Saturday, February 2, 2013

Kansas, Medicaid expansion, and human rights

In his well-covered “state of the state” speech, the Governor of Kansas, Sam Brownback (full text from the Lawrence Journal World, reported by the Kansas City Star or as you prefer either the Huffington Post’s reporting of it or the Kansas City Business Journal’s), addressed the thorny issue of Medicaid, the program that ostensibly provides medical coverage for the poor, but in reality only covers a portion of them. Most states do not cover childless adults, no matter how poor, unless they are demonstrably disabled, and what qualifies varies from state to state. The financial standard for eligibility is also very variable from state to state; in many places, including Kansas, it is well below the poverty line. Most Medicaid recipients are children in dire poverty and their mothers, and most Medicaid dollars are spent on nursing home care for the medically indigent (and, given the cost of nursing home care, it is really easy to become indigent if you are in one for very long). One of the mainstays of increased coverage for the uninsured in the Affordable Care Act (ACA) is the expansion of Medicaid to all people under about 140% of the federal poverty level.

Brownback said that “Many states have made the choice to either kick people off Medicaid or pay doctors less. Neither of those choices provides better outcomes. Kansas has a better solution,” but, while whether it is better or not may depend upon one’s interpretation of that word, it is not likely to cover more Kansans. He has indicated that no state money would be spent on expanding Medicaid. This does not, however, mean that there will be no Medicaid expansion in Kansas, as for the first several years the costs of such expansion under the ACA will be 100% borne by the federal government. If the state opts for taking the money (and the governor, unlike many other very conservative governors in the US, has been coy about this) it will be able to do so without state dollars. Brownback is committed to eliminating the state income tax, to compete with states like Texas (“Look out Texas, here comes Kansas!”) and is confident, along with his funders like “Americans for Prosperity”, that business growth resulting from his already-implemented tax cut, which has cut almost 1/3 of the state budget income, will more than make up for it (critics note that other states without income taxes have other big sources of revenue, such as oil in Texas and tourism in Florida, that Kansas does not have). This job growth is also part of his plan for getting people off Medicaid With jobs providing an off ramp from Medicaid, we will be able help those in need of services and reduce our waiting list.” (Did I mention there was a waiting list?) But, of course, this assumes that those jobs will come with health insurance. Definitely not a certainty, as most will be low-wage jobs, the kind most likely to not have health insurance coverage, and a state requirement for such coverage is definitely not something supported by the Governor or his political allies.

Whether Brownback will actually refuse the federal funds is uncertain; not all conservative governors have stuck to this principled, if cruel, position. Governor Jan Brewer of Arizona, a darling of the right with her aggressive enforcement of Arizona’s anti-immigrant laws (in an interesting coincidence, largely written by Kansas Secretary of State Kris Kobach), has reluctantly agreed to accept this money (“Medicaid expansion is delicate maneuver for Arizona’s Republican governor”, New York Times, January 20, 2013), as have Republican governors Susana Martinez of New Mexico and Brian Sandoval of Nevada. Of course, all three have a large and growing Latino population which supports and will benefit from Medicaid expansion, and whose votes are becoming increasingly important. Latinos are also the fastest growing population in Kansas, accounting for 70% of the state’s population growth from 2000-2010; they are not only in the bigger cities such as Wichita and Kansas City – the state’s first majority-minority counties are in its southwest -- but they are still not a significant enough voting block for Brownback to have any concern that they might swing an election to a Democrat. Indeed, in the 2012 election, extremely conservative Republicans supported by the Governor and lots of money from Wichita’s Koch brothers unseated most of the states just very conservative Republicans in primaries, giving him control of the state senate as well as house. Indeed, one of those defeated was the Senate majority leader, a rancher from the far southwestern corner of the state where the Latino vote did not prevent him from being beaten by a Koch-funded political newcomer.

Of course, there are reasons to doubt the core economics of Governor Brownback’s policies, based on the state’s economy picking up as a result of his tax cuts; even if one believes that will happen, it will be a long time and those whose benefits have been cut (who, given that the vast majority of the state budget is spent on education, followed by Medicaid and other core social services for the aged and disabled, will be the most vulnerable and our future) will suffer. As for the benefit of no state income tax, I lived in Texas, and the result is that every other tax is burdensome, and those taxes are much more unfair than a graduated income tax: real estate taxes that hurt the elderly and sales taxes that hurt those for whom the costs of the necessities of life are most of their income.

Expanding Medicaid, as called for by ACA, will not solve the problems of uninsurance. There remain not only the undocumented, but those who are employed by businesses that do not provide health insurance, including many that are too small to be required to do so even under the new law (and these are the jobs that Brownback’s policies, if they are successful, are most likely to create). But it will certainly help many families. And that should be the role of government, to help its people survive, and become educated, and be able to maintain their health. Economic growth will likely follow, at least much more likely than by cutting the taxes on the most wealthy.

And of course, at the most basic level, economic growth is not the goal; it is at best a strategy for improving the lives of our people. An article in Kansas City Star on January 20, 2013 ( “As the number of minority students grows in area schools, a learning gap remains” addresses the growth of minority, African-American and Latino, students in suburban as well as inner-city school districts. The article notes that the way school taxes are tied to real estate, “The rich get richer.” But it also quotes an educational leader who notes that “The moral imperative is now an economic imperative….The purchasing power of the new generation will depend heavily on the achievement of students of color. Social Security will need their economic success.
‘Everyone needs to understand…Someone else’s child is directly linked to your economic security.’” That is all true, but, at bottom, the core reason to provide education and health care is not so people will be able buy more stuff.

Recently, I saw the movie Les Misérables. I may be one of the few who did not see the stage play, but I am familiar with the story and loved the Jean-Paul Belmondo version set in WW II. Yes, it was long and not every actor was a great singer, but it told the story, and the story is of the oppression of the poor by those with power, and the occasional brave resistance of people who speak truth to power. And, in the last scene, after Jean Valjean dies, he is transported to a heaven not of clouds and harps and angels with wings, but one in which he and all of those who fought with him are standing on a barricade, continuing the fight.

Yes, the rich and powerful will buy and will influence politicians, and they will often win. But as health workers, and as citizens, it is our job to keep on advocating for the core needs of people, especially education and health care, to be met, not as a byproduct of economic development but as a human right.

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