The underserving poor?

Medicaid expansion is in the news in Oklahoma with an initiative petition in the works to allow the people of Oklahoma to vote on an expansion. Medicaid is a federal-state partnership, with the state paying for part of the care and the federal government paying for the rest.

Medicaid expansion has already passed in several states through the initiative petition process, leaving the legislatures to figure out how to pay for it. Will the Oklahoma Legislature act before the people vote on the expansion? If Oklahoma’s recent history with criminal justice reform and medical marijuana is any guide, no. But I am hopeful that this time the Legislature will take the lead as we do have legislators with experience in health policy working on ways to expand health care in Oklahoma.

The Medicaid expansion debate does require us to discuss who should be eligible. Back in 1965, when Congress tacked Medicaid on to the Medicare bill, they made a judgement about the kind of people who could not afford health care but who should be eligible for it. Congress chose to use existing welfare categories, which were those who typically received some sympathy: seniors, children and their single caregivers, and the unemployable. The unemployable were those who were totally and permanently disabled; they could not work and so did not “choose” to be poor.

Medicaid’s creation in 1965 extended the long history of dividing the indigent into those who were poor because they could not work and those who could work but were still poor. By statute, Medicaid perpetuated the categorization of the indigent into the deserving poor and the undeserving poor. And that bias exists today. Even if you are working, but are unable to afford health care premiums, then you are the undeserving poor.

Do people who cannot afford health care deserve health care? The unaffordable cost of a serious illness or accident drives low-income individuals and families into debt or bankruptcy.

Provisions in the Affordable Care Act tried to address the unaffordability issue by making Medicaid available to anybody who made less than 138 percent of the federal poverty level if states choose to take advantage of the expansion. However, the ACA did not erase distinctions in types of low-income residents as the federal reimbursement rates differ.

Today, active campaigns in Oklahoma seek to reinforce, in the public, the idea that only some poor deserve health care. These campaigns do not baldly claim to differentiate between kinds of poor people. Nobody in the public sphere comes out and says only certain poor people deserve aid. Instead, the campaigns use the term “able-bodied,” as in “Medicaid expansion will only help the able-bodied.” The implication of these campaigns is that the working poor choose to be poor and so do not deserve health care.

How should the state address this? Should we keep the status quo, accept the Medicaid expansion, or do something in between? And how should we pay for changes? Let your elected representatives know.

— Derrel Fincher, Representative for Oklahoma House District 11, can be reached by phone at 405-557-7358 or via email at derrel.fincher@okhouse.gov.