It Tolls for Thee

Because We Are Involved in Mankind

No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were: as well as if a manor of thy friend’s or of thine own were. Any man’s death diminishes me, because I am involved in mankind. And therefore never send to know for whom the bell tolls; it tolls for thee.¹

Photo by Marek Okon on Unsplash.

This famous passage is from a sermon John Donne wrote in 1623 when he was gravely ill. It has been on my mind lately because Congressional Republicans plan to cut $880 billion from Medicaid over the next decade, a decision that will inflict terrible suffering on millions of Americans.

---

Anyone’s Death Diminishes Me

You may think I’m exaggerating. “Millions of Americans? Give me a break!” you may be muttering to yourself. You may believe that Medicaid is only for poor people, and so this issue won’t affect you.

But in fact, as the chart below shows, all kinds of people, including not just poor but also middle-class and affluent Americans, benefit from Medicaid.

Source.

Maybe we—or people we care about—have jobs that pay so poorly that insurance is unaffordable, and so Medicaid comes to the rescue. Maybe we—or people we care about—live in a rural area where the only hospital within driving distance gets most of its funds from Medicaid.² Maybe we—or people we care about—are coping with addiction, and we know that Medicaid covers four in ten people with opioid use disorder.

Maybe we—or people we care about—are raising a severely disabled child, whose therapies, medications, mobility equipment, and feeding-tube maintenance are paid for by Medicaid. Maybe we—or people we care about—are responsible for a frail elderly family member, who requires skilled nursing to turn her regularly and to manage her toileting, care that is paid for by Medicaid. Maybe we—or people we care about—have a loved one suffering from advanced dementia who needs to be in a secure memory unit, paid for by Medicaid, so he won’t bolt into the street.

Most caregivers are unable to quit their jobs and sacrifice their life savings, sleep, and health to provide the round-the-clock care their loved one requires. Many caregivers are seniors themselves and suffer from health problems that prevent them from lifting and turning their loved one multiple times a day. Most caregivers, out of respect for their loved one’s dignity, would prefer that a nurse be the one to handle toileting and bathing. Medicaid helps these families by paying for visiting nurses.

But say we’re lucky, and neither we nor anyone we know needs Medicaid. These cuts would still hurt us, because they would inflict a moral injury on us. Moral injuries occur when we are forced to go along with something we know is evil. Medicaid currently pays for 41 percent of births in the US.³ Imagine that Republicans cut Medicaid to the bone. Millions of pregnant women may be forced to deliver at home without medical assistance. Common, treatable problems during labor and delivery—such as preterm labor, breech birth, labor that doesn’t progress, hemorrhage, and a compressed umbilical cord—will kill newborn babies and/or their mothers. Thousands more babies and mothers will incur severe, life-altering injuries that could have been prevented with adequate medical care.

But What about Work?

Some will protest that they want to reform rather than eliminate Medicaid, and that work requirements are only fair when recipients are able-bodied and are not currently in school or caring for young children or elderly relatives. In theory, I agree: Work is good for us. It gets us off the sofa, gives us purpose, and makes us feel like valued members of society. Of course we should encourage people to work.

Photo by Spencer Davis on Unsplash.

However, in practice, as this explainer shows, work requirements for Medicaid are unnecessary, because most able-bodied people on Medicaid are working already. They’re actually worse than unnecessary; they also obstruct access to healthcare and are not cost-effective. When Arkansas imposed a work requirement, 18,000 adults were kicked off Medicaid, not because they weren’t working—97 percent of Arkansans on Medicaid who were able to work had jobs—but because the paperwork to document their employment was confusing and prohibitively time-consuming. When Georgia imposed a work requirement in 2023, only 4504 of 350,000 eligible people enrolled in Medicaid. And in spite of such a small number of participants, the program was expensive: In the year after the start of the work requirement, Georgia taxpayers paid $26 million, of which 92 percent went to enforcement and administration, and only 8 percent went to medical care for needy people.⁴

These results shouldn’t surprise us. Punitive bureaucratic requirements have been imposed on poor people before with little payoff; research shows that mandatory drug testing of welfare recipients costs states thousands of dollars per positive test result, for example. Of course it rankles that there are cheaters out there, but the bureaucratic apparatus necessary to catch a few scofflaws hurts the law-abiding majority and costs more than it’s worth.

---

Pluralistic Ignorance

As I have written before, “pluralistic ignorance” is a clunky term for a simple concept: We often think we are the only ones who feel a certain way about an issue, when in fact we are in the majority. If we only realized that most people agree with us, we would feel more confident about speaking up for what we know is right. It’s difficult to be the lone voice crying out in the wilderness but easy to join in with a chorus.

Social Security and Medicare are extremely popular, but we may not be aware that Medicaid enjoys the support of the vast majority of Americans too. Surveys show that only 17 percent of Americans want to cut funding to Medicaid, while 40 percent want to keep funding at the current level, and 42 percent want to increase funding. Americans are rarely this unified; we need to search high and low to find anything else as unpopular as cuts to Medicaid. Don’t believe me? Well, more Americans liked Highlander II: The Quickening than want to cut Medicaid. More Americans say pineapple is their favorite pizza topping than want to cut Medicaid. More Americans would be okay with their teenage daughter partying at Diddy’s house than want to cut Medicaid.⁵

Now we know: There are more of us who support Medicaid than want to cut it—by far! Armed with this knowledge, we can make our voices heard, with our friends and family, in our online comments and Substacks, and by calling our elected leaders. It is especially effective to share personal stories of how Medicaid has helped you, your family, and your community. You can find contact information for your representatives here.

What’s a Life Worth?

Readers are likely familiar with my penchant for arguing that most situations are win-win, not zero-sum. I hope I have persuaded you that adequately funding Medicaid is a win-win for our country. But if not, here are some additional figures to show that Medicaid delivers excellent value for money:

Medicaid’s administrative costs are very low—between 2 and 5 percent, as compared with 17 percent for private insurance.

In addition, the share of the federal budget that goes to Medicaid is only about 8 percent, which means that the bottom 80 percent of US families pay very little for it. As this chart shows, families in the bottom two income quintiles pay almost nothing in federal taxes, the middle quintile pays about $10,390, and the fourth quintile pays $20,810. So middle-class households pay between $831 and $1665 per year in federal taxes for Medicaid, plus an additional, much smaller, amount in state taxes. So let’s round it up to $1000 to $2000 per middle-class family per year (which is likely an overestimate).

That pittance buys us myriad benefits: medical care for low-income people, disabled people, people struggling with addiction, and the very old; relief for overburdened caregivers; funding for healthcare jobs; and stronger rural economies. All this, plus let’s not forget the moms and babies who survive childbirth thanks to Medicaid. How much are their lives worth? One measure comes from the US government: When there is a disaster that causes deaths, FEMA sets the value of a person’s life at $7.5 million. The mathematicians among us will note that $7.5 million is a few orders of magnitude more than most of us pay for Medicaid. See? Told you Medicaid was a bargain!

---

How about you, readers? Have you or people you care about ever benefited from Medicaid? Have you called your senators and representatives? Please share your thoughts in the comments!

The Tidbit

A few hours ago, New Jersey Senator Cory Booker broke Strom Thurmond’s record for the longest speech ever delivered on the floor of the Senate. His impassioned, inspiring speech clocked in at more than twenty-five hours. As a commenter waggishly noted, he toppled another Confederate monument. For a much-needed boost of hope, I highly recommend watching his closing minutes, in the video below.

I know who does have the power: the people of the United States of America. The power of the people is greater than the people in power.

. . .

Our founders said we must mutually pledge to each other our lives, our fortunes, and our sacred honor. We need that now from all Americans. This is a moral moment. It’s not left or right, it’s right or wrong. Let’s get in good trouble.

1. Most of this passage is self-explanatory, but the last sentence refers the church practice of ringing bells when a parishioner has died. “Never send to know” means never send a servant to the church to find out who died.

2. More than 400 rural hospitals are at risk of closing if Medicaid is cut. When rural hospitals close, people who have treatable medical emergencies die. In addition, rural hospitals provide more than 90,000 healthcare jobs. Eliminating these jobs would devastate rural economies.

3. See this chart for examples of prenatal and postpartum healthcare Medicaid provides to women and babies in addition to labor and delivery.

4. The source for all the facts in this paragraph is here.

5. Ok, I made this last one up. But you get my point.