An Immigrant, Undocumented, Uninsured

I have a friend I’ll call Maria. She lives in San Francisco, but her story is very probably the same as any number of Marias in Atlanta, New York, Chicago and elsewhere. You may not know her, but I’ll bet your paths have crossed.

Maria came here from Mexico 22 years ago. She has never applied for citizenship, largely because for the first few years she was in the country her English skills were so limited it would not have been remotely possible. Recently she has been afraid to try. Maria has a 20-year-old undocumented daughter, an extraordinarily smart illegal immigrant/recent college graduate niece and a large, extended family of mostly undocumented immigrant adults and American citizen children. The niece, tired of living in a very rough part of town, went online a few years ago and found them some minimally affordable rental housing toward the ocean. They have a strong sense of belonging.

Maria and the other women clean houses for a living; the men work for landscaping companies. They drive cars without licenses because they can’t get licenses. But they are little threat due to the fact that one minor brush with the law and (Maria’s daughter explained to me in some detail) you’re out $1,000 including towing charges and fines.

Maria’s family does not do in-home care; however, there is another large, mostly undocumented community of Pacific Islanders who are highly recommended and routinely called upon when seniors (and others) here require but cannot afford extended nursing care. Not nurses by a long shot, they are nevertheless highly skilled.

Whenever Maria or other members of these communities need medical care they go to the county hospital. If the need is sudden or extreme, they go to the emergency room. Either way, they pay small amounts and they get excellent care. I’m grateful for that. They are all truly good people, honest, hard-working and contributing members of the larger community. They don’t pay income taxes (and have no Social Security accruing) but they buy local, pay their rents on time and add to the economy.

I do not support illegal immigration and am SURELY not advocating health insurance coverage for the undocumented, the very mention of which is enough to sink any reform in a New York minute. But it is a subject of contention constantly just below the national surface — or sometimes above the surface, as with the ill-mannered Joe Wilson.  As reported last week in the San Francisco Chronicle (and widely elsewhere), the current policy is clear:

Under long-standing federal policy, people who are in the United States illegally don’t qualify for federal health programs, and the current proposals for reform in Congress hold to that. With the exception of limited emergency Medicaid primarily for pregnant women and children, and some hospital funding, federal dollars do not pay for the care of people who are in the country illegally.

The health care reform bill in the House explicitly bars “undocumented aliens” from receiving federally subsidized health benefits. A Senate version doesn’t address the issue, suggesting that current policy would remain unchanged. A second Senate bill has yet to be released.

Some would have us go farther, requiring a system verifying immigrant status to be incorporated in the final health bill.

“If you don’t have a provision that clearly requires applicants’ immigration status to be verified, just to state that illegals won’t be covered is misleading,” said Yeh Ling-Ling, executive director of the Alliance for a Sustainable USA in Oakland.

Opponents argue that such verification systems would add a layer of bureaucracy and cost, and unintentionally screen out U.S. citizens who lack proper documentation. They also contend that denying a segment of people access to health care, even if they are illegal residents, could increase costs for emergency care as well as the risk for contagious disease in the general population.

However angry those are who are raising their voices about “illegal aliens,” that last sentence is worth consideration. If you cannot bring yourself to care much about the health of uninvited fellow residents of our corner of the planet, you may still want to look at this reality: treating colds in emergency rooms is an expensive folly; colds left untreated for want of an option breed more colds.

A lot of the anger is easy to understand. The economy has tanked, times are tough, you gotta blame somebody. But until all we documented citizens are ready to quit eating strawberries and drinking wine, and to forgo such niceties as in-home care and mopped kitchens, we would probably do well to care about the lives of our undocumented neighbors.

Via: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/09/11/MN4A19GI9I.DTL#ixzz0R040rESh

Public Option: the Single Payer Salve

Single payer proponents are still stung by the loss of their big issue to other big issues — or big players, if you will — but the prospect of a strong public option is the balm that may still salve that wound. This was one of the messages delivered by Giorgio Piccagli, President of the California Public Health Association, North and member of the Executive Board of the American Public Health Association at a panel discussion tonight sponsored jointly by OWL of San Francisco (The Voice of Midlife and Older Women) and the League of Women Voters of San Francisco. Audience members were urged to fight, among other things, for retention of the provision which would allow states to have single payer. (A California single payer bill passed the Senate Health Committee this spring and will be heard by the full Senate in 2010.)

Fellow panelist Debbie LeVeen echoed the call, saying a “robust public plan” must be national, to insure it’s large enough, must have authority to set prices and to bargain on drugs, and use the Medicare provider network.

Backing his call for reform with increasingly heard data such as sobering figures about uninsured Americans (45 million uninsured and another 50 million under-insured, for a total of about 1 in 3 of us) Piccagli said the lessons of the past 40 years include the fact that classical economics of supply and demand do not apply to health care: increasing the number of doctors, or competition among hospitals, only results in rising costs.

If the energies formerly tied to single payer can be channeled into a push for a public option some feel a viable reform bill will emerge. The San Francisco audience, many of whom were fervent proponents of single payer (which was endorsed by both OWL and the League of Women Voters) and most of whom are seasoned activists, left the room armed with cards to send appropriate legislators and plenty of ammunition to support their call now for a public option.

Said the third panelist, Co-Director of the Center for Policy Analysis Ellen Shaffer, about prospects for a robust public plan, “I think it’s up to us.”

Obama plays the Medicare card

President Obama, with Vice President Biden and Speaker Pelosi behind him, delivers a joint address to Congress on September 9 (Alex Wong/Getty)
President Obama, with Vice President Biden and Speaker Pelosi behind him, delivers a joint address to Congress on September 9 (Alex Wong/Getty)

For almost anyone over 50, the central issue of health care boils quickly down to Medicare. Will I keep it? Will it be there when I need it? Will it change?

In his address to a joint session of Congress Wednesday night, President Obama looked straight at the camera while saying he wanted “to speak directly to seniors: Medicare has been here for four decades, and is a sacred trust that must be passed down” to future generations. Then he pointed out to those seniors that the legislators opposing his reform plan are the same “folks who voted against Medicare in the beginning” and this year voted for a budget that would privatize it. He said also that much of the plan will be paid for by reducing waste and inefficiency in Medicare and Medicaid. Anybody who’s had (and thank you, I have) Medicare coverage for more than 15 minutes knows about waste and inefficiency. So cut those, and leave the system, and we should all be happy.

We should all be happy, that is, if such care extends to everyone. And if Mr. Obama’s references to the U.S. being the only developed country that lets its citizens suffer daily for want of adequate health care didn’t communicate the moral wrong that reform will attempt to right, you weren’t listening. What we heard was outline, and the president’s throw-away line about a few details yet to be worked out got an expected congregational chuckle. Some of us are more optimistic than others about whether any substantive change for the common good will remain by the time the final bill is drawn.

The details are ahead for the devil to be in, and he/she is surely ready. Whether public support will be forthcoming seems likely to boil down to a whom-to-believe game. Obama repeatedly stressed that “nothing in our plan requires you to change what you have.” But in delivering the Republican response immediately after the speech, Representative Charles Boustany of Louisiana promised listeners that they would be in for “replacing your family’s current plan with government-sponsored healthcare.” Boustany also tossed in references to “rationing care” and to general “fear and anxiety,” giving a distinct impression that battle lines are still drawn.

About those battle lines: Republicans sat on their hands as Obama once again proclaimed the rumors about bureaucrats who would kill off senior citizens — he skipped dignifying Sarah Palin by using the death-panel words — to be “lies, plain and simple.” And although he got the other side of the aisle to stand when he insisted there must be reform of medical malpractice laws, there were no smiles when he pointed out that the cost of health reform will be less than the tax breaks for wealthiest Americans passed during the previous administration.

Somehow, what truths and certainties do exist must be kept alive in the fray: Medicare is not going away. End-of-life conversations won’t kill off grandma. (Sadly, this provision may be already dead anyway.) The plan’s not going to cover illegal immigrants or pay for abortions. Medical malpractice laws must be reformed. Nothing will adequately replace the public option. A health care plan that offers access to all, imperfect or not, is only common decency.

This senior’s trust is still in Barack Obama.

Saving for Retirement: Take Two

About those initiatives to encourage Americans to save for retirement (see below)? There are those around the country who would say, Phooey. Or possibly something stronger.

Born in the 1930s, ’40s and ’50s, these are people who did everything right: they saved a respectable percentage of all earnings, invested cautiously in companies that seemed to be socially and fiscally responsible, some of which were supposed to be subject to regulation, and switched funds to other choices when those companies acted badly. They paid off their mortgages and credit cards on time (credit card companies never liked them) and lived within budgets. Most of these folks raised their own children on the time-honored formula that said when you have a dollar you give ten cents to your church or synagogue, ten cents to charity, put ten cents into U.S. Savings Bonds, etc, etc, and only with the last five cents would you buy an ice cream cone.

These citizens have now watched their IRAs fade to nothing and their investments income disappear. Want an example? That $10,000 carefully saved for a cash cushion in case of an emergency and invested in a money market fund or savings account once could be counted on to grow, or to pay for a weekend trip. Now, thanks to the Fed’s target rate for fed funds it might earn $25 in a year. The citizens do not notice any hardship, meanwhile, being visited upon the CEOs of those investment fund companies, or anybody at Goldman Sachs.

Beyond saying Phooey a lot, these citizens are worried. The same people who got them in the mess Mr. Obama inherited now seem to be running the economic show in Washington. The citizens want universal healthcare, but can’t help wondering if they’re going to be sunk, themselves, by a catastrophe for which they no longer have funds. The citizens can’t exactly re-enter the workplace.

In short, the prospect of golden years ahead for others is not ameliorating the tarnish of their own.

Saving for Retirement Just Got Easier

Those Golden Years we used to hear about might yet come to pass for some — if the Obama administration gets its message across. The New York Times’ Edmund L. Andrews reported Sunday on four new initiatives aimed at helping Americans put aside something for the rainy days of their retirement.

President Obama, noting that millions of Americans do not have enough savings to cover their retirement, announced a package of initiatives on Saturday to spur increased savings.

The administrative actions, which do not require new legislation from Congress, are intended to make it easier and more automatic for people to put money into tax-advantaged retirement accounts.

The new initiatives address a substantial audience. “Half of America’s work force doesn’t have access to a retirement plan at work,” Obama said. “And fewer than 10 percent of those without workplace retirement plans have one of their own.”

Based on “behavioral research,” the initiatives include savings-encouraging devices such as automatic enrollment plans for retirement savings accounts, check-off boxes on tax returns allowing for refunds in the form of U.S. savings bonds, or the payment of unused vacation time or overtime into retirement accounts.

White House officials said the new initiatives would go into effect immediately and come on top of two related proposals that Mr. Obama sent to Congress as part of his budget.

One would compel all but the smallest employers to offer retirement savings plans, and the other would expand the saver’s tax credit, which matches a family’s savings up to $1,000 a year.

Mr. Obama’s mother would probably be bewildered by the need for such initiatives. Savings devices, from employer-sponsored automatic enrollment plans to the ridiculous no-interest Christmas Club monthly deposits so popular with banks (and even with rational people who proclaimed this the only way to accumulate holiday funds), were ubiquitous a generation or two ago. They managed at least to keep a lot of people from going into credit card debt.

Perhaps, if the instant gratification/super-consumer movement can be made to co-exist with the President’s plans, some balance of spending and savings will return to working Americans. Now, if a few more Americans can just find jobs…

via Obama Outlines Retirement Initiatives – NYTimes.com.

New Way to Count Old Poor

As if there weren’t enough bad news to go around, a new(ish) formula for calculating the national poverty rate could boost the number of over-65 poor from 9.7 percent — or 3.6 million of us — to 8.6 percent, or a hefty 6.8 million. Just like that, the poor get poorer; or in any event they get to be more of us.

It’s not really a new formula, it’s a revision of the half-century-old National Academy of Science’s formula…

which is gaining credibility with public officials, including some in the Obama administration. The original formula, created in 1955, doesn’t take account of rising costs of medical care and other factors.

If the academy’s formula is adopted, a more refined picture of American poverty could emerge that would capture everyday costs of necessities besides food. The result could upend long-standing notions of those in greatest need and lead eventually to shifts in how billions of federal dollars for the poor are distributed for health, housing, nutrition and child-care benefits.

Using this formula, overall poverty in the U.S. would rise to an estimated 15.3 percent, or 45.7 million.

The current calculation sets the poverty level at three times the annual cost of groceries. For a family of four that is $21,203. That calculation does not factor in rising medical, transportation, child care and housing expenses or geographical variations in living costs.

I’m not at all sure my current family of two could eat (OK, and drink too, with an occasional dinner out) on $21,203. It may certainly be time for a re-calculation. And a little more help.

via New measure doubles number of elderly poor.

Pelosi Reaffirms Public Option, Insurance Reform; Healthcare "A Moral Imperative"

House Speaker Nancy Pelosi, addressing a Chamber of Commerce-sponsored Health Summit in San Francisco this morning about Obama’s health reform, stressed elements of the three House bills that might seem palatable to her audience: cost containment, IT design and integration with existing systems to create universal access to care. But she did not back down on a few other consistent statements such as the assertion that no bill will pass the House without a public option.

“We will invest in medical research and technology,” Pelosi said; and will incorporate elements such as electronic medical records for individuals to speed care.

It was clear there were mixed levels of support for reform in her audience. California Pacific Medical Center CEO Warren Browner MD, MPH drew muted chuckles and no boos with a throw-away comment that President Obama had “spent more time on choosing a dog” than on crafting a health policy. CPMC, a Sutter Health Affiliate, was presenting sponsor of the event.

Speaker Pelosi, though, hammered away at the primary intentions of reform: “improve quality, expand coverage and contain costs” while providing universal access to quality healthcare. “We will,” she said, focus on “quality, not quantity; wellness of the person not utilization (of facilities and technologies); value, not volume; and a commitment to prevention and wellness.”

San Francisco Mayor Gavin Newsom addressed the gathering earlier, touting the success of his “Healthy San Francisco” universal coverage program now in its second year. An independent Kaiser Family Foundation poll recently showed Healthy San Francisco to have a 94% approval record, prompting City/County Department of Public Health Director Mitch Katz, MD to ask when any program of any sort had ever gotten a 94% approval record. Citing the need for protection of such elements as in-home services in an aging population, Newsom said the program’s success was attributable largely to partnerships with local hospitals, clinics and medical facilities (CPMC is one), specifically singling out Kaiser Permanente, which signed on in July. The program does not offer a national model, Newsom said, but has many elements a national plan could adopt. Healthy San Francisco includes things that might not get into a national bill but are favorites with wellness proponents: community organic gardens, city-funded salad bars in schools and an ad featuring a soda-equipped young boy admitting to “a drinking problem.” Another key to the program’s success, Newsom said, is its ultra-simple one-page enrollment form.

Pelosi insisted that the final bill will include “insurance reform: no refusal based on pre-existing conditions, no co-pay for prevention, no cut-offs.”

And the major themes were reiterated: “As President Obama has said, universal healthcare is a moral imperative,” she said; “we are the only country in the developed world without it. I say to those who would have us do a little bit, and another little bit, and another little bit — Lyndon Johnson settled for half a loaf; this is the other half of the loaf.”

What to do about Mom?

My friend Joan is distressed about her mother.   Joan – that’s an alias, we both value her privacy – lives quite near her parents, visits regularly, helps out with finances, health issues and everyday needs. They are in their late eighties. Other siblings live in other states. Until recently everything was fine; now the parents are in separate areas of their assisted living residence, Joan’s mother is in frequent despair and need. What’s a daughter to do?

This story is being repeated thousands of times every day across the country. Only this story has a peculiar twist: Joan’s parents did everything right. They lived frugally, planned ahead, raised their children to be successful and independent, moved early into a retirement community which offers care through illnesses minor and terminal. With Joan’s help they kept their affairs in order, including updated advance directives. (You don’t have your advance directives done? Horrors. Let me know and I will be at your door, cyberspacially speaking, to walk you through them immediately.) Joan’s parents were among early advocates for advance planning and end-of-life choice.

Joan comments: “Frankly, Mother is tired of being alive.  She’s not depressed, just ‘finished’, especially as she sees these slow declines in her quality of life as a steady and inevitable progression.  Her greatest desire would be to have a massive stroke and not survive.  But then her greatest nightmare would be to have a stroke and live . . . Even with the best advanced directives reflecting her choices, that’s a fine line to navigate.”

The moral of this story is that no amount of planning and preparation can guarantee the kinds of last months and years we might want. My own mother died peacefully at home, followed 20 years later by my father, same story. But that was in 1967 and 1987, in the small town of Ashland, Virginia where they had lived since 1939. The town looked after them; their out-of-state daughters merely visited and counted their blessings. Towns and neighborhoods like Ashland are in diminishing supply.

But all is not gloom and doom; this writer is constitutionally unable to write doom and gloom. Joan is at least clear about her parents’ wishes, and her parents have good care plus all allowable precautions: DNR orders, POLST forms, understandings with their medical professionals. Most of these are possible for today’s Boomers and their Beyonder parents; if you can’t find them I’ll happily tell you how. Joan’s parents are also in housing of their choice. And those choices are many: co-housing, retirement communities, assisted living facilities, many of them available to middle and low income Americans. Anyone over 50 who thinks he or she should postpone considering all of these issues, documents and choices until next year is delusional. Essays re housing choices have appeared in earlier Boomers and Beyond posts; others will follow. The secondary moral of this story is that without planning, late years can quickly turn into hell for elderly parents and adult children alike.

What we don’t have, of course, is health care such as Joan’s parents still enjoy for others who need it. The thing is, we can.