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Medicaid Change – What health reform proposals say about our values

Full credit to Dr. Gary Greenberg of the Urban Ministries Open Door Free Clinic here in Raleigh for making this point to me recently. All the health reform proposals now in Congress, even the most conservative Baucus Senate Finance version, include what amounts to an enormous change in our values about health care. All health reform proposals would set an annual individual income floor of about $14,000 (one of the Senate bills is slightly higher – about $16,000) where every person would qualify for Medicaid — state/federal health coverage for very low income people.

That’s a big change in our values, at least the reality if not the perception. Most people believe that if you become very, very poor, there is a safety net health coverage program to help – Medicaid. But that simply isn’t true. To get Medicaid not only do you have to be very low income but you also have to fall into certain categories that, over time, legislators have felt as more deserving than others. This is where the term “deserving poor” comes from. So, for Medicaid right now, you have to be low-income and a child, pregnant woman, parent making less than about $7,000 a year, severely disabled or elderly and making less than about $10,830 a year. Don’t fall into one of these categories? Then it doesn’t matter how poor you are – you won’t get Medicaid in North Carolina.

For example, a 55 year old adult who got cancer, lost his job, sold his house and all other assets for treatment, and now is completely impoverished can’t qualify for Medicaid coverage. A 35 year old adult without kids who is working multiple part-time jobs but making less than the poverty line of $10,830/yr can’t qualify for Medicaid coverage. A 40 year old low-income worker whose business has shut down and who just needs coverage for a few months until he finds another job can’t qualify for Medicaid.

As Dr. Greenberg makes clear, these are the sorts of people coming into his clinic for free treatment because they have nowhere else to go. And he often sees them long after they should have been seen by a doctor. In addition, the great treatment Open Door provides and their relationship with other providers in Wake County through innovative local health access projects means specialty care can be found, but this system is no long-term substitute for full comprehensive health coverage.

The reform bills in Congress all change this by setting an absolute income floor below which very low income people can get health coverage when they clearly can’t afford to pay. Above this limit we expect everyone to contribute a fair amount to their premiums and co-pays, and how much that should be is driving a substantial part of the current debate. But the bills in Congress signal an important change in our values – if someone falls far into poverty at least we won’t deny them the treatment necessary for good health and the opportunity for success. Based on my discussions with many different North Carolinians, that’s something we can all agree on.