Sunday, July 02, 2006

Dying From Red Tape

Millions of poor Americans may lose their health benefits:
A Medicaid rule takes effect tomorrow that will require more than 50 million poor Americans to prove their citizenship or lose their medical benefits or long-term care.

Under the rule, intended to curb fraud by illegal immigrants, such proof as a passport or a birth certificate must be offered at the time a person applies for Medicaid benefits or during annual reenrollment in the state-federal program for the poor and disabled.

Critics fear that the provision will have the unintended consequence of harming several million U.S. citizens who, for a variety of reasons, will not be able to produce the necessary paperwork.
Unlike many Republican policies towards the poor, which read as though they were written by someone who was cackling and twirling his mustache, this one seems reasonable on the face of it. Citizenship (or, in some cases, permanent residency) has always been required for enrollment into Medicaid, and this new rule simply establishes a documentation requirement. Probably most of the people reading this post could produce the necessary documents without much effort - a phone call to Mom to ask for the birth certificate, perhaps, or, at worst, a letter and a check sent to the registrar of the county where they were born. A reasonable amount of effort to ask people to put forth, if the payoff is reducing fraud and saving health care dollars.

But it only seems reasonable if you haven't had much contact with people living on the margins of American society. This rule affects homeless people who have only a garbage bag full of posessions to their names, and no idea where any of their relatives might be. People institutionalized because of mental illness or mental retardation. Elderly people born before all births were recorded - particularly elderly black Southerners, who were likely to be born at home due to Jim Crow hospital policies, and the rural elderly poor. People who are no longer able to communicate clearly due to disability. They don't have passports. They may not know where they were born, or be able to communicate it to their caregivers.

Look at some of the plaintiffs in lawsuits challenging the new rule:
Ruby Bell, 95, born in an Arkansas county that did not issue birth certificates until 1914, and George Crawford, 80, who is so incapacitated from strokes that he cannot speak. According to attorneys, the church members who care for Crawford in Illinois don't even know where to start looking for documents that would pass muster. [...]

Alphonso DeShields, who was born in his parents' home in Spartanburg, S.C., a few months after World War I began. For five years, he has lived in a nursing home in Northwest Washington. He has a severe heart condition, cancer and other ailments.
Do these sound like they must be just a few odd, isolated cases? I've worked in health care for the desperately poor for six years now, and I can tell you that they sound pretty typical to me.

Even if most of these people are eventually able to document their citizenship, they are likely to experience gaps in medical treatment. Probably the ones dependent on institutional care won't be kicked out, but others will go without their insulin or HIV drugs or blood pressure pills. They'll wind up in the ER as indigents, suffering from preventable complications of chronic illness. And beyond the human cost, the financial cost of all of this documentation will be appalling. Social service agencies, nursing homes, and institutions will spend money that could be spent on direct services, tracking down their clients' birth certificates in cases where citizenship is not in the slightest doubt.

We all know that the Bush Administration and their allies in Congress have never signed on to the maxim, "better that ten guilty men go free than one innocent man be punished" - their Guantanamo policies make it clear that they believe the reverse, many times over. On the domestic side, it's clear that they also believe that it's better for ten deserving people to go unhelped than for one "undeserving" person to receive benefits to which they are not entitled. And yet they, the majority of them, call themselves Christians.