To make it easier, attach it to a local hospital.
One of the things that scares me most about Obama's insurance mandate is that it gives open season to hospitals to run up bills for needless tests. Without a system of disincentivization, why would a hospital refer you to a clinic or office if your insurance will cover ER care you don't immediately need? You think costs are high now?
Just wait.
I think government assistance may not by itself fully explain the occurance you outlined in your OP, so trying to fix the problem only by altering it might not be effective.
This is a reasonable solution, what I bolded here. It's actually similar to the system we have in Canada, where there are free walk-in clinics all over the place and people with non-emergency medical problems are referred to them first if they show up to an ER.
However, I don't know of any that are 24-hour in operation, and really for them to be an effective curtail to people showing up to the ER with a minor fever they need to. I wish that we could get 24-hour walk-in clinics, however the funding for such a thing doesn't exist (and if you suggest increasing healthcare costs which are already quite high, the Conservative government on both the provincial and federal level has a fucking fit)
I like your idea, at least for more densley populated areas.
But I doubt we could work it out because OMG GOVERNMENT RUN HOSPITALS.
Also - I have a hard time believing they wouldn't degenerate into underfunded hellholes.
that's why we call it the struggle, you're supposed to sweat
While I feel for you Pony, and I am very sorry for the shitty situation you had to go through. I feel like the part I quoted is a failure of imagination and heavily bias. You saw them implement certain policies that "cracked down" but also fucked you over, this doesn't mean that every policy that could ever possibly be implemented to crack down on the freeriders would fuck over the people who legitimately need the help. We just have to think long and hard about the ramifications of every policy we consider implementing and ask ourselves if it could possibly fuck over the people in genuine need.
Basically, I think the policies that fucked you over were just not fully thought out but that does not preclude the existence of policies that crack down on freeriders and don't fuck you over.
I think studies would need to be had to confirm it, but the math in my head points toward a 24-hour clinic staffed by lower-cost PAs, NPs, and nurses/medics --where people pay a little-- makes aggregately more fiscal sense than a large number of people being charged higher fees and occasionally having expensive needless tests run by MDs.
It's the same control group, basically, just lower prices for one set of staff and tests.
It's important to remember that the goal of the welfare state isn't just to keep the poor, the uneducated, the mentally disabled fed and clothed at some subsistence level, it's to stabilize their lives in a way that enables them to address the underlying causes of situations in which they find themselves. If we cause a guy to miss a payment and therefore not make rent and therefore have to move back with family or into a shelter or whatever, in the interest of wanting to make sure he wasn't a "free rider," we have fundamentally crippled the effectiveness of the welfare system.
Aside from that, the costs created by these so-called free riders will have to be borne at some point anyway. I don't see the problem with doing it at the level of welfare, especially if we can attach positive incentives to it.
that's why we call it the struggle, you're supposed to sweat
While I'd wager that 12 children is far from the norm, the occurrence of young people with multiple small children while still on government assistance is actually pretty routine. The easy answer would be to cap those benefits, but in that case you don't hurt the parents for being irresponsible, you instead just hurt the children of irresponsible parents.
Honestly, one of the biggest concurrences within these groups are religious and educational. Between the severely under-educated and the furthest far-right religious types, things like optimal lifestyle-advancement practices aren't going to happen. What the problem is now is that there's no tangible disincentive for these people in this situation to do anything different than keep on keepin' on.
EDIT: see y'all soon, guys, I gotta sleep.
Why does this actually represent a decrease in costs, though? I mean, the costs of basic treatment should be the time (time, basic equipment, etc.) whether a hospital is doing it or a universal clinic thing is.
that's why we call it the struggle, you're supposed to sweat
I think this is the part we disagree on. In my view, you can raise some barriers that only affect free riders and not people such as pony.
I would rather live in a country where people can take advantage because we care too much.
Than live in a country where people can't take advantage but some who need help are ignored because we don't care enough.
And, incidentally, myself.
Perhaps you feel people should start getting payouts right away and then a more thorough investigation into whether or not they really need it starts up? Forcing them to pay back when it turns out they're just freeloaders? Something like that?
It's important to understand that the test itself is a significant barrier, not just the objective criteria being evaluated. You can come up with whatever criteria you want, but if the process of evaluating it adds significant time to the process, you'll wind up excluding people (including some of the ones you hypothetically want to help.)
I guess the real answer if you wanted to approach welfare's goals honestly would be caseworkers whose job it is to evaluate funds and who doesn't and how much and so on, but going that route would probably wind up being more expensive than if you were just very permissive in the first place.
that's why we call it the struggle, you're supposed to sweat
It was intended as inflammatory.
Many people who profess to have a belief in charity and benevolence towards your fellow man only believe it applies to certain kinds of their fellow man. At which point it stops being either charity or benevolence.
so its ok to let kids suffer because their mother may have not made good life choices
I don't think changing emergency room policies is really the way to approach the problem.
It's like trying to clean a window with a hammer.
"The report by the Texas Health and Human Services Commission and the Texas Department of Insurance said state and federal expenditures for Medicaid will be an estimated $30 billion in the fiscal year that begins Sept. 1, 2011. That represents a 170 percent increase over the $11 billion in 2000."
Coughing and a mild fever? Yeah. Absolutely. That can wait until the morning.
Are you saying that not treating the kids would have made them unduly suffer?
A) We (as the US) are a nation of 300 million people. It is impossible to create a system that allows all those in genuine, innocent need of services to access said services without also allowing in at least some measure of jackholes who are able to abuse the system.
And therein lies the problem, both from a pragmatic and a public image perspective. The only way to prevent 100% of the abuses is to have a system so draconian that it screws over a huge number of decent people. And the only way to allow 100% of the decent people to access the system as intended is to have such a crazily lax system that it will be bankrupted by all the abuse.
And because we live in a nation of 300 million people, even if we have a system that is balanced as well as possible, even if it delivers perfect service 99.9% of the time, that 0.1% is going to be large enough to provide a shit-ton of anecdotes and statistics "proving" that the system is broken.
That said, I think that currently the US system, at least, has far more problems with providing insufficient or nonexistent care than with being abused.
Of course, the whole thing could be largely solved by a single-payer system that covered 100% of Americans, but that's another post.
In a related note, my future brother in law explained the healthcare system in Australia to me and I was blown away. It's disheartening how seemingly everywhere else in the first world is getting this right on some level, except us.
They tried to bury us. They didn't know that we were seeds. 2018 Midterms. Get your shit together.
and honestly the cost of giving a few kids some aspirin and checking their temp and not getting paid for it is far lower than 1% of them coming back with something truly life-threatening.
Stop right here.
I'm going to make a suggestion.
If you are going to say something like "Hey there's solutions to this problem, you just lack imagination!" then you better fucking provide some.
Because otherwise? You're no different than dickhead anarcho-capitalists and libertarians who insist "the free market will fix it!" without actually explaining how.
If you can't offer even theoretical ideas, then don't be so damn quick to simply say someone else "lacks imagination".
The effort to kick them off cost ten times as much as the amount they saved.