Tài liệu Poor Families in America’s Health Care Crisis docx

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Poor Families in America’s Health
Care Crisis
RONALD J. ANGEL
The University of Texas at Austin
LAURA LEIN
The University of Texas at Austin
JANE HENRICI
University of Memphis
iii
cambridge university press
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isbn-13 978-0-521-83774-3
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isbn-13 978-0-511-21971-9
© Ronald J. Angel, Laura Lein, Jane Henrici 2006
2006
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Contents
Preface
page vii
1 The Unrealized Hope of Welfare Reform: Implications
for Health Care 1
2 The Health Care Welfare State in America 33
3 The Tattered Health Care Safety Net for Poor Americans 53
4 State Differences in Health Care Policies and Coverage 77
5 Work and Health Insurance: A Tenuous Tie for the
Working Poor 101
6 Confronting the System: Minority Group Identity and
Powerlessness 129
7 The Nonexistent Safety Net for Parents 158
8 Health Care for All Americans 186
References 213
Index 239
v
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vi
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Preface
The United States stands alone among developed nations in not pro-
viding publicly funded health care coverage to all citizens as a basic
right. Rather than a universal and comprehensive tax-based system of
care, our health care financing system consists of three main compo-
nents: private insurance, consisting mostly of group plans sponsored
by employers; Medicare for those over sixty-five; and a means-tested
system of public coverage for poor children, the disabled, and low-
income elderly individuals. Unfortunately, these three components are
far from comprehensive. More than forty-five million Americans have
no health care coverage of any sort, and millions more have episodic
and inadequate coverage. As a consequence, the health care they receive
is often inadequate, and their health is placed at risk. Although many of
those without coverage receive charitable care or are seen at emergency
rooms, they enjoy neither the continuity of care nor the high-quality
care that fully insured Americans expect. As we demonstrate in this
book, the lack of adequate health care coverage is part of a vicious cycle
in which the poor face more serious risks to their health and receive less
adequate preventive and acute care. Because minority Americans are
more likely than majority Americans to be poor, this health and pro-
ductivity penalty takes on an aspect of color. African Americans live
shorter lives on average than white Americans do, and they suffer dis-
proportionately from the preventable consequences of the diseases of
poverty.
vii
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viii Preface
Because of the universally recognized fact that good health repre-
sents the foundation of a productive and happy life, in recent years
the U.S. Congress has extended the health care safety net for poor
children. Medicaid and the new State Children’s Health Insurance Pro-
gram (SCHIP) have extended medical coverage to nearly all children
and teenagers in low-income families. Unfortunately, as we document
in the following chapters, not all children who qualify on the basis of
low family income are enrolled. For nondisabled adults under the age of
sixty-five, no such programs exist. Pregnant women and those with seri-
ous disabilities, including HIV/AIDS, qualify for publicly funded health
care, but adults who are not disabled or pregnant or those in fami-
lies not receiving cash assistance have few options. Those who work
in service-sector jobs are unlikely to be offered employer-sponsored
group coverage that they can afford, and in the absence of universal
health care they have no choice but to go into debt in the case of serious
illness or simply do without care.
Conservatives and liberals approach health care financing and any
potential reform of the current system from different perspectives. As
is the case with other aspects of the welfare state, those approaches are
based on different philosophies concerning individual responsibility
and the role of the state in providing citizens with the necessities of a
dignified and productive life. Health care, however, is different from
other aspects of the welfare state, including cash assistance for the
poor. Since the 1980s and 1990s, public disenchantment with cash
assistance has led to a demand that the poor be forced to take more
responsibility for their own welfare and not become wards of the state.
As part of welfare reform, the entire apparatus of time limits, sanctions,
and work requirements with which the states had experimented for a
decade before the federal government made it the law of the land was
put in place.
Even in this changed climate, with its rejection of long-term cash
assistance, health care for the poor was recognized to be different.
Welfare reform was intended to reduce the cash assistance rolls but not
the Medicaid rolls. Medicaid use was, in fact, expected to increase, even
though the unintended consequence of welfare reform was to reduce
the Medicaid rolls at least in the short term. The expansion of public
coverage for poor children represents a response to the new reality of
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Preface
ix
medical care, one that increasingly affects working Americans. Since
the 1970s, the cost of health care has grown at a rate far in excess of
general inflation, and both employers and workers find that they must
pay ever more for less coverage. Many employers have responded by
requiring that their employees pay a larger part of the cost or by drop-
ping their health plans altogether. Others have resorted to contingent
and contract employment. As a result, a growing number of workers
are not regular salaried employees and receive no retirement or health
benefits from the enterprises to which they provide services. Today,
a growing number of working Americans find themselves with no or
inadequate health coverage. One can be a highly responsible working
adult and find that one cannot obtain health care for one’s family.
Health care coverage is not really an issue that belongs to the polit-
ical right or left. Because a healthy population translates directly into
a productive workforce, adequate health care directly serves the pur-
poses of business in producing profits. Businesses that must compete
globally with competitors in nations in which the workforce is cov-
ered by government-sponsored plans face a disadvantage if they must
provide even tax-subsidized care to their workers. Universal access to
adequate preventive and acute health care therefore benefits business
interests as much as it does labor interests. Management and stock-
holders benefit as profits rise, and citizens in general benefit as healthy
workers are able to pay taxes for Social Security and the rest of the
middle-class welfare state.
In this book, we draw on newly collected survey and ethnographic
data from three cities – Boston, Chicago, and San Antonio – to char-
acterize the nature of the health care system and its consequences for
low-income families. Given the reality of poverty and minority-group
disadvantage in the United States, most of our sample is African Amer-
ican or Hispanic. Although the purpose of the study was to investigate
the consequences of welfare reform for families and children in poverty,
we learned much more about their lives, including how central issues
of health are to the challenges they face. Much of what we document
relates to the despair and humiliation, as well as the inadequate health
care, that many families suffer because of their dependence on the
means-tested and often stigmatizing system of health care financing
for the poor.
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x Preface
We are clearly in favor of universal health care coverage in which
all citizens, regardless of their ability to pay, receive basic preventive
and acute care. As more working and even middle-class Americans
find themselves without coverage that they can afford, the demand for
a more equitable, rational, and comprehensive system will grow. Such
a system will be expensive, and current debates revolve around the
issue of how best to provide the best coverage to the greatest num-
ber of citizens at a sustainable cost. Whatever the ultimate route to
universal coverage, however, we believe that it is eventually inevitable,
both because of the indefensibility of the current highly inequitable
and incomplete system and because of the unique and essentially pub-
lic nature of health care.
The study that forms the basis of our analysis was multidisciplinary
and included the following Principal Investigators: Ronald Angel, Uni-
versity of Texas at Austin; Linda Burton, Pennsylvania State University;
P. Lindsay Chase-Lansdale, Northwestern University; Andrew Cherlin,
Johns Hopkins University; Robert Moffitt, Johns Hopkins University;
and William Julius Wilson, Harvard University. The following Lead
Ethnographers were responsible for collecting the ethnographic data:
Laura Lein, University of Texas at Austin; Debra Skinner, University
of North Carolina at Chapel Hill; and Constance Willard Williams,
Brandeis University. Many other ethnographers, coders, and tran-
scribers assisted in these efforts. A full list of those who participated
can be found at the study Web site: http://www.jhu.edu/∼welfare/.
A study of this size required a great deal of financial support. Several
federal agencies and private foundations contributed generously.
Without their support, we could not have carried out the study.
We gratefully acknowledge the support of the National Institute of
Child Health and Human Development through grants HD36093
and HD25936 and the Office of the Assistant Secretary for Plan-
ning and Evaluation, Administration on Developmental Disabilities,
Administration for Children and Families, Social Security Adminis-
tration, National Institute of Mental Health, The Boston Foundation,
The Annie E. Casey Foundation, The Edna McConnell Clark Foun-
dation, The Lloyd A. Fry Foundation, Hogg Foundation for Mental
Health, The Robert Wood Johnson Foundation, The Joyce Foundation,
The Henry J. Kaiser Family Foundation, W. K. Kellogg Foundation,
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xi
Kronkosky Charitable Foundation, The John D. and Catherine T.
MacArthur Foundation, Charles Stewart Mott Foundation, The David
and Lucile Packard Foundation, and Woods Fund of Chicago. We
thank Pauline Boss for the insights she gave us during the early stages
of developing this book. Finally, we thank the families who graciously
participated in the project and gave us access to their lives.
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xii