The Repair Work At The Bottom Of The Net

Unless and until we have politicians who can speak, frankly and directly, about the need to help people in poverty, it's unlikely we will see progress on poverty issues.

Why does this point - a common sense one I think regular readers here can agree with - need restating?

Because if you want a clearer insight into why healthcare reform is flailing, consider this common sense point: no one is talking about the fact that the most substantial changes to health insurance being proposed are the changes to Medicaid, which would (finally) make that program actually useful and effective in providing good, basic healthcare to the poor.

I've immersed myself in healthcare issues for a long time; and up until this week, I've focused as many have, on other key, if troubling, aspects of the healthcare plan making its way through Congress: the enormous cost, the complicated political landscape, and the maze of vague promises and complicated details surrounding much of the work. I have been - and I remain - very skeptical that at this point we are on a path to seeing an actual bill pass, one that the President can sign, with the reforms we desperately need.

Those last views, of course, are fighting words to some; it can sound as if I'm opposed to reform, or in favor if failure. I'm not... but I have advocated, all along, for a more direct conversation with the public, one that makes clear just what we're dealing with in healthcare issues, and engages a broad conversation where many voices can be heard. And I don't think, until some time in the past two weeks, that we've come anywhere near to having it... which may well be too late to make meaningful progress this year.

I was reiterating this perspective after the President's press conference this week, when Tim Foley over at Change's healthcare blog gave me a new key for seeing what this reform bill all about: the details of proposed changes to Medicaid. I will summarize them briefly, but you can read Tim's fuller description here, or as he suggests, go read the House bill for yourself.

The current problem with Medicaid, as I've mentioned previously, is that it's a 50 state mess: block grants are given to states for covering the poor, and the grants do not provide enough money, generally, to cover everyone in poverty, and many states resist adding funds. The net result is that many people at or just above the poverty line struggle with almost no access to insurance or care.

The House proposal is an enormous improvement: it would return the program to direct federal control; it would insure everyone up to 133% of the poverty rate. It would mandate reimbursement rates for doctors and providers under Medicaid equivalent to reimbursement rates in Medicare.

By itself this is a huge change to our healthcare system and enormous improvement; it's the real guarantee that no matter what happens to a person, there will always be insurance available. It is repairing the social safety net so there's not a giant hole at the bottom of it.

And the problem is... you wouldn't know any of that listening to the current debate. (Well, actually, another problem is that the Senate Finance Committee - which has yet to produce a bill - seems unlikely to follow the House committee's lead.)

Instead the President and Congress have focused attention on a sales pitch to middle class voters - promoting the dual message that, for most people, nothing will change (that's entirely true, since most people are insured, mainly through their employers, or seniors via Medicare), but that for many uninsured people new options will be available. And the concerns that have been raised by - the not poor - pundits and observers and lobbyists have been concerns about cost and government control and a resistance to change.

No one is mentioning that this plan, if enacted... would finally mean decent health care options for poor people. And no one is mentioning that what's been holding up the bill in various committees in both houses... is probably the huge increase in cost for a program that helps the poor.

The Medicaid changes, by themselves, are a huge additional cost outlay to the government (which is the scandal of those block grants - trying to do this on the cheap, for years, has been the real problem with Medicaid), and indeed, the "how to pay for healthcare reform" debate which threatens to derail the whole process is in, many ways, a debate almost entirely about finding the funds for the Medicaid piece - changes to Medicare, even the much discussed "public option" don't represent nearly such an enormous increase in direct government spending. Changing Medicaid on a massive scale does.

Unless and until we have politicians who can speak, frankly and directly, about the need to help people in poverty, it's unlikely we will see progress on poverty issues. If President Obama can't say "poor people" or challenge the popular assumption that the middle class is too self interested to care about those less fortunate... how can we get the reform most urgently needed in healthcare? The real story of healthcare reform isn't about "healthcare for all"; it is making sure we provide healthcare, specifically, to people in poverty. That we spend money - quite possibly very large sums of money - to try and fix an appalling failure to provide insurance and options to poor people. And it means that, for people who care about poverty issues, we may be witnessing the silent kill of something we desperately need. Again. Because no national politician can, or apparently, will speak for the needs of people in poverty.

Photo of Judy Feder at a Center For American Progress meeting on Medicaid (2005), from their flickr photostream, used under a Creative Commons license.