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.

Latinos and health care in Kansas City, Kansas

Kansas City, Kansas, where I live, makes up the bulk of Wyandotte County. It is the poorest county in Kansas, with a large number of low-income residents of all ethnicities, and stands in many ways in stark contrast to Johnson County to its south, Kansas’ richest county. It is not as poor or depressed as Camden, NJ (see February 18, 2012 blog, Camden and you: the cost of health care to communities); while it has lost many blue-collar industrial jobs, a large number still remain in its Fairfax industrial district (including a GM plant) and along the two enormous trainyards in town. Many of the workers in those plants no longer live in KCK (as the city is known to distinguish it from KCMO). It is seen as a regional “success story” because of the development in the western part of the county around the NASCAR track (and now including a huge mall with Cabela’s, Nebraska Furniture Mart, and a new professional soccer stadium). However, all occurred with tax abatements from the county, so people’s property tax assessments are very high because the value of the real estate is low.

KCK was incorporated early in the 20^th century, combining a number of independent towns, most based around a primary industry, and sometimes even named for it (Argentine, home of a silver smelter, and Armourdale, where there was a meat-packing plant). Much of its history – and present – is determined by its border with Missouri; even today, living in this metropolitan area is greatly affected by being in two states. The Missouri River divides Missouri and Kansas south to Kansas City, where it turns east toward St. Louis, and most of the border between the two states is a two lane street. Quindaro, in the northeast part of the city, is on the Missouri River; it was settled by African-American slaves who crossed the river from Parkville, MO, and, after being dragged south by the current, coming out in the free state of Kansas. Quindaro was a major underground railroad center, and the ruins of the original settlement are now an archeological site, with a statue of John Brown on what was the campus of Western University. The current Quindaro neighborhood is overwhelmingly Black and poor.

Latinos, mostly from Mexico, arrived in 3 waves. The first came to help build the railroads that have been so central to KCK, the second to work in the silver smelter, and the most recent, as in so many US cities over the last 10-20 years, looking for any kind of jobs. 70% of the population increase in Kansas from 2000 to 2010 was Latino; while there are other concentrations, especially in southwest Kansas where there are meatpacking plants and the first majority-minority counties in the state, KCK is definitely a center for Mexican-Americans. The new Latino population is overflowing the boundaries of the traditional Hispanic community, the Argentine (a little confusing, as it is named for silver, not the country of origin of its Spanish-speaking majority), to cover much of the city. A huge mural portrays the history of Argentine, including the migrations of blacks and Latinos and the “clash of cultures” seen in the segment reproduced here.

The Latino community of KCK, like others, suffers the health problems associated with poverty, with young families, and with chronic diseases. The youth of this population means that pregnancy and childbirth, and well-child care, are a dominant health need. Diabetes is very common in the community. And many people do not have good health care access. Most of the industries in town are small, and do not offer health insurance, or offer it with very high premiums, copayments and deductibles. At a time when the National Business Group for Health, representing mostly Fortune 500 companies whose employees have the best health insurance, is predicting big increases in employee premiums, copayments, and deductibles, workers at small companies will be harder hit. And, of course, a large portion of Latino workers are undocumented, and thus ineligible for insurance, although most pay taxes. Even their children, who should be eligible for Medicaid or SCHIP, often do not have coverage because their parents are afraid to enroll them. This is not an idle worry in a state whose legislature is trying to deny in-state tuition at its public universities to students who are legal citizens and residents, often born here, but whose parents are undocumented.

As the poorest county in Kansas, Wyandotte County also has the poorest health status in rankings of Kansas’ 105 counties by the Kansas Health Institute in 2009. In national health rankings by the Robert Wood Johnson Foundation in 2011, Wyandotte County came in at 95 – because there was no data for 10 of the state’s smaller counties. As recently as February, 2012, the Community Dashboard published by Kansas Health Matters, continues, unsurprisingly, to show major health challenges. These go far beyond access to medical care to include the entire gamut of the social determinants of health. Access to preventive care and to early diagnosis and treatment of disease is important, but so is having a place to live. And enough heat in the winter. And enough food to eat. And a safe neighborhood, and safe housing. Often providers decry patients missing their appointments; a recent home visit by a health worker found the steps to be so rotten in front of the house of one such patient that it was lucky they didn’t try to come in – they likely would have fallen and broken their hip.

But access to medical care is an important component of health, and it is limited for residents of KCK. Being in Kansas, there are no publicly funded hospitals (there is one across the state line in Kansas City, MO); there are no publicly funded clinics (as there are in San Antonio, TX, where I used to live). There is no state, county, or municipal funding to provide health care to the uninsured and underserved, not in Wyandotte County or even in the very wealthy (but still with a large number of poor, including Latino poor, residents) Johnson County.  The Affordable Care Act (ACA) promises to increase the number of Americans with insurance, and will make a large difference for many, but will be far from a solution to the issues confronting Latinos in KCK.

First, of course, undocumented people will still not be covered. Then, much of the increase in coverage for the poor will be in the form of expanded Medicaid eligibility, largely funded by the federal government, in 2014. Of course, this depends on finding providers who will accept Medicaid rates.  Many of the Latino and other workers in KCK work for companies too small to be required to provide coverage. People who are not Medicaid eligible or undocumented may be offered the opportunity to purchase insurance, or required to if the “individual mandate” is ruled legal by the Supreme Court, but are not likely to be able to afford quality coverage. We read a lot about “quality of care”, but “quality of coverage” is also important – not all insurance is the same. There are often high premiums, co-payments, and deductibles and also low maximal coverage limits. ACA will help to some degree, but many of our people will be left out in the cold.

KCK has a number of “safety net” clinics, if no publicly funded ones. There are a couple of branches of a Missouri-based Federally-Qualified Health Center (FQHC), but these depend on the higher reimbursement they receive from Medicare and Medicaid; recently the one in the Quindaro moved several miles further west, to a neighborhood with more of these government-insured patients. This was better for their business plan than staying in a neighborhood full of uninsured people, but it left Northeast KCK with no doctors. Luckily, another safety-net, which doesn’t get increased Medicare/Medicaid reimbursement and depends on both grants and paying everyone (including the doctors) $14/h, opened a branch in the community. So, at least, there are community organizations, like these clinics, and the student-run free clinic, and Latino community service agencies, to help. But the need is far greater.

And, of course, like elsewhere, there are not enough primary care providers, especially with the new people to be covered under ACA. This is documented in a recent Washington Post piece “Success of health reform hinges on hiring 30,000 primary care doctors by 2015”. Of course, to “hire” them, they have to exist. Which means training them. Which means paying them enough, compared to other specialists, that medical students choose to enter them.

The health problems faced by Latinos in Kansas City, KS, are not unique. But they are serious. And they demand serious solutions, to be confronted by the city, county and state as well as the federal government and insurance companies. And that is yet to happen.