You get the idea.

As we all know, the Republican party is all about Personal Responsibility -- for poor people, at least, since they can't afford the lawyers and accountants needed to escape all that unpleasant responsibility stuff. For example, look at Indiana, where the state's Medicaid expansion has gone so well that Donald Trump has appointed Seema Verma, the consultant Mike Pence hired to design the state's Medicaid program, to head the federal Centers for Medicare and Medicaid Services (CMS). Ms. Verma was paid about $5 million over four years to design a Medicaid system that would make sure poor people took more responsibility for their health care, by pummeling them with as many sticks as possible. NPR's Morning Edition ran this terrific story today on what a fine job the state has done of erecting barriers for poor people to jump over to prove they really deserve even limited health insurance:

Personal Responsibility is one of Verma's favorite phrases; when she testified before a Congressional hearing in 2013, she said the federal Medicaid program didn't have enough of it:

Its rigid complex rules designed to protect enrollees have also created an intractable program that does not foster efficiency quality or personal responsibility.

You know, unlike the rigid complex rules you'd find in private healthcare plans, which are so simple and straightforward that many Americans read their policy paperwork for leisure.

So here's the brilliant idea Verma came up with for five million smackers: Make the poor pay for the insurance they can't afford, which is why they're on Medicaid in the first place. But you see, it's only a token payment into a health savings account, between a dollar and $27 a month depending on their income, which gives them the all-important "skin in the game" that will make them Personally Responsible, like magic! Without all that Personal Responsibility, Mike Pence never would have accepted Medicaid expansion in Indiana. Instead of plain old Medicaid, where any slob who meets the income requirement can get minimal access to healthcare, Indiana applied for a waiver to design an alternative that would meet the state's need to shame poor people and throw even more bureaucracy at them.

For instance, the program has incentives: If you get vaccinations and other preventative care, you can qualify for a discount in the next year's premium! But there are also some sticks, because everyone knows the biggest problem poor people have is that while they may be working three minimum wage jobs, they have no sense of Personal Responsibility:

People whose incomes are above the poverty line can be cut off for three months if they miss a payment. Those below the poverty line are knocked down to a plan with fewer benefits. And if a patient unnecessarily goes to the emergency room, extra money comes out of the health savings account.

Cindy Mann, a federal CMS official who negotiated the details of Indiana's plan with Verma, said the original draft of the plan would have cut people off coverage for a full year if they missed a single payment, but the feds didn't allow that for some reason.

The NPR story offers us a case study of how well that Personal Responsibility thing has worked for one woman, Amber Thayer, who has three kids and lives in a shelter in Indianapolis. She's a recovering addict who's staying clean with a prescription for the opioid replacement Suboxone, and she's in school, training to be a nursing assistant. Now, filthy liberal socialists might be inclined to praise her for being pretty darn Personally Responsible in getting her life together like that, but the state of Indiana had to encourage her to take even more Personal Responsibility. So when a bureaucratic snafu led to the state not crediting her for her mandatory one dollar payment, her benefits were cut off to teach her a lesson. She had a receipt and a bank statement showing she had made the payment, but the state took six weeks to get her benefits restored, because their records only showed that missed payment, proof that she was not very responsible at all, shame on her.

During the six weeks she was trying to get her benefits back, she somehow managed to scrape together the money she needed to pay for her Suboxone, one dose at a time, which seems pretty responsible of her, too. She even had the foresight to see the potential dominoes falling if she didn't get that medication:

"I'm fearing, you know, the withdraws," Thayer recalls. But she was also afraid the loss of insurance would interfere with her ability to take her nursing assistant exam, which in turn would threaten the stipend she gets because she is in job training. "If I don't get my stipend, we're not going to have our money to help us move into our home."

That's how poverty is -- you're only one missed payment, one car breakdown, one bureaucratic screwup away from a chain reaction that ends with you on the streets and your kids in foster care. Some guy wrote a book about it that was too offensive for a rich parent in Texas to tolerate, so she tried to have it banned. We must of course note that if Thayer were not a bad person, she never would have become an addict, so really, this was all her fault.

So how well is all this Personal Responsibility working out for Indiana's poors? Maybe not so great. A lawyer for Indiana Legal Services, Adam Mueller, says his clients don't feel like they have "skin in the game" -- for some crazy reason, they feel like they're simply being forced to jump through more hoops.

"They don't feel like they have skin in the game," Mueller says. "One guy told me that it feels like Indiana is trying to take his last $12."

Arkansas tried a similar system for a while, but eventually it turned in such a nightmare to administer that they scrapped it and went with regular Medicaid. Imagine that! Adding an extra layer of bureaucracy costs more and results in crappier health care? Maybe it's worth it, if it teaches poor people to be more responsible. Then the state can look forward to saving money by telling poor people not to take their kids to the emergency room for something trivial like a broken arm.

[NPR]