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From our friends at the Health ThinkShop: Why is my neighbor getting that for free?! The experts tell us … and the Band Plays On…

To work or not to work?  That is the question.  How will Obamacare work for working families?

The Policy ThinkShop is currently having an internal discussion on poverty in America and access to basic healthcare services.  It has come to our attention that many of the states are not supporting healthcare reform and that those states make up more than half of the Nation’s minority community (racial and ethnic communities who are usually overrepresented in poverty statistics).

We asked one of our policy pundits (a current policy expert who grew up in a household below the poverty line) from our Health ThinkShop team to research the topic and provide us with perspective:

America has always had a problem with poverty.  It has struggled to measure it, to understand it. Real Americans have even struggled to even look at poverty for very long without animating it and personifying it at the crossroads of maternity, fatherhood and good old hard work.  The welfare reform ACT passed by the Clinton administration (PRWORA, 1996), or “welfare reform,” focused greatly on people’s seeming refusal to work.  Ironically, the current ACA “Obamacare” greatly focuses on people’s ability to work, while not being able to afford healthcare.

American’s seem to experience significant cognitive dissonance when contemplating concern for the poor if it means giving them things they themselves can barely afford.

This national psychosis is mostly pondered  and acted on by Michael Harrington’s “other,” Other America–these are people who are not poor and have time and resources to define, discuss and develop responses to the poverty problem.  Indeed, the public, policy and media discourses on “things that affect the poor” are usually an insular conversation between the “policy experts” and the media pundits.  Politicians seem to make up their minds based on polls taken after the experts and the pundits have their say, America’s living rooms listen,  and the general public reacts accordingly.

  • Background: As noted by the federal government “[t]he poverty thresholds were originally developed in 1963 and 1964 by Mollie Orshansky, an economist working for the Social Security Administration (SSA). It is important to note that Orshansky’s “multiplier” methodology for deriving the thresholds was normative, not empirical–that is, it was based on a normative assumption involving (1955) consumption patterns of the population as a whole, and not on the empirical consumption behavior of lower-income groups.However, her work appeared at a strategic time. The Johnson Administration had announced a War on Poverty in January 1964, and in late 1964 (when preprints of Orshansky’s January 1965 article were being widely circulated) the Economic Opportunity Act of 1964 was being implemented and the Office of Economic Opportunity (OEO) was being set up. As noted [by the [federal government official reports] , OEO adopted the lower of Orshansky’s two sets of poverty thresholds as a working definition of poverty for statistical, planning, and budget purposes in May 1965. Certain aspects of the poverty thresholds were revised in August 1969 based on the recommendations of a federal interagency committee; in the same month, the Bureau of the Budget designated the just-revised poverty thresholds as the federal government’s official statistical definition of poverty. Additional minor revisions in the poverty thresholds were made in 1981 based on the recommendations of another federal interagency committee.”

The Kaiser Family Foundation has a new report on the central policy tool of the current Affordable Care Act (ACA)–the expansion of Medicaid to persons currently making too much money to qualify for Medicaid–they don’t qualify because they make just over the cutoff for persons in total poverty who currently qualify for the government health program.  Since the federal government began “measuring” poverty, cutoffs and regulations or advisories defining poverty status and access to program benefits have become political and policy footballs.  They have become impactful and controversial because a change in the definition can have huge impact on budgets–especially state budgets who are themselves quite “sick and out of work” in these recessionary times.  To be sure, liberalizing these government program access cutoffs can also have huge positive impacts on the poor, but the poor are not usually at the policy table or in the voting booth for that matter.  Curiously, there is also a nationwide effort by local states to lock the voting booth through added voting requirements that will likely keep poor people (and disproportionately minorities) out of the booth.

The previous debate on poverty in America was about so called “lazy people on welfare.” It included, for example, lots of talk about teen pregnant mothers and absentee (“dead beat”) fathers.

The tenor of the debate was moralistic and accusatory and the target was “lazy women on welfare having babies.”

Today, the debate on healthcare reform and its implementation is more nuanced. The inherent contradiction is that ACA (Obamacare) is about providing access to healthcare services to people who work too much and make a little too much to fall into the previously conservative standard proscribing who qualifies for Medicaid.  This time around, it has been difficult to demonize the potential recipients of this service, though, since the very issue is that they work.

America is at a crossroads.  All of its promises and hopes, the American Dream itself, hang in the balance as millions of people remain in limbo regarding access to basic healthcare services.  Of course, healthcare is one of those commodities that is linked to

life, liberty and the pursuit of happiness.  So we better get this right.

This is not a question to be put to the general public in the media circus or to be debated in partisan circles.  It is a moral leadership question that will require thought, research and reason.  America is not the only nation dealing with economic adversity and inclusion of poor people who may not appeal to tax payers and voters.  The European Community has experienced great economic upheaval, union protests and the rise of xenophobia.  Americans faced these issues in the 2012 election with the top 1% debate, the OCCUPY MOVEMENT and the eventual election of a so called “liberal” President Obama.

America seems increasingly divided between the haves and the have nots.  It is a delicate matter that can destroy America and turn it into another post-industrial democracy struggling to fend off immigrants, while keeping hordes of malcontents from burning and destroying in the name of “protecting the homeland.”  Partisan politics and partisan media sources try to out do one another with vitriol and cynicism appealing to their followers.  To millions of young Americans coming home from ambiguous wars overseas this rhetoric could be confusing.  To millions of Americans in limbo, post College education and pre loan payments pressures, and without a job in site, all this rhetoric could lead to scapegoating.  Wars of global reach are squeezing the federal budget at a time when the states don’t want the federal government to help with local matters.  At the same time, the states can hardly help themselves as recessionary pressures leave them squeezed at home.  Home rule and state rights become less relevant when states themselves loose efficacy not because the feds are in their way but because they have no money.

We may be on the verge of fomenting possibly out of control discontent among partisan and politicized so called “real Americans” who seem willing to throw the Nation’s most critical policy debates into their Tea Party voyage and eventually overboard!

Xenophobia is the direct product of segments of a desperate populous for whom democracy no longer seems to be delivering on the social contract.  As mainstream citizens are forced to live on stagnant wages and are therefore forced to sacrifice basic wants, in order to pay for expensive and not always effective health services, they bristle when they hear that their neighbors are getting it for free!

But as the refrain went “No man is an island.” Health is also one of the socioeconomic, if personal, statuses that may equally affect those around you. If you are sick your disease may be contagious or it may cost more money to help you get better than you can afford. The problem has been that if you do not have access to health information, health education and health services (especially preventive health services), you’re going to cost society sooner or later at the emergency room of an expensive hospital or health center–or you’re going to be a threat to public health–as the spread of HIV so clearly demonstrated.  Sick people cost big money and diseases tend to fester and spread where poor living conditions exist.  On the East Coast HIV often spread through needle sharing in “shooting galleries” (usually empty dilapidated building where drug addicts congregate to share the doping experience) in the cities of Jersey City, Newark and Camden, for example.

Public health is our first line of defense against birth defects, spread of disease and in promoting health literacy.  The public health infrastructure ensures that we are aware of emerging health problems and that communities have a basic infrastructure for responding to (wether through prevention, treatment or recovery supports) emerging epidemics and all forms of local health challenges.  Yet public health is not enough.  America also needs an effective and cost efficient local healthcare system that persons with new healthcare access can benefit from.  It does not currently exist in appropriate culturally and linguistically competent fashion, for example.  If State policy is controlled by those who, by definition, are so different from the so called “poor” then how will that policy process overcome stigma and urban myths about the poor?  

The discussion of poverty and health access must be discussed in a more enlightened and intelligent discourse that allows for reason, planning and long term investment thinking so that policies are supported–especially at the budget table where wise investment and “who is deserving” may predominate the decision calculus of government bureaucrats.

The dilemma this time is not that persons who may qualify for ACA programs are lazy or immoral–presumably, its quite the opposite.  They are young struggling families with young children who can’t afford health benefits but work hard for themselves and the well to do who benefit from their labor.

“People of color will be disproportionately impacted by state decisions to expand Medicaid. People of color make up the majority of uninsured individuals with incomes below the Medicaid expansion limit in both states moving forward and not moving forward with the Medicaid expansion (Figure 1). This reflects that people of color are disproportionately likely to be low-income and uninsured.

Nearly half (47%) of uninsured people of color with incomes below the Medicaid expansion limit reside in the 21 states not moving forward with the expansion at this time (Figure 2). Some 43% reside in the 24 states moving forward, and 10% are in the 6 states where there is ongoing debate over the Medicaid expansion.”

Kaiser Family Foundation Latest (July 2013) Report. Click and Download Here: http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8450-the-impact-of-current-state-medicaid-expansion-decisions.pdf

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