Sometimes all it takes is a few minutes with a researcher to find out that you’re spending too much time watching congressional testimony.
While politicians strive to make this healthcare reform debate about the always sympathetic middle class, as well as about what people who already have private insurance will gain, it seems they’re failing to mention a growing segment of the population: uninsured, low-income families.
Thus, it was refreshing and depressing at the same time to hear Laura Lein — dean of the University of Michigan’s School of Social Work and co-author of Making Ends Meet: How Single Mothers Survive Welfare and Low Wage Work – address some of the unheard issues in the healthcare debate. The talk was sponsored by Women Employed, a national organization advocating for women’s economic advancement founded here in Chicago in 1973.
Now that it’s abundantly clear that we’re not getting a single-payer system out of the current healthcare reform initiative, questions must be addressed regarding who will be eligible for subsidized healthcare, and how they’ll prove that eligibility. Simply looking at the many problems Lein’s research has identified with eligibility requirements, it appears that we have a long and difficult road ahead of us in implementing healthcare reform (if we get it).
In one study, Lein found that some families had to separately prove their eligibility to participate in 30 to 35 different programs just in order to get by. While qualification requirements vary from program to program and from state to state, more often than not it seems that such programs punish enrollees for becoming more stable.
For instance, some states’ welfare regulations mandate what is called an “asset test” to determine eligibility, often meaning that enrollees cannot own cars or homes. But this test can be overly inclusive in its information gathering techniques. If a parent tries to help out an adult child by co-signing on a car loan, they can be classified as “owning” that car, even if they don’t have real access to it.
“Why is it that these eligibility rules become so draconian in the lives of low-income families?” Lein asked rhetorically.
Lein also pointed out a disconnect between the real world and world in which eligibility rules are created, in that the way low-income people get access to healthcare is contrary to the way many politicians think of how the policy should work.
“Welfare, rather than employment, is the route to healthcare,” she said. Indeed, many entry-level jobs that can help transition low-income people off of welfare do not offer health insurance, while at the same time might disqualify a low-income person from accessing Medicaid, for which they were previously eligible.
Another element of instability relates more directly to health insurance itself. Lein told a story of one of her colleagues coming across a young girl that looked perfectly healthy until her smile revealed corroded braces still on her teeth. The family had started an orthodontic regimen for the girl when they had health insurance, which they subsequently lost.
In that case, Lein said, the problem of access to care fell under an often ignored category of “interrupted healthcare.” While a permanent disability or untreatable ongoing illness could be covered under government programs, Lein noted, a mere lack of access to healthcare that could solve an untreated problem does not constitute a “chronic” problem.
One study Lein described entailed conducting ethnographic research over an 18-month period on 80 low-income families in each of three cities: Chicago, Boston and San Antonio. In some communities, Lein said the research team found families had “health profiles that are more similar to those in third-world countries than those in the U.S.,” making care for such groups even more difficult within a system set up to deal with first-world health problems.
Furthermore, the instance of serious health issues multiplied problems experienced by any individual family. In the three-city study, they found that 45 percent of families had two or more members suffering from chronic physical and/or mental illnesses that significantly affected their daily lives.
The one group that has become perhaps the most polarizing in this debate (other than women) is immigrants. The controversial nature of insurance for undocumented immigrants became such a flashpoint that an amendment preventing legal immigrants from receiving healthcare insurance gained significant support before eventually being voted down as grossly unfair to tax-paying citizens who happen to be from other countries.
In the three-city study, Lein said the issue of immigrants and healthcare was on the collective mind of the community in San Antonio in particular. She said the image one got from the local media was that immigrants were flooding over the Mexican border in order to take advantage of the U.S. healthcare system.
“This was really contradicted by our interviews,” Lein said. Not only did immigrants tell her that healthcare was better in Mexico, but Lein had the chance to see for herself. While doing fieldwork in Mexico, one of her three children got an earache. She said the physician and a translator spent 45 minutes with her, gave her daughter a full physical, confirmed that Lein would be able to afford the medicine her daughter required and even explained the workings of the inner ear to her child. The $15 Lein paid the clinic would cover as many check-ups as were necessary.
“By the time I left [Mexico], I was ready to go back for my routine care,” Lein said with a little laugh.
Why does Mexico do such a better job taking care of routine health problems? Lein says it has to do with the system we set up, which tied health to insurance and insurance to employment.
Lein explained that as little as 40 years ago a great deal of childhood routine care, such as vaccinations, came through the school system. She said that insurance is a system built to take care of expensive problems that are unrelated to routine and universal health needs.
“We tend to use the term ‘insurance’ to talk about healthcare,” Lein said. “We’re creating an insurance scheme for what is really not an insurance problem.”
Another part of the problem is our healthcare delivery system itself. Lein compared the situation to paying for kindergarten vs. financing college. She said that kindergarten is “routine” in that it is relatively low-cost and it is expected that everyone needs it. College, on the other hand, costs more and is utilized by fewer people, so that other funding mechanisms must come into play.
“If you want to deliver something at a low cost to everybody, you don’t insure them. You deliver,” Lein said.
Anne Ladky, executive director of Women Employed, added that the paradox of our healthcare system being set up around insurance and employers, rather than the ultimate goal of healthy people, makes the attempt at reform particularly challenging.
“Trying to keep it there and make it something else is going to be really difficult,” Ladky said. She went on to note that her organization is prevented by their insurance carrier from covering part-time employees no matter what, even if Women Employed is willing to pay the extra costs. She said this counterproductive prohibition is one that should be examined, but so far has received scant if any attention on the Hill: “It’s not just about preexisting conditions.”
With all of her experience looking at the problems associated with eligibility requirements, perhaps it is not surprising that Lein would rather they get left out of the healthcare debate going on in Congress.
“I’m a single-payer person,” Lein said. “I see [eligibility criteria] as a very slippery slope.”
And that might explain the location of Lein’s address today. While immigrants and low-income people are not often asked to appear as witnesses on congressional panels, it seems that single-payer advocates are even less welcome at the table these days.
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