13 October 2010

The Deserving Poor

One the the benefits of visiting Vegas for the ACEP conference is that I met an alum at the dinner for my residency program, who also happens to be a health policy wonk, ER doc, and progressive blogger.  Who knew?  Anyway, she is currently blogging over at Doctors for America (formerly Doctors for Obama, I recall), and she put up this very nice post:

The "Deserving Poor" and the "Undeserving Poor"
A cruel disparity exists in the US.  Most states in the nation currently recognize two separate groups of the poor—the “deserving poor” and the “undeserving poor.” The deserving poor include pregnant women, children and their parents or caregivers, and the disabled.  The undeserving poor largely consist of childless adults.  The deserving poor are provided with health coverage through the Medicaid program.  The undeserving poor—no matter how destitute they are—do not qualify for Medicaid benefits.  As of 2006, there were about 9 million adults without dependent children living under the poverty line who were uninsured.
I highly recommend you click through to read the rest, and add Progress Notes to your reader -- there aren't enough openly progressive medical blogs out there.

On a policy point, I would like to point out that this is one of the real advantages of the PPACA -- it expands medicaid to 133% of the federal poverty line and eliminates this notion of the "undeserving poor," and does so in a very efficient manner.  Medicaid is by far the most cost effective method of expanding insurance coverage.  More importantly, the PPACA takes this cost almost entirely on the federal budget.  This is important because state budgets are strained to the breaking point by medicaid, and the costs of medicaid are highly counter-cyclical. By that we mean that as the economy craters and state revenues plummet, more and more people find themselves jobless and become medicaid eligible and the cost to states for medicaid soars at exactly the time they can least afford it. So by paying for the medicaid expansion federally, health insurance is expanded relatively painlessly to state governments.  I might add that another benefit of the feds paying for the medicaid expansion is that they will now be responsible for the bulk of medicaid costs in most states, which sets the perfect precondition for a full federalization of medicaid.  This would be great on so many levels: standardized enrollment and eligibility criteria, roll the administration under CMS instead of making 50 state governments reinvent the wheel, and free the states' inelastic budgets from the crippling and ever continuing explosion of the costs.

Now I can already hear the objections -- "Medicaid is shitty insurance!" "I lose money on every case!" "Coverage doesn't mean access to care!"  All true.  Of course, this is mitigated at least somewhat in that the PPACA brings medicaid reimbursement for primary care services to parity with Medicare services.  Medicare may not be the greatest payer, but it's an improvement for sure, and this will also improve access to primary care.  (It's also another argument for federalizing Medicaid -- it would probably create parity for all service lines.)  But it's also a darn sight better than nothing, which is exactly the alternative offered by those advocating for the repeal of health care reform.


  1. Rheumatologist10/13/2010 9:41 AM

    I don't take Medicare or Medicaid. Don't take any insurance. If people want to see me, then can pay me cash, just like I pay my plumber, electrician, mechanic and grocer. Welcome to life; it's expensive.

  2. Rheum --

    That's nifty for you, but it doesn't exactly count as a health care system, does it? First of all, you shut out the poor this way, which is perfectly within your rights but doesn't work when you scale it up to the entire nation. Second of all, you are a low-cost service provider in the grand scheme of things. Hospitalization, chemo, remicade and the like are much more expensive -- and unaffordable without risk pooling/cost sharing. Mediacre and medicaid are pretty essential for these purposes.

  3. My friend is one of those undeserving poor, at the age of 24 he's been given 3 more years to live due to degenerative genetic diseases, however, the diseases haven't progressed to the point of total takeover yet. He can't hold a job due to chronic pain, loss of bladder control, etc, but he can sit at a desk and smoke weed for now to kill that pain and that just makes him ineligible for all kinds of jobs - least of his problems is that no desk job will allow him to smoke. It takes a long time to qualify for long-term disability where I live. By the time he receives anything substantial he'll be half way to his deathbed. (ironic?) With treatment, his quality of life can improve, maybe he can actually get medication for his many "non-fatal" symptoms, maybe he might be able to get a job where he can pay his bills. But that's a lot of maybes and time's running out. What to do then with a poor, dying, and eventually homeless man?

  4. Great post(as usual), and thanks for the link to the progressive blog.

  5. Thanks for a great post. It is helpful to read a sane, rational voice after working in an office with a loud, rumor-spreading, fearmongering, medicaid-hating anti-"Obamacare" dentist.
    ugh, it feels good to call him that without the threat of losing my job.
    Honestly, when I hear a person use the term "Obamacare," my respect for them drops.

  6. Yes, with 10% unemployment we're all a disgruntled boss away from being the undeserving poor.

  7. "deserving poor" means "ghetto teen who has found a thug to have sex with, thus, lifting her up the ses ladder." Her Surrogate Husband will support her from there.

    Having sex with a thug is a lifestyle strategy. Surrogate Husband will then give her WIC, Medicaid, earned income credits, section 8 housing, gov't-assisted housing, gov't-assisted recreation, food stamps, title 1, child care credits, free and reduced school meals, Head Start, etc.

    Many men can not compete with Surrogate Husband. Men must earn at least $35,000 to compete with SH, or they will eventually be discarded.

    Sadly, Surrogate Husband is an absent Surrogate Daddy.

    40% of our babies are born to


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