On Healthcare and Poverty: The Ill-informed and Heartless U.S.A.

The healthcare debate spurred by the election of Trump has overlapped with my own adventures with the healthcare system due to my accident at the end of 2016 and my parents’ serious and fatal health events throughout the summer of 2017.

As a result, I have witnessed vividly how ill-informed most people are—from the general public to healthcare providers of all types—along with how that overlaps with massive and heartless misconceptions about poverty in the U.S.

While the U.S. has a long and disgusting history of racism and demonizing people in poverty, the current failure to provide social safety nets for the struggling has roots in Ronald Reagan’s politics of hatred anchored by the false but effective “welfare queen” narrative.

However, even more significant, the erosion of social programs became standard policy under Bill Clinton’s tone-deaf and self-serving “get tough on welfare” policies in the 1990s.

A robust welfare system and universal healthcare driven by a single-payer system are not only morally imperative in the U.S., but also fiscally essential to provide the stability that would enhance the market and everyone’s ability to prosper.

Answering honestly key questions about the intersection of poverty and healthcare in the U.S. must be committed to facts and not ideology.

1. Who are the poor in the U.S.?

The poor in the U.S. are not a swarm of lazy able-bodied people drawn to free money and thus living off all the hardworking Americans who hate that laziness.

The facts, instead, show this:

First, you can see above that the non-student, non-disabled, non-working adult poor make up around 11% to 16% of the poor each year. This is a pretty small percentage….

As you can see, more than 80% of the officially poor are either children, elderly, disabled, students, or the involuntarily unemployed (while the majority of the remaining officially poor are carers or working people who didn’t face an unemployment spell). I bring up these 80%+ because these are the classic categories of people that are considered vulnerable populations in capitalist economies. These are the categories of people that all welfare states target resources to in one form or another, the good ones very heavily.

2. Why do many in the U.S. believe the poor are primarily lazy, responsible for their own poverty—ignoring how poverty is mostly a lived condition of the vulnerable?

Maria Szalavitz explains in Why do we think poor people are poor because of their own bad choices?:

It all starts with the psychology concept known as the “fundamental attribution error”. This is a natural tendency to see the behavior of others as being determined by their character – while excusing our own behavior based on circumstances.

For example, if an unexpected medical emergency bankrupts you, you view yourself as a victim of bad fortune – while seeing other bankruptcy court clients as spendthrifts who carelessly had too many lattes. Or, if you’re unemployed, you recognize the hard effort you put into seeking work – but view others in the same situation as useless slackers. Their history and circumstances are invisible from your perspective….

A great example of what the fundamental attribution error looks like in real life can be found in the bestseller Hillbilly Elegy. JD Vance writes of seething with resentment as he worked as a teen cashier, watching people commit fraud with food stamps and talking on cellphones that he could only “dream about” being able to afford.

From his perspective, the food-stamp recipients were lazy and enjoyed selling food to support addictions rather than working honestly. But he had little idea how they saw it from within – whether they were using illicitly purchased alcohol to soothe grief, pain and trauma; whether they were buying something special to celebrate a child’s birthday; whether the hard life that he had been able to manage had just gotten the better of others who were born wired differently or who didn’t have any supportive family members, as he did with his beloved grandmother.

3. But the Affordable Care Act (ACA)—known as Obamacare and mistakenly by many Trump supporters thought to be two different programs—is a healthcare disaster?

The greatest charge against the ACA should be that it failed to go far enough in terms of moving the U.S. to universal single-payer healthcare, but the ACA did achieve greater coverage for more people, especially the vulnerable.

What many who blame the ACA for healthcare problems fail to acknowledge is that Republican-led states have purposeful worked to sabotage the ACA:

While the ACA improved access to health care for millions of Americans, it also amplified existing inequities in how states are treated by the federal government. Unfortunately, the Better Care Reconciliation Act (BCRA) proposed in the U.S. Senate not only fails to fix this problem — it essentially locks it in forever. States like Massachusetts and New York spend about twice as much money per Medicaid enrollee as South Carolina. By capping allowable increases in Medicaid spending, BCRA would let northeastern states keep benefitting from more federal funding than states like ours.

This is further exacerbated by the fact that some states expanded Medicaid under the ACA and tapped in to billions of dollars to improve health coverage, while others like South Carolina rejected expansion. Even though BCRA would phase out the Medicaid expansion over several years, expansion states would still collect billions more during that period, while non-expansion states would receive token allocations. There’s something inherently unfair about this — especially since this punishes the states that opposed Obamacare.

4. Isn’t the real solution to better healthcare the free market and not more government?

As J.B. Silvers explains:

This foundational belief rests on general experience in markets for most goods, and it has led to Republican support for Health Savings Accounts (HSAs), in which people set aside their own money to pay for their health care costs.

Landmark research showed that this approach could work – but under special conditions. The RAND Health Insurance Experiment is the basis for current HSAs. It demonstrated that people could save money – with no worsening of their health – if the cost sharing (deductibles and co-pays) was completely pre-funded in individual HSAs. The only major exceptions were for kids and some chronic conditions.

But current proposals have extended this logic to populations, such as those with low incomes and few assets, where these findings are not applicable. Furthermore, HSAs generally are not fully funded to the levels used in the RAND research.

Yet, the Better Care Reconciliation Act, as the current Senate bill is officially called, adds a substantial boost to HSAs, and most state-level Medicaid proposals include a modestly funded health savings account. The problem with this Republican approach is that poor people don’t have any money to begin with and typically can’t afford to buy insurance or pay deductibles.

Silvers also discredits the “let them work” argument:

While the Medicaid expansion enrollees are working already (by definition, they have income above the poverty line), their job prospects and history are marginal. The 30,000 Medicaid recipients in the health insurance plan that I ran as CEO, for example, had about nine months of Medicaid eligibility before they got a job and lost coverage.

But the myth persists that Medicaid is loaded with moochers who simply do not choose to work and won’t pay for coverage anyway.

The fact is that very few fall in this category. Work requirements and required premiums may be simply a way to reduce Medicaid rolls using a faulty assumption.

I have watched and am watching my own hard-working parents suffer dramatic and personal negative consequences of being ill-informed and then participating politically on those calloused beliefs.

Understanding poverty, who the poor are, and how universal single-payer healthcare—these are foundational for the prosperity of all Americans, who must set aside lazy and unwarranted beliefs grounded in disdain for a poor class of citizens who do not exist.

All of us are are will be among the vulnerable categories who suffer the most in the U.S.—children, the elderly, the disabled, carers, the working poor, students.

A final important question we must all answer: Should we all reject being ill-informed and heartless?

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