Posts Tagged ‘poverty’

Idea of “earning” health care may be rooted in America’s slaveholding past

April 30th, 2015

I just recently came across this essay in OpEd News by Cecile Lawrence titled “Universal health care in the U.S. v. the peculiar institution,” connecting the absence to the right to health care in the United States to the legacy of slavery. Furthermore, America’s troubled racial history is a major reason for the country’s paltry social safety net. That relationship has even more resonance now as uprisings over the killings of unarmed black people by police and vigilantes roil from Oakland to Ferguson, Mo., to Baltimore. America has always projected an image of itself to the rest of the world that is false: that of the land of freedom, liberty, opportunity and equal rights. The country is being forced to confront the truth about itself: that it is and has always been the “land of freedom and opportunity” only for some. The right to “life, liberty and the pursuit of happiness” as written in the Declaration of Independence was only meant for the white men who established the United States and those like them.

As the essay above mentioned, inequality was built into the DNA of the U.S. Constitution, and slavery built American capitalism (a book outlining the latter point in detail, but not mentioned in Lawrence’s essay, is Edward Baptist’s The Half Has Never Been Told: Slavery and the Making of American Capitalism). Lawrence notes that the cultural attitude in America is that everyone living here who isn’t wealthy is only useful for doing

wage work…for the benefit of the capitalist system.

I would add that those who, for various reasons, don’t work, can’t work or can’t find work are seen as “less than,” “surplus” or “useless” (with the exception of retirees). American society makes it extremely difficult for such people to survive, let alone thrive, and they are resented by others for taking public assistance, the reason being that they “haven’t earned it.” Never mind that every American uses at least one government program of some kind (the mortgage interest deduction is a popular middle class government program).

Having to “earn” health care – rather than it being a right conferred to people by virtue of being born and/or living in America – is a principle embedded in racist culture. I believe it is the principle by which the U.S. stubbornly clings to the inefficient and unfair system of employer-provided private health coverage. One must “work” to have access to high quality health coverage, preferably at a good-paying, middle class job. If you are unfortunate enough to only land low-wage work, because of lack of education or a bad economy, and your employer doesn’t provide health coverage, you were left with nothing at all before the Affordable Care Act passed, or with lower-tier Medicaid after the law passed. For many poor people living in states where Republican-controlled legislatures have refused to expand Medicaid, the situation is the same as before health reform.

Since black people have been, and are still, subject to employment discrimination, it has been harder for them to access health coverage. In addition, Latinos, because of immigrant status, perceived status, and/or discrimination, have found it difficult to obtain health coverage. Poor whites who live in GOP-dominated states are racism’s collateral damage. Certainly, the situation has improved somewhat under the ACA, but problems remain for people of color. It is very convenient for reactionaries to demand that health coverage be “earned,” rather than conferred as a right, especially if one wishes to keep certain disfavored groups unhealthy and, therefore, unable to compete economically with the dominant (white and affluent) group.  Access to quality health care lifts people out of poverty and helps them start to accumulate wealth. It’s much harder to be productive if you aren’t healthy. What better way of keeping wealth and resources away from marginalized people than by keeping them away from health care? What better way to make sure they can’t leave low-paying jobs, and start innovative businesses? Makes life a whole lot easier for those who oppose health care as a right.

American-style capitalism owes its existence to and has always been dependent upon a desperate underclass. Establishing real social democracy with a European-style welfare state that benefits everyone would eradicate the toxic remnants of the slaveocracy in America – physically and culturally.


Don McCanne, M.D. – Blacks disproportionately being left uninsured

October 7th, 2013

Millions of Poor Are Left Uncovered by Health Law

By Sabrina Tavernise and Robert Gebeloff

The New York Times, October 2, 2013

A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help.

Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.

The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.

“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”

The disproportionate impact on poor blacks introduces the prickly issue of race into the already politically charged atmosphere around the health care law. Race was rarely, if ever, mentioned in the state-level debates about the Medicaid expansion. But the issue courses just below the surface, civil rights leaders say, pointing to the pattern of exclusion.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion. Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.
Blacks are disproportionately affected, largely because more of them are poor and living in Southern states. In all, 6 out of 10 blacks live in the states not expanding Medicaid. In Mississippi, 56 percent of all poor and uninsured adults are black, though they account for just 38 percent of the population.

Dr. Aaron Shirley, a physician who has worked for better health care for blacks in Mississippi, said that the history of segregation and violence against blacks still informs the way people see one another, particularly in the South, making some whites reluctant to support programs that they believe benefit blacks.…


By Don McCanne, M.D.

When the Supreme Court relieved the states of the requirement to expand their Medicaid programs as a condition of continuing to receive federal Medicaid contributions, it was understood that, in those states that did not voluntarily participate, many low-income people who were not eligible for plans to be offered in the exchanges (since they were to have been covered by Medicaid) would now also remain ineligible for Medicaid. Thus the most vulnerable are to be left with no coverage at all. What this New New York Times analysis adds to our understanding is that the sector hardest hit is poor blacks, especially those living in the South.

State politicians must carry much of the blame for this egregious health care injustice. If they agreed to participate, the states eventually would be required to fund only ten percent of this expansion, and none of the costs at the beginning. These politicians fully understood the demographics of the populations they refused to cover. So why did they refuse to authorized the quite modest expenditures that would bring health care to these people? Was it because they are poor? Or is it because they are predominantly black?

Regardless, we can blame not only these politicians, but also the voters who keep them in office. It is heartbreaking to realize that that so much of Martin Luther King’s Dream remains only a dream.

We still desperately need reform that is truly equitable and egalitarian. The Affordable Care Act didn’t get us there.

Re-posted with permission from

Don McCanne, MD: New Census Bureau numbers on the uninsured

September 19th, 2012

Income, Poverty, and Health Insurance Coverage in the United States: 2011

By Carmen DeNavas-Walt, Bernadette D. Proctor, Jessica C. Smith

United States Census Bureau, September 2012

Health Insurance Coverage – 2011

48.6 million or 15.7% – people without health insurance
• 7.0 million – children under 18 uninsured

193.7 million or 63.9% – people covered by private health insurance
• 170.1 million or 55.1% – people covered by employment-based insurance

99.5 million or 32.2% – people covered by government health insurance
• 50.8 million or 16.5% – people covered by Medicaid
• 46.9 million or 15.2% – people covered by Medicare


9.5 million or 11.8% – families living in poverty
• 31.2% – families with a female householder living in poverty

Income Inequality

Income inequality also increased between 2010 and 2011 when measured by shares of aggregate household income received by quintiles. The aggregate share of income declined for the middle and fourth quintiles. The share of aggregate income increased 1.6 percent for the highest quintile and within the highest quintile, the share of aggregate income for the top 5 percent increased 4.9 percent. The changes in the shares of aggregate income for the lowest two quintiles were not statistically significant.


By Don McCanne, MD

The numbers of uninsured decreased from 50.0 million in 2010 to 48.6 million in 2011. That might be good news for the net 1.4 million newly insured, but it is terrible news for the 48.6 million who remain without health insurance.

These numbers, of course, are transitional since new private coverage through the state insurance exchanges and the greater expansion of coverage under Medicaid will not take place until 2014. Even then, the new coverage will be either with private underinsurance plans (low actuarial value and inadequate subsidies) or with the chronically underfunded Medicaid program, with even greater impairment of health care access likely. Worse, 30 million will still have no coverage at all (CBO).

Perhaps even more shocking is that 31.2% of families with a female householder live in poverty – right here in the United States!

And income inequality? The aggregate share of household income has decreased for the middle and fourth quintiles. The middle class is being wiped out!

Of course we knew all this. So why aren’t we doing something about it? Howling in the wind doesn’t seem to be getting us very far.

Re-posted with permission from

Don McCanne, MD: Preventing the implosion of the Los Angeles County safety-net

October 24th, 2011

L.A. County expands no-cost healthcare

By Anna Gorman

Los Angeles Times, October 9, 2011

In one of the largest expansions of health coverage to the uninsured, Los Angeles County is enrolling hundreds of thousands of residents in a publicly funded treatment program and setting the stage for the national healthcare overhaul.

The county hopes to register as many as 550,000 patients and is assigning them to medical clinics for services at no cost to them.

Under President Obama’s controversial healthcare overhaul, millions more uninsured Californians will be eligible for Medicaid — the healthcare program for the poor — beginning in 2014. Even as the debate over the law continues in Washington, California is starting that expansion now and using federal dollars to do so. Altogether, the state expects to receive $2.3 billion to expand and modernize its Medicaid program, known as Medi-Cal, now available only to certain low-income residents.

In L.A. County, the stakes are high. In 2014, the newly insured county residents will be able to seek treatment wherever they want. To keep them with the county, health leaders recognize that they must make the system one of choice rather than of last resort. Otherwise, the only patients left will be illegal immigrants and others still ineligible for public coverage.

“Our survival depends on it,” said Mitchell Katz, director of the county Department of Health Services. Unless the healthcare system improves, he said, “if people have choice, they won’t choose us and the system will implode.”

Health workers began signing patients up for a program called Healthy Way L.A. in July and so far have enrolled 24,000, many of whom are receiving services. County residents are eligible if they are between the ages of 19 and 64, citizens or permanent residents of five years and earn less than 133% of the federal poverty level (about $14,500 for an individual and $29,700 for a family of four).

The coverage is not insurance and cannot be used outside of L.A. County, but it does give patients the ability to receive free primary and specialty care, mental health services, chronic disease management, medication and emergency treatment. Most of the enrollment is being done when patients go to the county’s network of hospitals and clinics.

Over the next two years, the county will pay half the cost for Healthy Way L.A. — or about $300 million — and the federal government will pay the other half. By 2014, when the patients become eligible for Medi-Cal, the federal government will pick up the entire tab, which will help bolster the financially strapped county’s health system.,0,4242519.story


By Don McCanne, MD

This admirable effort in Los Angeles County to include more uninsured adults in its health services programs demonstrates some of the complexities that arise in trying to coordinate health care financing and health care delivery under our current dysfunctional, fragmented system that is being expanded by the Affordable Care Act (ACA).

Traditionally, the county has been the health care provider of last resort. If we had a financing system that covered everyone, there would be no need to support separate financing of a welfare program for low-income individuals, though there would still be a need to be sure that adequate facilities were available in areas with high rates of poverty that might not attract private health care providers.

Between this need to ensure adequate capacity in underserved areas, and the anticipation that there will still be tens of millions of uninsured individuals, forward thinking county health administrators are wise to try to work within the current system, with the anticipated changes under the Affordable Care Act, to be sure that care will be available for these underserved populations. The efforts in Los Angeles County can serve as a model for other counties throughout the nation, though the task is difficult because of the budget constraints that states and counties now face.

So how is Los Angeles County going to finance the safety-net in an unstable environment during the health reform transition? The first phase is to expand the safety-net to cover uninsured low-income adults. This is not an insurance program, but it relies on a contribution of federal funds that would pay about half of the expansion in clinic services for this population. Thus it expands the traditional role of the county as the provider of last resort, with the addition of much needed federal funds.

By providing these patients with a primary care medical home now, the transition to a program financed completely by the expansion of Medicaid will be much smoother.

But then what? The 100 percent federal financing of the Medicaid program applies only to the expansion of coverage for these newly enrolled low-income adults, and it is only temporary, designed as an enticement to states to roll out their Medicaid expansions under ACA. States are already facing severe fiscal problems in trying to finance their Medicaid programs, so what will they do when the extra federal subsidies end for these state programs with greatly expanded enrollments?

This policy nightmare was created by our politicians who decided above all to protect the markets for the private insurance industry catering to all of the population sectors that are above poverty levels. For those in poverty, they decided to use chum money to get the states to expand their Medicaid programs, but then revert to the chronic underfunding that characterizes this program, but which would now be compounded by expanded enrollment.

What would have happened had our legislators instead enacted a single payer national health program? Full federal funding would have been provided for these low-income individuals on an equal basis as with everyone else. Income would play no role in a person’s ability to clear the financial barriers to health care. The safety-net facilities provided by the counties would be fully funded by the program.

Because of a lack of interest by the private health care sector in serving regions with high poverty levels, it is likely that the counties would continue as administrators of these institutions, but they would do so knowing that adequate federal funding would always be there through the single payer national health program.

Think of how much easier the task would be, under a single payer system, for Mitchell Katz, the director of the Los Angeles County Department of Health Services, to prevent the implosion of the county administered health facilities, which we will need regardless of whatever financing system we end up with. But then, Mitchell Katz isn’t looking for a way to make his job easier; he is looking for a way to be sure that health care will always be there for everyone who needs it.

Re-posted with permission from