John Oliver dove into the bureaucratic mess of Medicaid on Sunday’s Last Week Tonight, amid a “great unraveling” that has dropped enrollment by more than 11 million people in the past year, including 4.8 million children, the vast majority of whom were kicked off their healthcare for surprise procedural issues. “Just for once, could the government blindside people with something beneficial, or even just fun?” Oliver wondered. “Like if one day Congress announced they’d be adding Shrek to Mt Rushmore.”
In numerous cases, care was terminated without any notice from the state – one of several instances in which “everything about the current unwinding is emblematic of much larger issues with how we’ve always administered Medicaid”, said Oliver. The program was first enacted in 1965, as a partnership between the federal government and state governments, with much leeway given to states for running their programs with matching federal funds.
The program, when working as it should, provides insurance for low-income adults and children, and pays for crucial services for those with disabilities, mental illness and other chronic health issues. But even for those who qualify for Medicaid, “basic administrative fuck-ups” can prevent access to care, such as the case of one child who was declared “not born yet” by the state Medicaid system despite being a year old.
From state to state, Medicaid recipients are beset by poorly designed websites, long wait times and complex forms, among other issues. “Glitches can occur in any system, and they can happen more often in government programs, which do tend to be underfunded, understaffed and operating on ancient technology,” said Oliver. “And I’m not trying to rain shit down on honest government employees who have to process an endless barrage of paperwork. I have total sympathy for how demanding those jobs are.
“In fact, there’s exactly one group of government employees that it’s OK to make fun of for something that is not their fault, and that is Secret Service agents, for the fact that they are constantly being bitten by the president’s dog,” he added. “I’m sorry, I hope they’re all fine, but I’m still going to laugh every time I think about that.”
Administrative accidents aside, “there are times when it feels like the obstacles to getting Medicaid have been put there deliberately,” said Oliver, “so that states can keep those that they see as undeserving off the rolls.” Several states keep the bar for qualifying “troublingly high” while adopting a “deeply moralizing tone” with barriers to entry such as work requirements. Arkansas tried such a policy but ditched it after a year because of the mess it caused; Oliver cited the case of one chicken processing plant worker accidentally kicked off Medicaid by the requirement, costing him both his health and, when he became too sick to work, his job.
Georgia is now toying with the idea of a work requirement, “and it is proving to be just as stupid and just as frustrating”, said Oliver. “And that is the thing: so much of the talk around Medicaid seems to center on the fear that someone somewhere might be gaming the system.” Many state offices investigating Medicaid fraud are far over-invested in resources – Tennessee tried to recoup $900,000 from fraud charges against low-income recipients in 2022, by a fraud office with a budget of $6.4m.
“I’m not saying Medicaid fraud doesn’t exist – it does,” said Oliver. “But for the most part, the costliest fraud isn’t being committed by patients getting care they may not be technically eligible for, it’s providers” defrauding state healthcare systems with false charges and fictional care.
“Again and again, the priority seems to be making sure no individual gets a penny more healthcare than they deserve even as states are weirdly blithe about much bigger amounts of money flowing out the door to large organizations,” Oliver noted.
The last “massive flaw” in the Medicaid system, Oliver continued, are managed care organizations (MCOs), private companies contracted by states to deliver and pay for healthcare for about 72% of Medicaid patients. MCOs get paid a set monthly amount per person; their profit is whatever they don’t spend on patients, “and you can probably see where this is going”, said Oliver. That would be denial of care; in the first year that Iowa transitioned to MCOs, for example, there was an 891% increase in instances of Iowans being illegally denied care.
What to be done? Oliver has long advocated for a universal healthcare system, and did so once again. In the meantime, he advised handling the current unwinding and Medicaid enrollment in general with more care and efficiency, such as using existing information to re-enroll rather than onerous annual paperwork, as well as more oversight for MCOs. “The reality of Medicaid,” he concluded, “is that too often it’s hard to get, easy to lose and not a priority for the government or the companies we hire to deliver care.”
