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Social Policy 2

My current social work course for my Masters in Social Work, is Social Policy 2. Social policy 1 was a history of social policies in the United States, from child protective laws to voting laws, to Medicare and Medicaid, to civil rights and food stamps. The current course, though, is about advocacy: learning how to advocate for changes in policy when you notice a problem in the system. First we have to choose a particular problem area, then we research endlessly, and articulate the problem and who is impacted by it, and then (we haven’t gotten to this part yet) we figure out who to badger to successfully make change.

012

“I can badger! I’m a really good badgerer!”

I have been overwhelmed by the research part so far. In one week, I read thirty articles, wrote eighteen pages, and did at least ten drafts to whittle that down to a two (and a half) page proposal for my project. My focus: the gaps in Medicare, both as a result of the 80/20 split between what Medicare covers and what the beneficiary is responsible for, and in what is covered (not dental, vision, hearing aids, or long term care). Why is long term care designated to Medicaid (the health coverage meant for low-income individuals), rather than to Medicare (which is meant for the elderly and disabled)?

020

“This is exhausting.”

This all led me into the weeds of Medicaid, which is one of the primary targets for budget cuts, both of the current presidential administration and the Republican House and Senate plans to replace Obamacare. Many of the billions of dollars they plan to cut from Medicaid will inevitably come from long term care services for the elderly and disabled.

This led me to the backdoor legal schemes people are allowed to use to hide their income and/or assets, in order to qualify for Medicaid, and the difficulty of those low income people, who are not low-income enough, to afford the elder care lawyers who can competently advise them on the different types of trusts available.

If you have absolutely nothing ($845 a month income, for 2017), Medicaid will catch you when you start to fall through the safety net. But if you have even a drop more than nothing, you are screwed. There is the option of a spend-down plan, where you must incur medical bills in the amount of the difference between your income and the Medicaid income cap every month, in order to get Medicaid coverage, a month at a time. But publicly financed advisors (AKA Free) are not allowed to advise you on the trusts that could hide your extra income, and don’t have enough hours in the day to help each person who needs help to organize a viable spend down plan.

This leaves a lot of seniors without dental, vision, hearing aids, long term care or medical transportation, and in fear of the 20% of any doctor visit or procedure that is not covered by Medicare. Which leads people to skip even the services that Medicare covers, because they can’t afford the fifteen dollars for a cab, or the fifty dollar copay for even routine appointments.

030

“You mean I could skip going to the doctor?”

003

“I really don’t want to go to the dentist, Mommy. Ever.”

There is a campaign slowly going around the United States called Medicare-For-All, with a version that passed in Vermont, and one that made it through the New York State Assembly three or four times now (but has not been able to pass the state senate), and one in California too. What interests me is that what they are calling Medicare-For-All is really not Medicare as we know it. Someone decided that in order to create universal health care, we’d have to fill in the gaps in Medicare as it is, adding dental, vision, and long term care, and limiting co-pays.

So my question is, even if we as a country are not ready to pursue universal health care for everyone in the form of Medicare for all (and it seems obvious that we are not there yet), could we be ready to fill the holes in the health care system that covers the elderly and disabled among us? Is that a step we could tolerate?

Once I fix Medicare and Medicaid, my next project will be to figure out how to add pets onto our existing health insurance plans. Because, really, my dogs are family members. If human children get to stay on their parents’ health insurance until age 26, to make sure they can earn a living on their own before they have to buy their own insurance, surely my puppies, who will never be allowed to work for a living (anti-puppy prejudice!), should be covered by their family’s health insurance too. No?

002

Cricket is not excited by this idea.

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About rachelmankowitz

I am a fiction writer, a writing coach, and an obsessive chronicler of my dogs' lives.

83 responses »

  1. Medicaid programs are administered by the individual states, though – is that correct?
    Funds are allocated to each state which then makes the decisions as to whom and what are covered?
    For example, New York might have a more generous form of programs offered through Medicaid than South Carolina…I’m not sure, but regardless, I sincerely wish you good luck in your project. It would be nice to have someone develop common sense answers to questions involving the welfare of the poor and elderly.

    Reply
    • One of the reports I was reading recently went into some of the differences between states, and something really surprised me: while some states receive about 51% of their Medicaid funds from the federal government, the poorer states receive more, so that the average is about 57% funding for Medicaid from the federal government. That means that these across the board Medicaid cuts will impact the poorest states disproportionately more than the wealthier ones. There are some basic standards and rules for Medicaid, but you’re right, each state gets to decide, within certain parameters, how to spend the money. Without enough money, a lot of these poorer states will have to make decisions that will put lives in danger, and they will only get to decide which lives matter most.

      Reply
  2. This must be a very troubling time to be researching the usefulness of Medicaid as drastic cuts are being proposed as if they don’t affect actual people. I am so glad you have the love of your dogs and mom to ground you. By the way, I look forward each Saturday evening to your posts. A nice end to the week.

    Reply
    • Thank you! I think working on my research, now in particular, has been healing, as a counterpoint to what I see on television. Unfortunately, it also makes the cuts to Medicaid feel much more visceral, and visual, to me.

      Reply
  3. I wholeheartedly agree (with the coverage for pets). I had a conversation with someone the other day and they obviously didn’t ‘get’ the role that ‘pets’ play for some of us. I referred to my Hunydog as my ‘furkid’ and they looked at me as if I’d lost my marbles.

    About Medicare…good luck. It’s a windmill and I hope you tilt at it successfully! The reason (IMHO) that it’s such a mess and things are so out of reach for the TRULY disabled (of which I’m one) and subsequently the elderly (who are ENTITLED to the care), the reason it’s so messed up is that there are those out there who are not disabled, who play at it as a more viable income source. They don’t want to work or they feel entitled to the benefits for some reason of their own. And they pollute the whole pool.

    I know someone personally who should be on disability…severe health problems, has difficulty sitting in one place for a long time, which annoys the employer; and other things that make it more and more obvious they should be taking care of themselves instead of running a rat race. They are afraid to go after it though because (thankfully) it’s becoming so difficult to get.

    Also, as someone near to me pointed out, although we have paid into the fund that helps us in the rainy day of our disability – we didn’t put in ‘enough’ because there’s inflation and greedy politicians who think spending that hard earned money for other things (like vacations, Lear jets and couture for their wives and such) is more important than making sure the ‘insured’ is given adequate health care.

    These are obviously only my opinions. Thanks for listening!

    Reply
    • These are issues that are close to the bone, because they represent life or death for so many of us. Unfortunately, one of the reasons why disability is hard to get is because the Social Security Administration is underfunded, and under-staffed, and the staff they do have are often under-trained. As a result, they are often taught to deny, deny, deny, so that the pool of applicants becomes smaller and more manageable.

      Reply
    • hairytoegardener

      You said it well.

      Reply
  4. Excellent issue that needs a lot of advocacy. One of the downsides of Medicaid and long-term care is the fee ($100-$150 a day in Michigan) that people are charged–and it does not matter if they have any assets. Cutting out the loopholes so that people who don’t really need medicaid would help to free up more money for people who really need the help. Good luck.

    Reply
  5. Good luck with this, Rachel. Medicare and its supplement insurance are going to take a huge chunk out of my social security….which is why I keep working. My employer pays for my health insurance, and cancer treatment is not cheap. Keep fighting the good fight!

    Reply
  6. Can you get rats, gerbils and parrots covered too?

    Reply
  7. This is a big fight! I am rooting for you to win! These issues affect several of my family members as well as a number of friends.

    Reply
    • I would love to be able to make a dent in this. Even though the project is theoretical, I keep thinking, well, I’m putting all of this work into my report, and the research is convincing to me, so…

      Reply
  8. i knew nothing about people ‘hiding income’ to qualify for medicaid! All the while people have to be living on beans – like my late mom – to have medicaid. like most of us, I have been working away, paying taxes, and ‘hoping’ my retirement won’t be all eaten up by medical bills. I don’t know how I will keep paying for the healthcare I now have while employed. Oy Vey!

    Reply
    • The system really doesn’t make sense as it is. A few years ago they started to try and convince people to buy long term care insurance, on top of everything else, but it’s only affordable when you’re in your twenties or thirties, and who’s thinking about long term care then?

      Reply
      • I know. At my age now, spending several hundred a month EACH to cover us with long-term insurance as well as health coverage is nuts.

  9. As with others who have posted comments, I too have relatives “battling” the Medicaid merry-go-round. Well done piece! Thank you

    Reply
  10. That is an interesting topic of research. Most people have no idea how many gaps are in the Medicare program. I recently learned Medicare will cover cochlear implants, which is way more expensive than a hearing aid. I found that strange.

    Also, I think dogs should be covered by our insurance policy. They are our children, after all.

    Reply
    • I read that about cochlear implants as well. I think the logic was that it requires a surgical procedure and those can be covered by Medicare, just like cataract surgery can be covered, but not glasses, usually. Does it make sense? No. Should it be changed? Absolutely.

      Reply
  11. I work for a state social services agency. One of our largest programs (in-home long-term care) is paid for partly by Medicaid funds and partly by state tax monies. Many of the elderly and disabled people benefitting from this program would likely be unable to survive without it. It scares me to think what will happen when Congress makes deep cuts to Medicaid. Thankfully, I live in a progressive, liberal, forward-thinking state and it is my hope that the taxpayers will come to the rescue when our time of need comes.

    Reply
    • Either that, or California will secede from the US and start it’s own single payer health care system.

      Reply
    • As someone with a family member using the in-home long-term care — in a progressive state, but also knowing that my late father had to be reduced to insolvency when he was receiving long-term care, I have mixed emotions. As a recipient myself of Government–provided health care while in the military, I know that Government can be incompetent or beneficial; profit-driven health care can be merciless or providers of expert care. Additionally, when workers do not have good employer plans, save or invest over the course of their 40 year working life, we arrive at this situation. I would still think local or at most state-guided medicaid would be preferable to Uncle taking my income and distributing it. It’s horrible.

      Reply
  12. I am so grateful that the UK have the NHS, flawed as it is!

    Reply
  13. hairytoegardener

    Not sure I have anything valuable to add since everyone else has said it so well. I remember when my poor father-in-law had pancreatic cancer and was trying hard to get on disability. He was denied and told that as long as he could move his little pinky, he didn’t qualify. That was years ago. He’d worked his entire life as a welder. He died alone and penniless. The state I live in is NOT a progressive liberal forward-thinking state. My father is Dutch, and although the system there may have its faults, it’s not nearly as flawed as it is in the US.

    Reply
  14. Medicare is a hard nut to solve everywhere. If anyone is going to get it right it will be you, Butterfly and Cricket. Good luck with the research and social work course.

    Reply
  15. I live in France, so I have good medical coverage, including some dental and for eyes. And thankfully, everything is cheaper here, so that even my vet bills for my pets are nothing like my mom’s and siblings’ who live in the US. I can’t think of a solution – it seems ridiculous to me that the wealthiest country in the world claims it can’t take care of its sick and poor, I think the wealthy are too greedy and have sucked all the money up, using the Republican tax programs to fleece the poor and middle class.

    Reply
    • The United States is one of the only industrialized countries without universal health care. There are so many different successful versions of universal health care around the world, but we only hear about the ones that are failing, or we hear about the parts of those programs that are failing, because that’s what the politicians want us to believe. Americans are not well informed on this subject, at all, and I think that if we were, we’d see a lot of riots across the country.

      Reply
  16. You explained this so well and have given me a lot to consider. I hope you continue to share your thoughts on these issues. Too bad you aren’t running for office! And as someone who has spent quite a huge chunk of money to take care of my wonderful dogs over the years, I agree about the pet insurance.

    Reply
    • I think about all of the doctors’ appointments my Mom took me to as a kid, all necessary, and almost all covered by our health insurance. If I’d been on Medicaid, or had to pay out of pocket, or if my Mom hadn’t been able to take time off from work to take me to the doctor… One of the things most people don’t remember is that Hillary Clinton was the one who got CHIP, the Children’s Health Insurance Plan in place in the nineties. It’s an extension of Medicaid, specifically for children who are in families that are above the Medicaid income limit but still can’t afford insurance. The sad thing is, because most people don’t know about it, a lot of kids who could be covered by the program just aren’t. In a media society like ours, I don’t understand why politicians are so terrible at advertising these things, and giving people the information that will save their lives. Maybe we need to send some media experts to congress to give tutorials on effective communication campaigns.

      Reply
  17. It is amazing how much information you took in on Medicaid and Medicare. I am scared to think what will happen to those who truly do need Medicaid with the upcoming potential changes. I was surprised to earn that there are different policies within Medicare- I researched it when my husband when on years ago- he took the highest plan which costs the most but covers everything- he also had to take supplemental insurance to cover what they don’t cover, and a prescription plan.

    Reply
    • I think most people assume that once they get on Medicare it will be smooth sailing, and they won’t have to pay premiums or co-pays or out of pocket costs, because it’s presented as if it’s a form of welfare, but it’s not, and a lot of people fall through the cracks. There’s an even more extreme image for Medicaid, as if the people who are on it are getting a free ride. In fact, Medicaid doesn’t cover much, and the people who are on it are often working hard to earn a living, or are too disabled or elderly to earn a living, and they are still just barely getting by. I wish the politicians who are fighting against the Medicaid cuts would do a better job of showing the realities of who is on Medicaid and why they need it. The more we can see the actual people involved, the less likely we are to think of them as just numbers

      Reply
  18. Maybe your excellent research will lead you, Butterfly and Cricket to solve this problem! I believe in you!

    Reply
  19. The problem with healthcare to me seems like one stemming from human corruption. Government scams, industry profiteers, fake disability claims, frivolous lawsuits (of course some aren’t frivolous) etc leave honest doctors, patients and even officials defenseless. Public and private healthcare can only truly serve a moral people with no human laws, sadly. No public policy will ever be able to change the human heart, yet I do believe individuals can make small differences in the lives of others. I admire your efforts.

    Reply
    • Thank you! I think we’re all more aware of the people who scam the system than the people who help the system – it’s a more exciting story. I can’t remember which study I was reading (there’s way too much reading in social work school!), but it said that, on average, any system will have about 5% fraud. It’s a lot, but no where near as much as we expect.

      Reply
      • i think regular people committing fraud is probably the least of any system’s problem. The huge amounts of money in insurance, pharmaceuticals, lobbying etc–that’s where the problems are and it’s harder to root them out too–so much bureaucracy. Yet in such a flawed private system of medicine it’s surprising how many medical advances actually do happen. Too complex for me to think about this Sunday with a head cold. 🙂 Very interesting post, Rachel. I’m like your dog–i hide under the bed before ever going to the doctors.

      • Ha! Cricket is great at hiding!

  20. hairytoegardener

    Okay, I came back to comment again. One positive thing in this sea of negative, is that while many doctors don’t want to take Medicare or Medicaid patients, my former doctor decided that while he wouldn’t file private insurance (patients had to file it themselves), he would file Medicare insurance. He did this because he cared. I wish he were still my doctor. (Moved.) Also, there is a lot of discrimination when it comes to Medicaid. One of my adult children has who are on CHIP. She took her daughter and stepson for a dental cleaning, and the dental practice people were rude and unhelpful refusing to provide a referral for one of the children who had an issue. They were treated very poorly as if to say “Please don’t come back. We don’t want you as our patients.” Cricket, could you bite one of the dental office workers for me please? Just a little bite?

    Reply
  21. My biggest concern about Medicaid cut backs are effects on seniors living in nursing homes who have spent down all their savings and now have nothing left other than medicaid. With that gone, what will Trump do, put them out on the street? Skilled Nursing care can easily run $10K/month. How long can you hold out before you need medicaid?

    Reply
    • Seniors and the disabled in nursing homes or needing at-home care are likely to be hurt the worst by these cuts, if only because those are the largest proportion of costs within Medicaid. The sneaky part of the whole thing is that Medicaid is run state by state, so people will blame their state governments for the lack of care first and foremost.

      Reply
  22. My mother is currently enrolled in the Suncoast PACE (Program of All-Inclusive Care for the Elderly), which is a Medicare/Medicaid cooperative program which provides a variety of in-home supports with the goal of keeping elderly people in their own homes and out of nursing homes. It has been a god-send for us. Unfortunately for many people, not all counties in our state, or across the country, for that matter, have agencies willing or able to facilitate the program.

    Reply
    • It sounds like a wonderful program. The reality is, when possible, at-home care in the community is both better for the patient and cheaper for Medicare and Medicaid, but it is so much more difficult to organize than a nursing home, and requires a lot more creativity and thought, and, at least at the beginning, a lot more funding to get things started.

      Reply
  23. Thank you Rachel for this very interesting post, the comments are an education as well. I doubt a single payer healthcare law will make it through in California, but it is a start. Caring for our elderly, children, disabled, and sick should not be a profit making industry.

    Reply
    • I agree wholeheartedly on your second point, but I hope California can move forward with single payer, if only to keep the discussion out in the ether so it can gain adherents. The more people can start to imagine what it would be like for everyone to have adequate health care, the more we can move the political culture in that direction.

      Reply
  24. Glad to see another social worker on the horizon. Good luck with it. i was a social worker for forty years (yikes), I had a wonderful career. But health care for profit is fundamentally corrupting. In Israel where I worked ten years we had universal free health care, and social work was professional: we worried how to provide good service, not how to bill. I also worked with Medicaid elderly in LA. Also a good program. Yes, there’s cheating, especially by providers. Still, I think the gov’t gets cheated a bit more on its defense contracts, nuclear plants, and corn subsidies. Keep up the good fight!

    Reply
  25. Such a timely post! We have to save Medicaid for those who truly need it, it really is the difference between life and death for so many people.

    Reply
  26. Good luck Rachel with this. People in the UK are so lucky to have the NHS, although it doesn’t cover dental work. Love your photos and captions 🙂

    Reply
  27. Very interesting and timely post. My father has alzheimers and knowing that the cost of his care could bankrupt his wife is terrifying. Thankfully they were able to work with a lawyer that specializes in veterans benefits and trusts. It is sad that we have to do that in order to care for our loved ones. Best of luck with your project!.

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  28. Thanks for pointing out that “Medicare for all” doesn’t actually means simply expanding Medicare as it is to everyone. (When I took my healthcare policy class while working on my DPT, my professor pointed out over and over again that any facility that had too high of a percent of its patient population on Medicare would lose money rather than make it and eventually have to close.)
    Then after I graduated I worked for 2 years in one of the poorest counties in Wisconsin – I was astounded when I realized that the majority of people in the nursing facilities were on Medicaid because they had racked up so many medical bills they were now in poverty and could never have afforded staying in the continuing care center otherwise. I can’t stop wondering what will happen to them if Medicaid is cut, as many of them required daily skilled care that families usually just can’t provide.

    Reply
    • The potential cuts to medicaid are just astonishing, given the astronomical growth expected in the senior population and therefore in the need for nursing home and at home care as the Baby boomers age. We have a health care crisis coming and we will need to ratchet up our funding in order to even try to meet it. Cuts make no sense.

      Reply
  29. thank you for fixing
    those little social problems, rachel
    so that this can again become
    a first world society 🙂

    Reply
  30. Thanks for all you are doing and attempting to do. I agree that pets should be covered. They enhance the health and life of their owners and they are family members with fur.

    Reply
  31. I also think I should be able to write off my dog as medication….as a blood pressure lowering drug. Seriously…..

    I wish you well on your degree and your project.

    Reply
  32. Learn about Modern elder care home in Kolkatahttp://bit.ly/2tERScT

    Reply
  33. You always leave me feeling better than I did before I read your writing!!!!! Thank you.

    Reply
  34. Just to be clear, the NHS does provide necessary dental care and treatment free to low income folk, children and pregnant women, though reasonable charges are levied to everyone else. The problem for many is finding an NHS dentist in their area, though by law everyone is entitled to one. Such an interesting post!

    Reply
    • Does the NHS ever cover medical transportation if the doctor or dentist is far away?

      Reply
      • An interesting question regarding dentists (I’d have to look that one up) but certainly for low-income/benefits seriously ill patients there is transportation, not however everywhere or for everyone. These things depend a bit on what the issue is. Taking the elderly to day care etc or appointments is done in minibuses. Pip

  35. I have so many friends who rely on Medicaid who are currently sweating it out, watching the progress of the Trumpcare bill which in any form will apply a blowtorch to Medicaid, and it’s horrible to watch. But worse still is wondering what will happen to them. I’m a little more fortunate in that I’m now on Medicare, and I do have supplemental insurance. It’s still terrifying.

    Reply
    • It really is awful. The crazy thing is that, of all of the criticisms of Obamacare that I’ve heard from people over the years, too much Medicaid was rarely mentioned. In fact, the criticisms were of the states that failed to expand Medicaid when they had the chance. And yet, this seems to be the one unchanging part of the repeal plans. Why?

      Reply
  36. All I can say about the US healthcare system is that unreasoning political fears seem to stop people being helped and it sounds incredibly complicated. It was complicated and inefficient before “Obamacare” because people with any money spent a lot of effort seeking a deal, the companies spent plenty on advertising and there were ludicrous things like someone being covered in one state but not another.

    What I can say about social policy anywhere is that the customer-centred ideology, for all its benefits, is dangerous because so often the customer (client) is narrowly defined – the struggling couple and not the possibly abused child, the guy with drink problems and not the neighbours or partner.

    Reply
  37. Very astute analysis. Great work. I feel your frustration. I think it’s like Humpty Dumpty. All the Presidents’ men past and present can’t put Humpty together again.

    I will add that I am very satisfied with my Medicare coverage. Age 66. T-1 insulin dependent diabetic.

    Reply

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