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Republican plans for Medicaid reveal old attitudes about America’s ‘undeserving poor’

Republican plans for Medicaid reveal old attitudes about America’s ‘undeserving poor’

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HHS Secretary Tom Price stands before Office of Management and Budget Director Mick Mulvaney. Photo: Chip Somodevilla/Getty Imag
HHS Secretary Tom Price, left, and OMB director Mick Mulvaney are pushing for major changes to Medicaid. [Chip Somodevilla/Getty Images]

Will Rep. Jason Chaffetz, a Republican from Utah, change the way we think about health care?

Recall that Chaffetz, who chairs the House Government Oversight Committee, told CNN recently that people might be able to afford health care if they simply didn’t buy that fancy new iPhone. “Americans have choices and so maybe rather than getting that new iPhone that they just love and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care.” About the same time, his colleague Rep. Roger Marshall, a Kansas Republican and Congressional newbie, expressed similar sentiments in an interview with STAT. Said Marshall, “Just like Jesus said, ‘The poor will always be with us.’ There is a group of people that just don’t want health care and aren’t going to take care of themselves.”

Now, I’ve interviewed a lot of poor people in my almost 50-year reporting career and have never found any of them who didn’t want health care or didn’t try to take care of themselves. I can remember their stories vividly, like the California woman with breast cancer who cried because she had no way to pay for tamoxifen. The Arizona woman who went blind from diabetes also comes to mind. She skimped on insulin, not because she wanted to, but because she needed the money to feed her two children who also had diabetes. Her salary of around $12,000 as a nurse’s aide disqualified her from Medicaid and food stamps.

But the meme of the undeserving poor, a notion so ingrained in American thinking for decades, has returned with a vengeance in the fiery debate over repealing and replacing Obamacare, and the comments from the two congressmen, as distasteful, as they may be, dovetail with the Republican’s messaging around their health care plan.

Our collective disregard for poor people is crystal clear in the drive to purge many of them from the Medicaid rolls. At the core of the Medicaid fight is money. The program provides health care and long-term care for 70 million Americans with a yearly budget of about $532 billion. That makes it a juicy target for Congressional and state budget cutters who believe the way to slice the program’s growing costs and save money — some $880 billion over 10 years — is to cap the number of people in the program and limit the federal dollars flowing to the states that help pay for their benefits.

The meme of the undeserving poor, a notion so ingrained in American thinking for decades, has returned with a vengeance in the fiery debate over repealing and replacing Obamacare.

That’s easier and more politically palatable than confronting the underlying reason for the program’s explosive costs and taking serious steps to control them. That’s a topic almost no one wants to touch since it affects the incomes of the health system’s biggest stakeholders. It’s easier to yank medical care away from the poor than to cut the incomes of doctors, hospitals, and drug companies, which give big bucks to political campaigns and whose ideology rules the Washington zeitgeist.

So the paring process begins by pitting good beneficiaries against the bad ones. “There’s a long held tradition in our social welfare policy that we have the deserving poor and the undeserving poor,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University. “Those fighting Medicaid expansion at the state level are saying the same thing,” Alker said, adding that some believe there are able-bodied adults taking away benefits from people who really need them. That rationale is a big reason why only 32 states have expanded Medicaid under the Affordable Care Act.

In defending the Republican plan, White House Budget Director Mick Mulvaney said a week ago Sunday on “This Week with George Stephanopoulos,” “What we’re doing is making sure that the truly indigent still have care. Medicaid is still there. In fact we think it’s going to be even better.”

Better for whom? Indeed the plan will cut federal Medicaid expenditures, but will it be better for those remaining on the program who could get health care with loads of strings attached, like the poor people in Indiana. In that state, “bad” recipients who don’t faithfully make their payments into a “Personal Wellness and Responsibility Account” or POWER account, are penalized. Those with incomes above the federal poverty level, about $12,000 for an individual, lose their coverage for six months if they miss a payment. Recipients with less income simply get less coverage. Their insurance turns into a lower-value plan that requires copays and doesn’t include dental or vision coverage. Plus, they then can only get a one-month supply of prescription medicines, not the three-month supply also available by mail order that those able to make their POWER payments receive. How does that encourage those Medicaid recipients to take better care of their health and take their medicines when the state makes it so hard to do?

In the U.S., the ability to access health care is a decidedly unequal business, and under Trumpcare, it’s likely to become more unequal, especially for Americans in the Medicaid bucket. Mulvaney told Stephanopoulos that Morgan Griffith, a Republican Congressman from Virginia, had “some really good ideas,” and one of them was “putting work requirements in on Medicaid.” (Federal law has traditionally not allowed work requirements as a condition for receiving Medicaid benefits.) Mulvaney said Medicaid recipients could use health savings accounts (HSAs) and would receive a refundable tax credit to help them out. That thinking skirts the question: Do people with so little money for necessities have spare cash to put into a HSA? Still, Mulvaney said these measures “allow people who can’t afford health care right now to get it,” adding that he didn’t understand criticisms of the proposal. He also said coverage is not the president’s goal. He wants everybody to get care. And that’s what we’re doing.” Was the budget director obfuscating the difference between care and coverage? Coverage and care are not the same.

Health and Human Services Secretary Tom Price has said states are likely to be given lots of freedom to design their own Medicaid programs and imposing a work requirement may be one of them. Fifty-nine percent of adults on Medicaid (without Supplemental Security Income) are working themselves, and nearly 80 percent live in a family with a worker, according to the Kaiser Family Foundation. Kentucky has already asked the federal government for permission to require “all able-bodied working age adults” to work 20 hours a week. That could include volunteer work, job searching, or job training. The penalty for not complying is suspended insurance coverage. Neither the government nor insurance companies require able-bodied adults to work or volunteer 20 hours a week to keep their private health insurance. Is that because they aren’t considered poor? 

Despite the Republican talking points, coverage and care are not the same. Everyone needs health insurance to pay for health care. If the coverage people are likely to get through slimmed-down Medicaid or from the Republican plan doesn’t buy much, they don’t get much care, a point made by tweeters reacting to Chaffetz’s remarks about the poor and their iPhones. Emily Willingham, who crunched the numbers on how much certain health care costs would be if measured in iPhones, said it best in her piece for Forbes:

It’s inspiring to think that health care could be affordable if only one were to avoid “getting that new iPhone.” Of course, given that the cost of a new iPhone is under $1,000, that would mean that health care would have to cost $1,000 or less each year, with the assumption that those profligate poor folk are acquiring a new iPhone on an annual basis.

The current war on the poor probably won’t end soon. A 1960s book by sociologist David Caplovitz, “The Poor Pay More,” revealed how the poorest Americans paid more for goods and services than those who had more money. The book helped galvanize support for the consumer movement and support for government remedies. Under the GOP plan, the poor will pay more but this time it will be for their health care, not appliances and food as it was when Caplovitz wrote his book. A recent Kaiser Health Tracking Poll released at the end of February showed that 65 percent of Americans prefer to see Medicaid continue as it is — no block grants or per capita limits. Maybe, just maybe, the pushback against Chaffetz’s remarks presage a shift in how we view the poor and the help they need. Perhaps Chaffetz has unwittingly changed our health care narrative.

Veteran health care journalist Trudy Lieberman is contributing editor of the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.


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There is great understanding and awareness demonstrated by the author, but there is also an area that requires improvement. It has also become too easy to be a blamethrower, resulting in damage to those who are quite devoted along with those who deserve blame.

Many physicians have spent their lives caring for the patients left behind at great cost to themselves and their families. The designs for payment have forced them out of practice and away from people that were their "family." The designs have increased their debts, have forced them to work longer hours and more years, and most importantly have stolen their ability to make a difference in the lives of their patients - as demonstrated in RAND studies. Matters have worsened over the years as physicians have had less influence - and more barriers to overcome to generate the type of relationship needed for some of the most difficult situations in life.

The designs that compromise most Americans and the team members that serve them have largely been shaped by associations, institutions, academics, foundations, and corporations. Not surprisingly the designs continue to favor the largest, most specialized, and most concentrated. Even those who used to be enemies have learned to work together for mutual profit.

The histories of medical education and organized medicine and teaching hospitals and largest systems are interlinked. More recently managed care, managed cost, digital corporations, and other players have been added. The pathway to future leadership runs through these training grounds. Those participating (MBA, lawyer, accountant, physician, consultant...) are all shaped in ways favorable to the status quo.

Meanwhile most Americans and those who serve them have been steadily compromised by these designs. Health care is local and personal and impossible with the compromises most impacting team members. The solution is local - a collaborative approach involving a wide range of local health care providers and those involved in local community resources. This is a movement toward a culture of health with environments of well being shaped from the earliest months and years of life.

Most Americans need to understand this. The media can facilitate understanding or add to the confusion. The designs deny physician, nurse, and clinician leadership to the least organized that lose the most by health care and other designs. Designs that redistribute dollars, services, jobs, leadership, and organizing ability are required to address disparities, maldistribution, and lasting meaningful changes.


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