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Recent Newspaper & Online Columns by Kate Scannell MD

States opting out of Medicaid expansion is simply unconscionable

By Dr. Kate Scannell, Syndicated Columnist
First Published in Print: 07/21/2012

Last Tuesday, I was eating lunch in a downtown Oakland diner when a 20-something man entered and politely asked the owner for work -- any work at all. The owner apologized profusely, regretting that he had no employment to offer.

Minutes later, a woman and her daughter sat down at a nearby table and carefully counted what coins they carried -- ostensibly assessing whether they could afford a lunch plate. After the daughter asked, "Do we have enough?" the mother replied, "no," and they left the restaurant, declining an offer of help.

On my way out, I told the owner that I had overheard his conversation with the job seeker. "Awfully hard times," I said.

The owner shook his head and said that he had never had so many people seeking work. And that he had never felt so helpless. "Business is down here, everywhere," he said. "We have no jobs to offer. Last week, a young man with an M.A. came in, begging to work in my kitchen."

As we talked, an elderly woman passed by, pushing a shopping cart stuffed with garbage bags. Echoing a commonly heard refrain, the diner's owner charged, "Washington politicians have no idea what it's really like for most of us. To survive -- find work, live in a safe place, get decent health care -- they just have no idea."

At home that evening, I kept thinking about people from the diner. It had been painfully obvious that they were struggling mightily -- for a $3.50 lunch special, a minimum-wage job, a small business establishment on a worn corner of Oakland. Were these people and their struggles really invisible to "Washington politicians?"

You almost want to believe that's true because the alternative -- politicians seeing but doing little to help -- is even more dispiriting. Still, on street corners across America, joblessness and economic insecurity are on hard to ignore.

Perhaps the seeming invisibility of careworn Americans is a byproduct of cognitive dissonance. That is, while our eyes might detect a family rummaging through garbage bins along Main Street, our brain rejects that as possible; it simply couldn't -- and shouldn't -- be happening in the world's wealthiest nation.

Regardless -- whether unseen, or seen but disbelieved -- impoverished Americans exist, and their ranks are growing. Recent U.S. census data reveal that in 2010 our country's poverty rate jumped to 15 percent -- representing more than 48 million Americans.

Of course, it is not only politicians who may have blind spots on this issue. But it is to them that we look for moral leadership and problem-solving when so many millions of us urgently need a helping hand. Serving as our governmental representatives, they are supposed to be of us, for us, and by us. All of us.

That's why it's so disturbing to hear that several states are threatening to boycott Medicaid expansion as proposed by the Affordable Care Act (ACA) -- our nation's new health care reform law. Uniquely known within California as "MediCal," Medicaid since 1965 has provided health care insurance to vulnerable Americans immersed in poverty.

If fully implemented, Medicaid expansion under the ACA would extend insurance coverage to about 17 million Americans living at or below 133 percent of the federal poverty level -- by current standards, that means an annual income of roughly $14,900 for individuals, or $30,650 for a family of four.

Clearly, Americans living within those narrow income brackets are squeezed out of the private insurance market. Medicaid offers them a chance to "be seen" by a doctor when they're sick, to be made visible as patients deserving of care.

Currently, at least eight state governors have vowed to opt out of the ACA's Medicaid expansion initiative, and more are threatening to do so. Many surely intend the opt-out as a political jab against President Barack Obama, even though it's their impoverished citizenry who will suffer the greater injury. Some dissenting governors have claimed that Medicaid expansion will ruin their state budgets -- this despite the fact that the federal government offers to finance 100 percent of each state's costs through 2016, 95 percent through 2020, and 90 percent thereafter.

I want to believe that these overt threats against the poor are being made by politicians who have no idea what it's really like for people struggling to get by. It's too intolerable to think otherwise. Still, there's one glaringly obvious truth about the poor -- they don't wield a lot of political influence. It's easy to ignore them during political battles, easy to disregard them when prioritizing constituency interests during budget-slashing.

Make no mistake -- the Medicaid program is far from perfect. It could be made more cost-efficient and user-friendly. Its reimbursement rates to health care providers need 21st century tweaking. But these are problems to be solved by those of us with political power and social agency. And they are problems that, if carefully examined, can allow us to see our way to a better world.
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Kate Scannell is a Bay Area physician and the author of "Death of the Good Doctor -- Lessons from the Heart of the AIDS Epidemic."
Copyright, 2012 Kate Scannell