As Craig Garthwaite and Timothy Layton point out: “Originally a small, inexpensive safety-net program, Medicaid has grown into a major national health-insurance provider, covering nearly one in four Americans and more people than the public health insurance programs of the United Kingdom, Germany, or France.” They review the program and offer some recommendations in “Coverage Isn’t Care: An Abundance Agenda for Medicaid” (forthcoming in Advancing America’s Prosperity, edited by Melissa S. Kearney and Luke Pardue, published by the Aspen Economic Strategy Group.

I would add that whether you favor government-run national health insurance or oppose it, Medicaid is a major example of such a program in actual operation, and thus worthy of your attention. A few facts:

• Total Medicaid spending by federal and state governments was $880 billion in 2024. “Medicaid is jointly financed by state and federal tax dollars while being designed and administered by each state. This setup leads to remarkable variation in the program’s structure across the country. … The program’s growth in size and scale means that it now comprises a substantial fraction of state budgets, with the average state spending almost one-third of its budget on Medicaid …” Indeed, a certain number of proposed changes to Medicaid from federal-level politicians focus on reducing federal spending by shifting a greater share of Medicaid spending to states.
• Medicaid ” has expanded gradually from a program of categorical eligibility, restricted to specific low-income groups (such as pregnant women or the disabled), to—with the passing of the Affordable Care Act (ACA)—a broad-based entitlement for nearly all low-income adults.” Medicaid covered about 20 million people during its first two decades, up through the 1980s, but a series of expansions since the 1990s than has roughly quadrupled Medicaid enrollment in the last three decades, reaching 78.5 million by December 2024.
• “This growth has been coupled with a structural shift, with roughly 75 percent of beneficiaries now receiving care through private managed-care organizations rather than government-operated insurance programs. These firms include familiar names from other health insurance markets such as United, Aetna, Humana, and Centene, making the modern version of Medicaid quite different from the classic perception of a safety-net healthcare program run and operated by legions of government bureaucrats.”
• “Medicaid bothpays for 41 percent of births in the US and is the largest single payer for long-term care services in the US. It is the nation’s only true cradle-to-grave insurer. The medical requirements of these many different types of beneficiaries are meaningfully different, and it is therefore likely that the optimal insurance design differs, perhaps greatly, across these groups. Despite this fact, the program largely takes a one-size-fits-all approach and attempts to provide a single comprehensive set of benefits to all enrollees.”
• “Medicaid involves relatively little expenditure per enrollee. Medicaid accomplishes this feat by paying very low rates to all medical providers. This frugality does not come without meaningful consequences for enrollees. Many providers simply refuse to accept Medicaid enrollees. Others consider treating these patients as a form of charity care. For example, many hospitals declare `underpayments’ from Medicaid as part of their contribution to the public good. … Beyond payment rates, state Medicaid programs also often make it fairly difficult for providers to actually get paid. Data suggests that fee-for-service (FFS) Medicaid is the biggest denier of bills from providers, with a “denial rate 17.8 percentage points higher than fee-for-service Medicare” (Gottlieb et al. 2018). Medicaid managed care is the second-most likely to deny, denying just under 10 percent of bills and challenging around 13 percent. Both FFS an managed-care Medicaid also have much longer times to payment, making working with Medicaid a much bigger hassle for providers than working with Medicare or commercial insurers.”

This last point is a central focus of the proposals offered by Garthwaite and Layton. As they say in their title, being covered by Medicaid is not the same as receiving actual health care through that coverage. On the subject of Medicaid reform, they write:

The current [Medicaid] program is defined by a stark economic tension—it promises access to the mainstream medical system while only providing the funding that can support a two-tiered one. This contradiction was manageable when Medicaid was a small program, but now that it covers a quarter of Americans, there is potential for an access crisis. Policymakers must therefore confront a fundamental choice: Continue to chase the mirage of equal access, or build a system that delivers abundant care to all Medicaid beneficiaries within its budget. We argue for the latter. An honest assessment reveals that an implicit—and dysfunctional—two-tiered system is already the reality. …

This effort should begin by explicitly acknowledging the existence of an implicit two-tiered system whereby Medicaid beneficiaries have coverage but lack access to high-quality medical care. Productive reforms should focus on a redesigned program that fosters an abumdant supply of providers of basic care for the Medicaid tier. Our proposal focuses on targeted regulatory relief and the integration of new artificial-intelligence technologies (AI) to create lower-cost, sustainable business models for providers who primarily serve Medicaid patients, with the goal of ensuring abundant access to basic care. While some might argue that these types of reforms provide a lower standard of care for low-income Americans and confine them to lower-quality healthcare services, we emphasize that the goal is not to diminish the quality of care received by Medicaid enrollees. Instead, our proposals aim to help the large number of Medicaid patients who currently have access to no care (or very limited care) under the current system to have easy and abundant access to (at least) basic healthcare services.

In that spirit, Garthwaite and Layton argue for allowing the immigration of additional internationally-trained health care providers to serve Medicaid patients, allowing intermediate-level health care practitioners like nurse practitioners and physician assistants to have greater autonomy in providing certain kinds of care, and to develop methods for AI-augmented care. They write: “For a beneficiary whose alternative is no access to care, the use of a new, well-designed technology is a clear improvement.” Frankly, I’d be happy to see these kind of reforms implemented across the entire US health care system. But using them in Medicaid would at least be a start.

The post Medicaid: What It Has Become first appeared on Conversable Economist.

The far reaches of the wingnut-o-sphere have spent the late afternoon and early evening attempting to tie a 30-year-old man who lived with his mother in a four-bedroom Colonial in the suburbs of Washington D.C. to the anti-fascist non-organization, Antifa. The man, Brian Cole Jr., “may have anarchist leanings,” according to a report this afternoon in the New York Post. Other than the NY Post report attributed to “sources,” nothing is known about the man’s political leanings, left, right, or center.

Very little else is known about the suspect. Quotes from neighbors who lived on the cul-de-sac near the suspect sounded like they were describing Ted Kaczynski: “He’s almost autistic-like,” one neighbor told the New York Post. “He’s very naive…He would not hurt a fly. He’s just not that kind of person. I don’t believe this at all. He’s not a terrorist.”

“He is very antisocial. Very,” another neighbor said. “He would never make eye contact. Almost like he just didn’t see you,” another neighbor told the NY Post.

The FBI and DOJ held a self-congratulatory frolic to announce the arrest this afternoon. FBI Director Kash Patel had made a career going on podcasts inventing conspiracy theories about the FBI and Deep State being responsible not only for the bombs found at the Republican and Democratic party headquarters but for the assault on the Capitol. Today, Patel sounded a little different, claiming the FBI had solved “a case of massive public importance.”

“When you attack American citizens, when you attack institutions of legislation (sic), when you attack the nation’s Capitol, you attack the very being of our way of life. This FBI and this Department of Justice stand here to tell you that we will always refute it and combat it.”

It is unknown if the rubber heels on Patel’s business shoes left skid marks on the floor of the DOJ headquarters from his about-face.

FBI Deputy Director Dan Bongino, who had called the assault on the Capitol “a set up” and “an inside job” that the FBI was protecting with “a massive coverup” went next. I watched his statement on my television, but his words were difficult to make out, his nose was so far up the ass of his Master and Commander at 1600 Pennsylvania Avenue. I did manage to decipher this: “This is what it’s like when you work for a president who tells you to get the bad guys.”

Okaaaaaaaaaay….

A few details about the case were revealed in an FBI affidavit. The bombing suspect bought six pieces of galvanized pipe at one Home Depot and pipe caps at another Home Depot. He bought 9-volt batteries, wires similar to those found on the bombs, and “white kitchen timers” at other stores near his residence, including a Walmart. One paragraph of the affidavit says the pipe bombs were filled with paperclips, steel wool and “homemade black powder.” Another paragraph says “Both pipe bombs were packed with steel wool.”

The FBI affidavit is incredibly detailed, right down to the fact that Cole purchased “five of the Nine Volt Distributor’s nine-volt battery connectors from Micro Center in northern Virginia on or about November 12 and December 28, 2019, including cash purchases made during the December transaction.”

Nowhere, however, does the FBI affidavit mention the purchase of any blasting caps that are necessary to set off a pipe bomb. You can pack pipes with explosive material and steel wool all day, and you can hook them up to 9-volt batteries with “black and red wire,” and you can screw on the “end caps,” and you can buy kitchen timers from Walmart, and you can place them on the ground outside buildings until you’re blue in face, but without blasting caps or lengths of what is called “det-cord,” or “detonation cord” and the igniter necessary to use it, the pipe bombs will not explode. The distribution and sale of blasting caps and det-cord is highly regulated and can be purchased only by firms or individuals licensed for work with explosives. The purported bomber, Cole, was not licensed and did not work for a firm in the business of using explosives. According to his grandmother, he sometimes worked for the delivery company DoorDash, and he had a job with his family’s bail bond company.

The FBI affidavit characterized the devices found outside the Republican and Democratic party headquarters as “improvised explosive devices” that “showed weapons characteristics were present.” The affidavit, however, omits any mention of Cole purchasing the key factor for any explosive device, the blasting cap.

It looks like Pam Bondi, Kash Patel, Jean Pirro, and Dan Bongino have arrested the guy who bought enough components to put together galvanized pipe, wires, steel wool and kitchen timers and produced two elaborate duds.

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This is not ChatGPT. This is not Wikipedia. This is verified, factual, memorized, first source truth.

Beck says that George will teach the Constitution, the Federalist papers, the civics. Beck says this project "will change EVERYTHING about education." George will counteract all those lies your teacher taught you. It's a proprietary AI database that will permanently preserve "the physical evidence of America's soul." 

There are at least two possibilities. One is that George will be a Washington-lite AI zombie that will, in fact, hallucinate and spew bias just like any other AI because Beck doesn't know what he's talking about. The other is that George has taken an old version of Jeeves and slapped a tri-corner hat on him, and that this is just a digital library with a search function because Beck doesn't understand AI, but he knows that it's a hot marketing term right now.

At least three outfits claim to have worked on an AI Zombie George Washington (here, here, and here) and they are all pretty much baloney. It makes sense that AI hucksters are going to go after the low-hanging fruit of public domain persons for zombiefication, and it makes sense that Beck, a seasoned patriotic grifter, would follow that path.

But boy is this shit a bummer, because Beck is going to wave his Giant Library around and convince a bunch of suckers that he can tell them the Real Truth about our nation's founders with even more unearned authority than he already deploys. But if AI zombies are good for anything, it's grift, and we had better steel ourselves for more of it. And please, God, keep it out of our children's classrooms.

This is the way stories about the demise of a cabinet secretary classically begin: The knives are out for Schmucko at the Department of Mistakes Were Made.

This time it’s more like the bazookas are out for Champagne Pete, as columnists have become fond of calling him. Stories leaked out of Hegseth’s Pentagon today about the Inspector General report that was ordered several months ago on the so-called Signalgate fiasco. Inspector Generals, especially the ones who are a part of the Pentagon and the armed services, generally do what the boss expects of them. When there’s a scandal, find some cubbyhole of a regulation or SOP – Standard Operating Procedure – to hide uncomfortable information. The attitude over there on the Virginia side of the Potomac is that they’ve got more important things to do than diddle around with an IG complaint that points to some awkward or embarrassing situation involving a deputy secretary or even one of the higher-up generals working for a chief of staff of the Army or Navy.

They couldn’t sweep this one under the rug. Back in March, as Hegseth joyfully engaged in his first shoot-em-up, an air assault on the Houthi militia that had been making shipping through the Red Sea miserable if not downright deadly, he just couldn’t resist sharing his excitement with a coterie of his fans that turned out to include his wife, a Fox News producer, and his brother, who holds down a previously non-existent job as “senior adviser and liaison to the Department of Homeland Security.” You know, Hegseth needed his brother being in constant contact with Kristi Noem because she is fond of dressing up in camo-mufti and she really, really needs to know what’s going on with Hegseth and his camo-warriors over at the Pentagon.

So, Hegseth set up not one but two chat-groups on the utterly insecure Signal app and shared classified details about the attacks in Yemen. When news of Hegseth’s little electronic cocktail party was revealed by the editor of the Atlantic magazine, Jeffrey Goldberg, who had been somehow included in the chat-group, Hegseth went into full-on-lie-a-minute mode, claiming that “no classified information was shared.” Naw, Hegseth was just informing his wife and brother and Secretary of the Treasury Scott Bessent about odds and ends like the precise moment the first bombs dropped on Houthi targets, and what kind of bombs they were, and which Air Force and Navy jets were dropping them. You know, just chat-group gossip.

The Inspector General report, however, found that the information Hegseth shared on Signal was classified and that sharing it on an insecure information network could have potentially put the operation and the pilots at risk if it had been revealed to the enemy.

Also revealed in the report was the fact that Hegseth refused to be interviewed by representatives of the Inspector General. The only cooperation he would give was a “short statement.”

Nothing to see here, said Sean Parnell, a personal friend of Hegseth and the Pentagon’s chief spokesman. “This matter is resolved, and the case is closed,” Parnell said prematurely today. Parnell went on to mischaracterize the highly critical report as “a TOTAL exoneration of Secretary Hegseth.”

The Inspector General report includes no information on any of the chat-group members, who included Vice President Vance, Secretary of State Marco Rubio, and of course White House jack-of-all-black-trades Stephen Miller. Nor did the Inspector General take a look into how Atlantic editor Jeffrey Goldberg ended up being included in the group.

Goldberg’s inclusion in the Signal chat would appear to be an important, if not the most important, aspect of any sort of real investigation into what turned out to be the sharing in real time of highly classified military information about a combat operation. Apart from Hegseth’s wife, Goldberg was the only civilian in the group. His presence in the chat-group went somehow undetected until Goldberg himself revealed in the Atlantic that he had been included.

Goldberg reported that several days before the strike on the Houthis, he received a “connection request” from Michael Waltz, who was not further identified to Goldberg in the Signal request. Goldberg reported that he “assumed” it was the same Michael Waltz who was then serving as the White House National Security Adviser, who Goldberg said he had “met.” Goldberg accepted the Signal request, thinking that Waltz might want to “chat about Ukraine, or Iran, or some other important matter,”
since Goldberg had reported international relations and national security matters in the past.

A few days later, Goldberg received a notice that he had been included in the “Houthi PC small group,” the Signal chat-group that included representatives of all the important departments in the Trump government. In real time, on his phone or computer, Goldberg sat there and watched as Rubio, Trump-trouble-shooter Witkoff, White House chief of staff Suzi Wiles, and the others logged in their presence in the group.

Nobody noticed or remarked on the presence of the editor of the Atlantic being among them. Goldberg was not unknown to either Donald Trump or members of his administration. He was the one who had reported that Trump’s refused to attend a ceremony at a World War I American cemetery in France and had called the fallen soldiers in the cemetery “losers and suckers.”

So how was Goldberg included in the Signal chat-group that ended up receiving highly classified information about the airstrike on Houthi rebels? Well, there’s another excellent example of an Inspector General sweeping uncomfortable information under the nearest rug.

It seems that we will have to rely on theories as to how and why this serious breach of military security took place. My friend Terrence Goggin, who writes his “West Point History Professor” Substack, has a theory that there is a small group of people at the Pentagon who actually are loyal to the Constitution and take their oaths to defend it seriously. He believes they are responsible for sneaking Goldberg into the Signal chat and are probably responsible for the leaks that have revealed some of Hegseth’s other dick-stomping, most prominent of which is his apparent order to “kill them all” in the first “drug-boat” strike in the Caribbean that ended up including a second strike on two survivors who were clinging to the wreckage of their boat.

Multiple members of both the Senate and House Armed Services Committees are calling for an investigation of this apparent war crime. If Goggin is right, and there is a secret group of national security figures in and out of uniform who have been spreading damaging information about Hegseth, their leaks reached a critical mass with the Inspector General report on Hegseth’s Signal chat-group.

The report will be released publicly tomorrow. Members of Congress were given a classified version on Capitol Hill today. The report itself will be interesting to read in full, and I expect there will be even more interesting leaks from the classified report in the coming hours and days.

Hegseth, with his Christo-fascist tattoos and history of drunkenness and sexual abuse and harassment of women, is a buffoon. Yesterday at the sleepy-Don cabinet meeting in the White House, the title on Hegseth’s nameplate was misspelled as “SSECRETARY OF WAR.” “SS” is the abbreviation for “Schutzstaffel,” the notorious paramilitary organization in Nazi Germany which swore allegiance to Hitler and was responsible for enforcing the racial policy of the Nazi party. The “Waffen-SS” was the combat arm of the SS, and the SS-Totenkopfverbande, the notorious “Death’s Head” units, were in charge of running the Nazi concentration camps that put to death millions of Jews and other “undesirables” under Nazi rule.

“SS” in the job title on a cabinet meeting plaque of a man like Hegseth, who has shown-off his Nazi-adjacent tattoos, is not a dog-whistle to the far right of the MAGA base, it’s a clarion call. Under any sane administration, that alone would lead to a resignation or firing of the cabinet member responsible for the misspelled title.

It would be nice to be able to say that all of this about Hegseth will probably lead to his downfall and that his days at the Pentagon are numbered. But he serves at the pleasure of Donald Trump, a man who issued 160 posts on Truth Social the other night, some of which made Hegseth’s “SS” name plaque look tame in comparison.

It’s wait and see time with Secretary of Whatever Hegseth. My feeling at this moment is that he is such a fuck up and clearly damaged human being, if this doesn’t get him, something else will. There are good people looking over his shoulder at the Pentagon. Hegseth has chosen the wrong man to pick on with his threat to court martial Senator Mark Kelly. The person who should be brought back into uniformed service to face a court martial is Hegseth himself.

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News outlets are reporting this morning that former Honduran president Juan Orlando Hernández has been released from a federal prison in West Virginia after Donald Trump gave him a “full and complete pardon.” Hernández was serving 45 years in prison after having been convicted last year of running a “narco-state” by using payoffs from drug cartels to support his political career in Honduras. Evidence in his trial proved that he had facilitated the movement of 400 tons of cocaine through Honduras on its way to drug gangs in the United States.

Hernández’s wife Ana García thanked Trump for the pardon in a post this morning on X: “Today we give thanks to God, because He is just and His timing is perfect. Thank you, Mr. President, for restoring our hope and for recognizing a truth that we always knew,” she wrote.

We have not seen any evidence that Hernández or people close to him paid a sum of money to Trump to secure his pardon, but with Trump’s moves against Venezuelan President Nicolás Maduro, whom he accuses of running Venezuela as a “narco-state,” what other conclusion can you draw? During the eight years Hernández served in office between 2014 and 2022, politicians from both American political parties, including Joe Biden, praised him for cooperating with the U.S. in fighting drug trafficking. Trump in 2019 praised him for “stopping drugs at a level that has never happened.” 2019 was the same year that the Honduran president’s brother, Tony Hernández, was convicted in the U.S. on drug trafficking charges and sentenced to a term of life in prison.

Just between us, there had to have been evidence that he moved one hell of a lot of drugs to get a life sentence. The conviction of the brother of the president of Honduras for drug trafficking shows without a doubt that the Department of Justice had a great deal of knowledge of how drug trafficking worked in Honduras, especially since President Hernández himself was named in the case as an unindicted co-conspirator of his brother.

The president overseeing the DOJ at the time of the conviction of Tony Hernández was Donald J. Trump. It is likely that the DOJ began its investigation of the Honduran President at the time of his brother’s conviction and sentencing. That means it was Trump’s DOJ in 2019 and 2020 that began treating Hernández “very harshly and unfairly,” as Trump has described his prosecution.

An American jury found Hernández guilty of trafficking hundreds of tons of drugs into this country. Prosecutors produced evidence at trial that he had protected drug lords in Honduras and prevented their prosecution in that country in order to facilitate their trafficking business. All of this at the same time he was being celebrated by U.S. political figures as an “ally” of this country in fighting drugs.

Trump’s pardon of such a man makes absolutely no sense unless Hernández arranged for Trump to be paid off.

Trump has moved dozens of American war ships into the Caribbean Sea off the coast of Venezuela and has spent the last three months blasting boats out the water that are said to be carrying drugs from Venezuelan gangs. Trump has accused Maduro of facilitating drug trafficking from his country through his association with drug gangs such as Tren de Aragua.

That sounds one hell of a lot like the way the DOJ accused Honduran President Hernández of facilitating drug trafficking from his country through drug cartels.

The mainstream media has been reporting that what Trump really has his eye on in Venezuela is its oil business. That may be true. Trump wouldn’t mind helping out his buddies in the oil business with leases on oil fields in Venezuela. In this country, Trump has shut down all government assistance to renewable energy in solar and wind projects and opened every square inch of U.S. territory he can to oil drilling, including the Arctic wilderness and the waters off the gulf coast of Florida and the beaches of California.

But Trump doesn’t own any oil companies. His most recent financial statements don’t reflect holdings in the stock of oil companies. Trump would rather take money directly. He pardoned crypto billionaire Changpeng Zhao, the founder of the crypto exchange Binance, after he had arranged to host trading for the Trump family crypto business, World Liberty Financial. The deal between the two companies was described at the time as potentially worth hundreds of millions of dollars to the Trump family.

Last week, Trump commuted the sentence of a hedge fund billionaire, David Gentile, who was convicted of using money from new investors to pay off earlier investors, a classic Ponzi scheme. The government alleged that Gentile had defrauded as many as 10,000 investors out of $1.6 billion. Gentile had just begun serving a seven-year term in federal prison at the time of his pardon from Trump. Gentile’s partner in the scheme, Jeffrey Schneider, was convicted and sentenced to six years in prison for helping to market the scheme to investors.

Schneider, notably, was not pardoned by Trump, even though he was convicted of a lesser role in the phony investment scheme.

How does this make sense? Only if Gentile, or persons working on his behalf, arranged for a payoff to Donald Trump for the commutation of his sentence.

It was reported that last week, Donald Trump had a telephone conversation with Venezuelan President Maduro. Some reports said that Trump had urged Maduro to leave the presidency of Venezuela and guaranteed him and his family “free passage” if he agreed to leave. This was after Maduro in October offered the United States “a dominant stake” in Venezuela’s oil business, according to the New York Times. That offer was rejected. Shortly after Trump’s phone conversation with Maduro last week, Trump announced that he was “closing the skies” over Venezuela to all civilian and military air traffic.

How do you think Trump’s conversation with Maduro really went? First, what the hell was he doing talking to a man he accuses of running a “narco-state?” Oh, that’s right: Trump just pardoned a former narco-state president, so talking to narco-state guys is a regular thing for Trump that makes perfect sense…if what they talked about was money.

Trump doesn’t do favors for people. Every single thing he does has a price. What did he get from pardoning more than 1000 January 6 seditionists? The undying support and love from his base. What did he get from making Elon Musk the head of the so-called Department of Government Efficiency? Nearly $300 million in campaign contributions in battleground states that put him in the White House, that’s what.

Trump rejected oil deals as a payoff to stop his military pressure on Venezuela. What do you think his price was to guarantee Maduro safe passage out of the country?

Why do you think that Trump, who once called crypto a “scam,” has embraced the fly-by-night money transfer business that converts dollars into thin air and back into dollars again at the whim of the people who run crypto businesses like Trump’s buddy, the owner of Binance, to whom he gave yet another of his pardons?

Trump converted his business, the Trump Organization, from constructing and owning buildings to putting his name on other people’s buildings in return for cash. The deals that were announced for two Trump properties in Saudi Arabia aren’t deals for the Trump organization to put up buildings. He doesn’t have to do business anymore with the kinds of sub-contractors he once ripped off to increase his profits. Now he just takes money from Arab princes to put his name on hotels and condos in the desert.

Donald Trump used to borrow money from banks. Now he’s out of the bank game altogether. His money is in the cloud of crypto so nobody can count it, nobody can see it, nobody can trace it.

That’s where all his payoffs are. No more paper trails. No more electronic trails. No more evidence of corruption. It all happens out there in a mysterious, impenetrable land called crypto. What other conclusion can you draw?

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