Would You Like Health Insurance With That?
Another innovation propelled by the World of Wal-Mart: health insurance at the store.

From today's Wall Street Journal:

Sam's Club, the membership-warehouse division of Wal-Mart Stores Inc., plans to unveil a new health-insurance offering for its customers on Jan. 4, making such a service available in all of its U.S. stores for the first time.

Sam's Club, with nearly 600 U.S. stores, will allow small-business owners with Sam's Club memberships to purchase health-insurance plans for their employees through Salt Lake City-based insurance broker Extend Benefits Group LLC. The coverage is available elsewhere, but Extend Benefits will charge Sam's Club members lower administrative fees: $150 to establish an account instead of $500; and $4 a month for administration rather than $5.

The Journal notes that membership fees make up a substantial portion of Sam's net income, and that this insurance program may help justify higher membership fees. Good for them, perhaps: we need more alternatives for securing insurance. Corporate employment and government programs must not be the only options.

Labels: Health care

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A License to Chill.
Hand your home address over to the state to get a license plate, and you may find a union organizer on your door. That's going to change.

Today's Wall Street Journal (link for subscribers) tells of Cintas, a leading supplier of workplace uniforms. UNITE, a union, sent people to scribble down the license plates numbers of Cintas employees, and used the information to track down the home addresses of workers, who were then given a pitch for why they should join the union.

Some employees were annoyed at the tactic, and a class action lawsuit was born, alleging violation of privacy.

"According to legal documents in the case, union organizers admitted to gaining access to motor vehicle records from Pennsylvania and eight other states with the aid of a private investigator."


The union, of course, will do what it can to find new members, though the facts of the case suggest that it will pay significant penalties. Unmentioned in the article, however, is the question of why the state should be disclosing personal information that it ought to be collecting only for its own purposes. (permalink)

Too Clever for His Own Good.
When is a fee a tax? That's an economic, legal, and today, political question.

In Minnesota, the politicians (Republican governor, Republican House, Democratic Senate, long history of expansive government) did the unthinkable: erase a large ($4 billion, I think it was) budget deficit without raising any significant tax increases.

Last year the "No New Taxes" governor gave ground. Whether it was an acknowledgement of a changing political landscape, a change in convictions, or the result of poor strategic or tactical considerations in politics is a question for others to decide. But the means of increasing the government bite into personal incomes was in some ways more damaging than the actual increase in taxes.

Here's why: Governor Tim Pawlenty insisted that a tax on tobacco was not a tax, but a "health impact fee." Never mind that it looks like a tax, walks like a tax, and talks like a tax (cigarette prices went up 75 cents a pack, and no, I don't smoke, thank you very much). Never mind that by some estimates, smokers actually save the taxpayer money by dying early. (To be fair, I think those estimates are for governments as a whole—the feds may save money while the states just may lose money. Then again, “saving money” could be an excuse for, oh, a 100 percent tax on anything but tofu.) Never mind that fees are for what government provides--a license to drive, permission to play golf on a city-owned golf course, etc. Nope, it's a fee, said the governor, not a tax.

Why the game with language? One possibility: the fee gave the governor a small bit of ground by which he could claim to have kept his no-new-taxes pledge. Another possibility: it would keep him out of legal trouble with Indian tribes and an agreement the state made a few years ago with tobacco companies.

Well, it didn't work. David Strom, one of Governor Pawlenty's most vocal critics on the "health impact fee," comments on a significant ruling recently handed down by the court that oversees the state's tobacco settlement.

Says Strom: "the tobacco companies agreed to pay the state a whopping $6 billion to cover the supposed increased health care costs imposed upon the state by smokers, and in return the state would indemnify them against any future claims by the state government to cover such costs.

What I did not know, and as a non-lawyer really could not know, was whether the HIF actually violated the letter of the contract.

Now we know."

Indeed we do. So much for creative revenue enhancement.

Oh yeah. David, you certainly can say "I told you so."

Labels: Golf

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A Dent in Middle-Class Entitlements.
For a look at how government programs can be a moral hazard and crowd out private initiative, look no further than nursing home financing.

Medicaid is perhaps best known as the program for "welfare families," single or divorced mothers of small children. But the single largest category nationally (and in most if not all states) in dollar terms is the adult population that needs long-term care, or colloquially, nursing homes.

Not everyone will need such care in their lifetime. This suggests that it's an unpredictable event (much like the possibility of a man dying at, say, 52), so you'd think there might be a good market for insurance policies.

Not quite. There is a long-term care insurance industry, but it market penetration is rather small--under 10 percent, I believe. (There are lots of numbers I could dig out from the hard drive for this essay, but hey, Christmas is less than a week away and there's a lot of work to do before the end of the year.)

Why is long-term care insurance to infrequently used? One reason is the stumbling of the insurance industry; companies have made some mistakes along the way, leading to some bankruptcies and rather unpopular premium increases.

But a more fundamental reason for the paucity of long term care insurance coverage is the moral hazard: why pay for insurance for an event that government will pay for? That's what takes us back to Medicaid, which funds the majority (again, if you want statistics, look 'em up--perhaps in the archives of this blog) of LTC.

Government funds the majority of long-term care? Isn't Medicaid just a program for the poor? Well, yes and no. There are ways to become poor, such as shifting assets to one's children, and thus qualifying for Medicaid. It's easy to rationalize this move by saying "Hey, I've worked hard all my life, paid my taxes, and I deserve this." And of course, when everyone else is doing it, the rare individual who pays for his own care has little impact on the public fisc.

State government politicians, meanwhile, like to get the feds (that is, people who vote in other states) to pick up as much of the tab as possible. So the last couple of decades have seen a cat and mouse game between federal and state officials, as one rule change in DC is met with new accounting gimmicks in the states.

Today, the Wall Street Journal (link for subscribers) says that the Washington branch of the political family is thinking of changing the rules again.

Now Congress wants to make it harder for some people who do have assets to get Medicaid to pay their nursing-home bills. The changes, already approved by the House and now before the Senate, would:

- Force people who transfer assets to wait awhile before Medicaid will cover their nursing-home care.

- Bar a person with equity in a home of more than $500,000 from Medicaid coverage. States can raise the limit to $750,000. Currently, in most cases, a person can own a home of any value and still have their nursing-home bills covered.

- Require states to look for inappropriate asset transfers during the five years before a Medicaid application, instead of the current three years.

- Classify certain annuities as assets that trigger the waiting period; annuities sometimes are used to turn large assets into small, Medicaid-friendly payouts.


All good measures, with this goal: "The changes could force the elderly and their caretakers to manage their funds more cautiously, perhaps by encouraging people with means to buy long-term-care insurance or to use the equity in their homes to pay nursing-home bills."

There's no easy way out of the LTC mess. Though technology can help (in-home monitors and the like), good long-term care is by nature labor intensive, which means expensive. Thanks to advances in science and medicine, as well as rising incomes, people are living longer. That's all good.

Demographic and lifestyle patterns have been changing for decades, changes that signal an increasing reliance on paid help. Women, historically the providers of LTC to family members, are overwhelmingly in the paid workforce, often unable to do much to help. Children from a family scatter across the country, making it hard for family members to pitch in together to help mom and pop. So the use of paid help, whether inside a nursing home or out, funded by insurance or by taxpayers, has increased, and will continue to increase, especially given that the "old old" (over 80 years) group is the fastest growing part of the U.S. population.

The ideal solution might be the development of a strong, vigorous, widely-bought-into market for long-term care insurance. But getting there requires dealing with a knot of problems across several policy issues, including regular health insurance and the federal tax code.

By contrast, reforming k-12 education to promote achievement, cost containment, and consumer choice looks easy.

Labels: Health care, Medicaid

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Sunbelt Revolution in Medicaid.
First the people went to the sunbelt. Then the political power. Now, the political innovations.

Florida and South Carolina are leaders in reforming Medicaid, the program that threatens to eat the budgets of every state. Nina Owcharenko writes that "Florida and South Carolina are pursuing federal waivers so that they can bring the principles of choice, individual control, and competition into Medicaid."

Why these states? Among other reasons, they attract a large number of retirees, who often end up in nursing homes, in Medicaid, and that program's most costly recipients of taxpayer money. Most of the money-saving efforts work best outside the nursing home environment, but even those can free up money for other purposes.

Labels: Medicaid

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Come Fly With Me--and Pay My Ticket.
Since deregulation, taxpayers have subsidized to sparsely-visited airports through the Essential Air Service Program. With changes in the program, market forces came more into play.

With recent changes to the program, the scope of the program has been cut. Michael Lowrey of the John Locke Foundation tells how one city in North Carolina lost its air service and another retained it:

"The difference is not some sort of government subsidy or advertising that Kinston provided or Hickory didn't provide but rather in markets. Kinston, effectively represented a new, not previously served, market for Delta. Hickory travelers already could fly Delta from Charlotte and enough weren’t willing to pay a premium for less frequent service closer to home." (permalink)

A New Resource for Health Care Policy Improvements.
Reform in health insurance policy and thinking is slowly coming, helped by a new organization.

Insurance by its nature means relying on a third party to pay some of your bills. But within the current policy framework, many other parties are involved: government regulators, politicians currying favor with patient groups and medical professionals, and HR departments who are looking for a way to save a buck or two on insurance costs.

Little if any of this is good for the individual consumer. Consumers for Health Care Choices
is one group pointing the way to a more sound approach in health care.

The group is off to a promising start with several issue papers.

Labels: Health care

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Tax Limits Live
Does the Colorado TABOR vote mean that tax limits are dead? No way.

The Taxpayers Bill of Rights wasn't perfect as enacted in the 1990s, but it served the state very well. One political vulnerability was the ratchet effect. While some advocates liked it, the ratchet effect--which happened exactly one time in over a decade, if I recall correctly--was a political vulnerability. And the folks who favor ever-larger government, or simply prefer raising tax revenue to doing more with less (or perhaps less with less), used the ratchet as an effective political tool.

Admittedly, I haven't studied the ballot language that the voters approved in November, but from what I recall, voters removed the ratchet. This resulted in many more dollars flowing to state coffers. This is true for the next five years (part of the ballot language). It's also true for the years after that, since it permanently bumps up the baseline.

On the other hand, the basic logic of TABOR is intact: tax revenues and spending cannot grow faster than population and inflation. Any measures that would result in government getting increases beyond that amount must be approved by a public vote. Sounds like TABOR is still a vital tool of prudent government.

What's next is a letter that Colorado's governor (an advocate of the recent ballot measure) penned for residents of Pennsylvannia, where a similar measure is being debated.


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Spending Limits Protect Taxpayers, Promote Jobs

Colorado Governor Bill Owens

11.17.05

As Pennsylvania policymakers consider limiting the growth of government spending, some Pennsylvanians may be under the impression that the government spending cap in Colorado—our Taxpayer Bill of Rights—is dead. To paraphrase Mark Twain, the reports of its demise are greatly exaggerated.

In our November 1 election, Colorado voters fixed a glitch in the spending cap law; they didn’t overturn it, as some reports might have you believe. There was no “up or down” vote. I believe that a majority of Coloradans support the law, and when the election dust settles, other states will see how well spending caps can work and more will adopt them.

Pennsylvania voters will have the opportunity to do exactly that if one of the Constitutional amendments winding their way through your General Assembly makes it to the ballot in 2007. Until then, Pennsylvanians may soon be the beneficiaries of a statutory spending limit that may land on Gov. Ed Rendell’s desk in the near future. For the sake of your economy and your commonwealth’s taxpayers, I hope he signs it.

The spending cap in Colorado is a success story. Added to the state Constitution by referendum in 1992, it helped keep the reins on Colorado’s budget, primarily by using a formula based on population growth and inflation. If taxes provided surpluses above that budget, the money was returned to the taxpayers.

This has meant that our budget could grow, but only at a prudent pace. So when the recession hit, the resulting drop in tax revenue meant serious belt-tightening, but it did not lead to the cataclysmic cuts seen in other states.

The recession did, however, uncover an unintended glitch in the law. As the economy recovered, the law didn’t allow for the budget to return to earlier levels, even though the revenue was available. Any future budget growth had to be calculated by using the lowest point hit during the recession as the base. That was too restrictive.

Compare the budget to a reservoir. During a drought, the water recedes. Then, when the rain returns, you should be able to refill the lake. But instead, because of the glitch, the reservoir had to stay dry. In Colorado, our budget was being kept too low by the rules even though state revenue was increasing.

On November 1, the voters—by approving our Referendum C—fixed the glitch. The voters gave the state permission to retain all surplus revenues for five years, allowing the budget reservoir to return to pre-recession levels. The measure also allows for similar flexibility in the future if an economic downturn again drains the reservoir.

As Pennsylvanians debate the merits of state government spending limits, if you hear from opponents that Colorado voters decimated the spending cap because they decided it wasn’t working, don’t believe it. The taxpayer protections that originally were part of the law are still in place. The same formula for figuring the budget, a requirement that tax increases be voted on and, after the general fund is replenished, the return of tax surpluses to taxpayers remains intact.

Most importantly, however, those who crafted Pennsylvania’s spending limit legislation learned from Colorado’s difficulties and corrected the glitches that led to Referendum C.

But once you get passed the minutiae, most people agree that placing appropriate limits on the growth of state spending makes sense. Why should government spending grow at a rate faster than the growth of the economy in general? The answer is easy. It shouldn’t.

My friend and colleague Ed Rendell understands this. He got it exactly right in his 2003 inaugural address when he said: “Like working families across the state, we must find a way to make government live within its means. That is my first priority as Governor.” His support of a spending limit would be a tremendous step toward fulfilling that priority promise. (permalink)

No Child Left Behind and Statistics.
The No Child Left Behind Act lives and dies on the quality of the statistics assembled to evaluate schools. So if the statistics are improperly derived and assembled, the value of the law is greatly diminished.

The Bluegrass Institute for Public Policy Solutions looks at how the Commonwealth of Kentucky evaluates students, and finds much to be desired. (permalink)

This Opinion Brought to You By ...
Talk about stupid decisions: pundit takes cash from lobbyist.

Doug Bandow has been a fixture at the Cato Institute for a number of years. I always thought he provided some solid presentations of opinions, though I don't always agree with them, especially on foreign policy.

While Bandow has done work for Cato, he has also worked, at the same time, as a syndicated columnist for the Copley News Service. Nice work if you can get it; a syndicated columnist is at the peak of punditry, appearing in dozens if not hundreds of newspapers across the country. And while Bandow probably got someone to bite on the syndicate on the strength of his writing skills, the Cato affiliation certainly didn't hurt.

Well, it turns out that some of his syndicated columns earned him a paycheck not only from the news service, but from a lobbyist, without disclosing that fact to Cato, whose name he was using, or the syndicate.

Now, there's nothing wrong with drawing a paycheck from Cato. You know where they stand, and foundations, individuals and companies that agree with them--or at least think they make an important contribution to policy debates--give them money. In turn, Cato hires people to write, mail out the publications, hold public lectures, and so forth. Many other organizations, left, right, and center, do the same thing.

(Note: companies give away money all the time, and they don't always give them to free-market or conservative groups. Operation PUSH, Planned Parenthood, Greenpeace, ACORN, etc., don't get money only from small-time individual donors.)

There's also nothing wrong with lobbyists, lobbying, and public relations firms. If government is going to have a large say in business through taxation and regulation, business ought to be free to plead its case. Not necessarily to win its case, but to make it.

The trouble comes, of course, when the different spheres--issues education and advocacy versus corporate lobbying--are mixed together. If Bandow wanted to write about Indian gambling (which he did), he had several options:

One, he could, anonymously, write talking points for the Indian's lobbyists to use, or to publish in their own fliers.

Two, he could write on the subject for a publication issued by the tribe (say, a monthly newsletter or web site). Readers could fairly assume that he was, in this case, paid by the tribe.

Three, he could write about Indian gambling as part of his syndicated column, and not take payment from the tribe.

Instead, he took the worse approach, besmirching the name of Cato and by extension, anyone who writes for issues-oriented organizations.

Now, some reactions from National Review Online contributors.

Jonah Goldberg was the first to mention it, and says:

If you take money from someone to do something, say so and let the reader decide. Bandow's a very smart guy, why on earth couldn't he see that? I'm sure there are close calls when you get institutional support and the like. But, cash from a lobbyist?

Katharine Jean Lopez, editor of NRO (I think) adds:

I don't understand either. And it infuriates me. Such things put everything the rest of us do into question. I'm here because I believe the mission of National Review, I believe conservative principles can do a country good...the reasons you'd think I'm here. I realize opinion journalism and commentary isn't a lucrative business, but you're not attracted to it because it is lucrative. You're attracted to it because it's the right thing. Because you can help advance some good ideas. To taint that is to do the ideas an injustice.

Ramesh Ponnuru had this to say:

I don't think the problem is widespread. And I don't think Cato's reputation is tarnished, either: They had one bad apple, and got rid of him when they found out. The Institute for Policy Innovation, on the other hand, does not look good.

Finally, Jonathan H. Adler, an NRO contributor and law professor: When I was working at CEI, I was offered cash payments to write op-eds on particular topics by PR firms, lobbyists or corporations several times. The offered $1,000 or more for an op-ed saying things I agree with anyway was a big deal given the salary structure at a small free-market non-profit. I turned down such proposals every time nonetheless. Send me good information, I would tell them, and if the information checks out, and the story is that good (as it often was), I'll write about it on my own.

Editor and Publisher magazine got the reaction from another right-of-center commentator, Cal Thomas: "The conservative commentator told E&P Online that what Bandow did was 'a big no-no' that 'damages the credibility of everybody' who writes columns.

'I'm getting tired of this,' Thomas added, alluding to other 2005 revelations about columnists on the take."

Nothing like inflicting unnecessary damage on yourself AND people of similar viewpoints. (permalink)

Money is No Object ... But is More the Answer?
Question the premise that what schools need today is more money, and you may viewed as a crank. And yet the Supreme Court of one state admits that more money does not guarantee better students or schools.

The decision from Texas, Neeley v. West Orange-Cove Consolidated, has lessons for any number of states dealing with school finance lawsuits, including Kansas.

(The court's decision is available in HTML, with some awkward formatting, or in an 88-page PDF file.)

As the court hints at (but takes no position on), competition is the missing ingredient in promoting academic excellence, not to mention setting the right price for education.

Labels: Education

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Is Anyone Listening?
One good thing about making a mistake: it shows that somebody's listening.

A reader responds to yesterday's post on pay periods:

"Regarding the two week pay periods...

Nobody is getting paid extra. They do two weeks work; they get two weeks pay.

Furthermore, "extra pay" is only an issue for salaried employees. Hourly employees are paid for the hours they work; pay periods are merely an accounting convenience to decide when to cut the check.

For pay periods that are weekly or bi-weekly, the first pay period of the year will usually include some work performed in the previous year. For a year to have a 27th biweekly pay period, the end of the first two-week period had to fall very early in the year. Thus, part of the "extra pay" is for work that was performed in the previous year." (permalink)

Leap-Pay-Year
Can you get paid more because of a quirk in the calendar? Employees in one state can. Not a bad deal if you can get it.

Here's a passage from the budget recommendations for the state of Kansas. (Part 1 alone takes up 256 pages, in a PDF file)

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The average fiscal year contains 26 biweekly payroll periods. Because of the biweekly nature of the payroll system and how the pay dates have fallen on the calendar since the current system was implemented in 1995, a 27th payroll period will occur on June 30, 2006, the last day of FY 2006. As a consequence, the state will be obligated to pay this extra cost on a onetime basis, which will not be repeated for another 11 years. Accordingly, the Governor's budget includes funds for this expense in FY 2006, which were not budgeted by the agencies. These amounts, the same as the pay plan, are included in the budgets of each agency.

The cost of the 27th payroll will total $64.4 million from all funding sources, of which $32.6 million will be from the State General Fund.
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Take that money and spread it around roughly 41,000 FTE, and you've got a bonus to each employee of about $1,500. Sweet.

Equal pay for equal work? Fine. More pay for the same amount of work? And the legislature actually expects this to happen on a regular basis? (permalink)

I Pledge Allegiance ... to the KPS.
Can a promise of free college education revive a struggling city?

That's the hope of the Kalamazoo Promise.

But first, Yes, there really is a Kalamazoo, as these fine items from the local convention and visitors bureau attest.

To date, the city may be best known for what's no longer there. Sarah Woolley, the subject of Glenn Miller's 1942 hit, I've got a Gal in Kalamazoo, has long since passed the scene, having died in 1981. Perhaps coincidently, Gibson Guitars, (long identified with B.B. King and other musicians) fled town for Nashville the same year.

What else happened around that time? Oh yes, Checker Motors stopped production of its famous taxi cabs.

The 1990s saw further downturns, with First of America (a regional bank) being bought by an Ohio concern, a local GM plant closing down. To make matters worse, the Upjohn Company, a pharmaceutical firm that was the region's "best and brightest" (and most well-paid) magnet was merged into a foreign company, and eventually disappeared into a small unit of Pfizer, the largest drug company around.

Today, then, the city lingers on supported in large measure by government, including Western Michigan University, which is buying the scraps of the old Upjohn Company.

All during this time, the city and its largest suburban neighbor, Portage, engaged in spats over property taxes, "burden sharing," and the like, while many fled the higher taxes and less desirable schools of Kalamazoo for its suburbs.

Now, the old money of the town is desperate to see something done. To their credit they're ponying up some money for the effort. Under the Kalamazoo Promise, which will pay up to 100 percent of the tuition (at state institutions only) of any child from the city.

Scratch that. The offer is limited only to students who graduate from the Kalamazoo Public Schools.

That's a pity. For while the offer will (and already has) encouraged people to move into the city (the city and district overlap but do not have identical boundaries), it gives a boost to one school system: KPS, which is now sheltered even more from the weakly competitive forces that obtain in most urban areas. To be sure, the plan does make living in the city more promising. But it identifies "education" with one specific school system, rather than letting the privately run schools in the area into the mix.

Oh, there's one other thing that Kalamazoo is famous for. It opened the first pedestrian mall in the country, in 1959, leading to the nickname "Mall City." But the mall was opened back up for vehicle traffic in 1998. Over the years the mall was unable to compete with changing tastes and preferences.

The city leaders recognized that an existing structure had outlived its purpose. One day, the school-district-as-monopoly-supplier of taxpayer funded education may also be recognized as obsolete.

Labels: Education

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An Oldie But Goodie: Bombers and School Books.
What's the biggest area of public spending? Defense? No. K-12 education.

In an essay from 2003, Jay P. Greene takes on the "Schools are underfunded theme."

My favorite part: "some argue that once "special" items are set aside, per pupil spending actually hasn't increased very much over time. This type of reasoning resembles (and is about as persuasive as) claims by publicly traded companies that they really had good profits once special charges are excluded."

Labels: Education

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It's Not Its
A note to bloggers: look up the difference between it's and its. With alarming frequency, I see it's incorrectly used. (permalink)

Is 65 Percent the Right Solution?
Standard and Poor's calls into question an education fad that requires 65 percent of education spending to go to the classroom.

The group First Class Education has been pushing states to impose the requirement on school districts. But there are a number of problems with that approach. Among the problems: it doesn't seem to work.

Standard and Poor's has evaluated the relationship between classroom dollars and student performance. In a move that should not be surprising, it concluded that "the specific ways that schools use their instructional dollars may have as much, if not more, to do with student achievement as the percentage of dollars spent on the classroom."

The 65-percent proposal looks smart, on the surface, especially for people who hold to traditional views of pedagogy. But it's also the same kind of one-size-fits-all approach to education that has gotten us into trouble.

A better route is to maximize competition and choice. There is no single environment in which all students excel. Focus on achievement, and the rest will take care of itself.

Labels: Education, School choice

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Vote for Me! I Expanded Welfare!
Does a pro-welfare stance win re-election campaigns? Some governors seem to think so. At least that's the argument that Merrill Matthews makes in an USA Today op-ed.

Matthews gives examples of a Democratic, Independent, and Republican governor who tout their expansion of Medicaid, the government-financed health care system.

"Ironically, for the past decade," he notes, "most governors have been trying to get people off the welfare rolls and into productive private-sector jobs. So why isn't the goal to get people off the Medicaid rolls and into private-sector insurance?"

Both welfare and Medicaid involve taxing some people go give to others. Yet Medicaid has avoided the stigma that propelled welfare into reform. (Welfare reform's effects have been oversold, but that's a story for another day).

As Matthews points out, welfare reform imposed a work requirement, as well as proceeded with a philosophy that people would make a transition to the private sector (in this case, work). But with Medicaid, there is not (yet) an expectation that people will transfer back to the private sector.

Of course, some people--the frail elderly who make up the bulk of Medicaid's expenses--cannot resume work. But there is still room within what we might some day call Medicaid reform, for private sector features. One way would be to convert money spent on Medicaid enrollees into cash payments that would then be used to purchase insurance in the private market, perhaps combined with a health savings account.

The welfare component would still be there--we are still talking about taxing some and giving to others, after all. But there are advantages--Matthews simply lacked the space to talk about them--of making the program more voucher-like.

Labels: Health care, Medicaid

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