Tag Archives: entitlement

The World Owes Me Nothing

I am fortunate to live amid incredibly smart, driven, hard-working people who care about making an impact. Sometimes, some of them trust me enough to come to me for business and career advice.

Before every such meeting, I try hard to set aside my beliefs and biases and just listen. For me, it takes genuine effort to actually listen and remember that listening to someone isn’t really the same thing as just waiting to talk. I do my best not to make someone clearly in pain feel good with the formulaic “10 steps to happiness” psychobabble.

The problem usually starts with a clear symptom : “I hate my boss,” “I don’t have faith in my CEO,” “I deserve more equity,” “I need a bigger title,” etc. Having been in their shoes as an employee, a manager, a CEO, I’ve dealt with many of these feelings myself, so I can often relate to where people are coming from. I suppose that’s the real value of talking to someone—it helps separate problems from symptoms, and knowing the problem is half the solution.

A lot of times, what I discover in these conversations—once we talk through what’s going on and dig deeper into the situation—is that these surface emotions are just really reflections of the real problem, which is larger, more corrosive and harder to admit.

Entitlement.

The problem is we all feel entitled to something. Entitlement is a subtle and implicit belief that we deserve things, that the world owes us something.

The truth, something we all know, is that the world owes us nothing. However, it is hard to remember that at the right time, when you are feeling entitled.

I am not suggesting that having expectations, desires and sometimes taking things for granted is unnatural or even bad. I am saying that if you stop for a minute and zoom out, you’ll start to realize that a lot of your pain goes away if you stop feeling entitled and that dealing with the reality of your situation becomes a heck of a lot easier.

So the next time you are feeling upset about something, try it . Zoom out and tell yourself, “The world owes me nothing,” and see what happens.

When I do it mindfully, I can tell you I feel a sudden emptiness, followed by a delightful lightness. Sure, it may only last for a minute, but that little lull puts things in perspective, replacing the heaviness of “I deserve better” with “I am grateful for what I have. There will always be more I want. It will never be enough, but it will all be OK.”

Try this for a week: Every morning, tell yourself , “The world owes me nothing.” See if it subconsciously affects your thoughts, alters your tone and orchestrates your actions throughout the day. Note how that sets you up for a simple but powerful call of duty, to be useful to people around you—your family, friends, co-workers, customers, investors, neighbors, strangers, everyone! Be grateful for the many, many things you have.

We begin life with a cry. In the end, the only thing that matters is how many people cry when we die. Or maybe that, too, is an entitlement.

Originally published on Medium

When Leaders Don’t Lead on Medicaid

The big debate across the states over the expansion of Medicaid only deals with half of the equation.

The first half of the equation is political: who gets added to the entitlement rolls and who doesn’t. Wisconsin’s Gov. Walker, for example, decided to: turn down federal funds for expanding coverage; add 80,000 adults who are below the poverty line; and move some 70,000 residents who are above the line to the new federal exchange and subsidies.

But Wisconsin, like other states and the federal government, has ducked the rest of the issue: the staggering cost increases. Medicaid expenses, for which the states pay about 40% and the feds 60%, are crowding out funding for just about every other priority: K-12 education, the university system, environmental advances and economic development.

It’s the same story on health costs at the federal level. Medicaid, Medicare and the health bill for federal employees are the biggest driver of the crushing federal deficit. One recent secretary of defense said the department spends more on health costs than on weapons.

The void in the debate is the deafening silence on how to get the costs under control, with the exception of cutting people off the rolls.

It’s especially sad because there are solutions. Leading-edge employers in the private sector have put together a new business model for the delivery of health care that drastically lowers costs while improving health. Their best practices are applicable in the public sector, as some units of local government have discovered to great advantage.

Here are some proven, audited, beyond-debate cost-cutting moves that could be made with Medicaid plans:

  • Consumer-Driven Health Plans (CDHP) — Indiana has received a waiver from the Obama Administration to install Health Savings Accounts and to set higher deductibles for Medicaid recipients. Such CDHP plans cut costs by 20-30%. School districts and counties have deployed HSAs, as has Indiana for state employees and Purdue. Medicaid is rife with utilization abuse, because of an absence of such incentives and disincentives.
  • Reference Based Pricing (RBP) — CALPERS, the giant California pension fund that buys health care for 1.3 million members, has installed caps on procedures, such as $1,500 for colonoscopies and $30,000 for joint replacements. It’s easy to pay twice those maximums or more. But why do it? Why not RBPs for Medicaid? Note: A good number of providers have accepted the maximum prices.
  • Medical Homes — Another 20-30% can be cut from medical costs by offering proactive primary care. Many companies have set up on-site clinics to provide holistic care and keep people out of expensive hospitals. Why not set up medical homes where there are concentrations of Medicaid patients? Primary care is a lot less expensive than specialty care, the main offering of large hospital corporations. It’s also less expensive by far than care from emergency rooms, to which Medicaid entitlees often default. Obamacare provides some funds for community health centers, so there is a start for such medical homes.

The biggest problem for introducing aggressive and innovative management into Medicaid dynamics is the joint ownership of the program by federal and state governments. Differing agendas produce stalemate in most states. And, in the void, the costs scream upward.

Gov. Walker turned down the new federal dollars for a larger Medicaid program because of skepticism about the long-term availability of federal dollars. The soaring, unsustainable cost increases give substance to his position.

But his worry should be redirected to the costs. His concerns could be mitigated if the overall charges were sharply reduced.

He would look presidential if he followed the lead of private sector payers. That, again sadly, is in the political arena, so he probably wouldn’t get a federal waiver from the Obama administration for innovations, even if Indiana did.

Who loses in the managerial paralysis, when leaders don’t lead? In the case of Medicaid, it’s the taxpayers and poor people.

Medicaid Expansion – A Hand Up Or A Handcuff?

Medicaid has several components, but at its core it is a health insurance program for the poor. States can differ, but most provide for those below the poverty level. Federal health reform requires expanding Medicaid to those earning up to 138% of the poverty level (about $25,000 for a family of 3). The U.S. Supreme Court has ruled that each state can accept or reject the expansion of Medicaid. Like other states, Georgia must make that choice. This analysis addresses the human impact — not state financing, our national debt, or deficit spending. The key question: Is Medicaid expansion beyond the poverty level a “hand up” or a “handcuff?”

Unlike other income levels in America, getting ahead is less likely if you are in the bottom 20%. The Economic Mobility Project of the Pew Charitable Trusts shows 65% of children born in the lowest 20% of incomes stay in the bottom two quintiles.

Upper Limit of U.S. Income Quintiles: 2010
Lowest 20% Second 20% Third 20% Fourth 20% Lower limit of top 5%
$20,000 $38,043 $61,735 $100,065 $180,801

If the core philosophy of Conservatives is producing upward economic mobility and Progressives are for helping the poor, why have both ideologies failed the poorest among us? Scott Winship, a researcher at the Brookings Institute has said, “The bottom 20% in the U.S. looks very different from the bottom 20% in other countries.” Americans are more likely than foreign peers to grow up with single mothers. In poor communities, drugs, alcohol, violence, and ineffective primary and secondary schools represent a huge barrier to economic mobility. The United States also has uniquely high incarceration rates, and a longer history of racial stratification.

With all those challenges, the Brookings study showed that regardless of race or ethnic background, if you stay in school at least through high school, don’t have a child until you’re married and over 21, and work full-time at any job, your chances of being poor are only 2 percent and your chances of joining the middle class are 74 percent.

More than other countries, poor Americans have to educate and work their way up from the lower levels. The United States provides many benefits for the poor, disabled, and unfortunate. No one of any rational political or ideological persuasion is opposed to helping those in need.

The key part of Medicaid is also called “Temporary Assistance for Needy Families” or TANF. Under health reform Medicaid would be expanded to 18-20 million new lives. Other health reform subsidies through exchanges are available up to 400% of the poverty level (about $92,000 for a family of 4). Programs affecting larger percentages of the population can create an attitude of entitlement and a culture of dependency that traps segments into intransigent generational poverty.

A study of entitlement programs in Colorado illuminates the concerns for Georgia and other states. Programs are available to low income families to provide housing, food, healthcare, educational, and other subsidies. A single mother with two children making $25,000 could be eligible to receive about $18,000 in government benefits.

Maximum Available Tax and Benefit Programs

Medicaid expansion and other health reforms add new subsidies for low and middle income families. Using the same example of a single mother with two children, Medicaid expansion to 138% of the poverty level can provide an additional $7,500 in benefits to those making $25,000.

Health Benefits

What are the effects on real people as they try to advance economically? The marginal effective tax rate from federal income taxes, payroll taxes, and state income taxes, for a single mom with two children earning $25,000 is about 29.4 percent. If one includes other programs, SNAP (food stamps), state children’s health insurance program, and the new health reform subsidies, the marginal tax rate rises to 54.5 percent.

If benefits like Temporary Assistance for Needy Families, federal housing subsidies, and WIC (nutritional program for Women, Infants, and Children) are considered, the marginal tax rate is as high as 81.9 percent because families lose even more benefits due to higher earnings.

Who would work harder, take that extra job, or seek a promotion when most of the added earnings would be taxed away or government benefits are reduced? The destruction of initiative can be the inevitable consequence of expanding Medicaid with an additional $7,500 (for a total of over $18,000) to someone making $25,000, but providing nothing to a similar family making $75,000.

Clearly, even the most compassionate among us can see that accumulated effects of entitlement programs can break the spirit of personal responsibility and the motivation for upward mobility. Medicaid expansion and the new health reform subsidies to over 50% of the population are likely to produce the same dependence and economic barriers to upward mobility already evident in the lower 20%.

The standard of living in Georgia is directly related to its citizens’ ability to produce goods and services others want to purchase. Subsidizing able-bodied populations does not create economic growth for those individuals or for the state. In our compassion to help those in need, we tend to look away from the politically driven expansion of those programs and the debilitating dependency culture they enable. Georgia has apparently decided not to play that destructive game. Good for us.

As we look to the future and better ways to solve the problems of healthcare and health insurance, maybe Georgia can create an island of opportunity within a sea of growing dependency. Maybe we can remove the handcuffs of those chained to the programs and ideas of the past and offer a hand up rather than a handout.