Health Equity Gaps for the Disabled

WM, Health:  Bridging Health Equity Gaps for People with Disabilities and Chronic Conditions, February 3, 2022

The major healthcare problem for people with disabilities is qualifying for SSDI and/or surviving on Supplemental Security Income. Their biggest problems are adequate shelter, food and spending money for such luxuries as toilet paper. Inadequate funds for food means higher carbohydrate diets than are healthy. 

The food inflation subsequent to the pandemic shifted to such a diet, which added pounds and the need to eat more frequently. The recent cost of living increase has improved my diet, as well as the realization that this was necessary for long-term health. Still, the recent COLA is inadequate to do much more than pay rent and buy food. 

My housemate’s situation, because he was not a high earner, has forced him to rely on SNAP and the addition of Medicaid to his Medicare. With these benefits, we have roughly the same standard of living.

My experience included Medicaid for the first two years of my disability. My health benefits have had various copay levels. I used Kaiser for Medicaid, Medicare Parts B and D and now Medicare Part C. 

Mental healthcare has been more fluid. On Medicaid, I had access to nurse practitioners for my needs, but was also able to participate in a Psychiatric Rehabilitation Program. My therapist came from a separate list of social workers. Currently, all of my mental healthcare needs are carried out with Kaiser, but I no longer have access to a PRP. I have the freedom to change plans every year. 

Meanwhile, my housemate has to recertify annually. Because his literacy is limited, either I or an overworked social worker provided through our housing provider must help him do so. Because he uses county services (he does not wish to join Kaiser or a similar plan), it is a good thing that he lives in the State of Maryland, which has an integrated system. The other main difference in our care is that mine includes free rides and he has to take the bus (actually three buses). 

The pandemic has given both of us access to telemedicine - because I am paying for cable internet. He has recently gotten a free tablet for his telemedicine needs. While he could do a hot spot on his phone, he currently uses my wireless to access his care.

I have past experience in constituent services as both an urban ombudsman and a congressional intern, so I can navigate the system. Most people have more trouble.

Returning to the main topic, for most of the disabled and underserved, especially undocumented workers who now rely on emergency room care and have little access to specialists, all solutions require a dedicated and well-paid cadre of social workers. They are the lynch pin to navigating gaps in coverage in the current system. Integrating care systems is not enough, although it has been a major improvement. This integration must include data systems so that case management is seamless in not only healthcare, but in managing all benefits. 

This takes money, as well long-term reform. I will address this shortly.

Before going on, we must address the need for comprehensive sick leave. On more than one occasion, I have needed care in an emergency room. In those instances where I needed late night care, the waiting room was packed with parents with sick children who could not get time off to take them to the doctor during normal office hours. This care is very expensive, not because of its inherent cost but because of billing practices. A new model with separate centers for non-urgent care is helpful in this regard. Hopefully, it will be universal in time.

The other major gap in care is undocumented workers. They often cannot pay for care, so the medical charities fund will cover the costs - after rounds of bill collection. For the merely poor and uninsured, medical bankruptcy is used to end collections - but undocumented workers have no access to this tool. 

The whole point of doing healthcare reform was to close gaps in coverage. Not including undocumented migrants was an olive branch to the Republicans. When support was not forthcoming, care for such workers should have been added to the Affordable Care Act. This exclusion must be repealed or the inherent cost shifting problems, especially for those disabled by doing the hard work of feeding America, will remain.

The pandemic has almost run its course, with Omicron likely providing universal immunity. The current supply chain issue in food, however, comes from undocumented workers having to either work sick or being too sick to work. We need to learn this lesson and cover such workers with universal coverage, mandatory sick leave and an end to right-to-work laws. Union coverage is the quickest way to close the gaps in care.

Comprehensive change is also needed. Please see the attachment for more details on the forthcoming.

Universal coverage, starting with a public option under the Affordable Care Act, with eventual evolution to some type of single-payer system seems like our best path. A public option will only pass if pre-existing condition reforms are abolished with public option enrollment being automatic upon rejection. 

The public option must be subsidized, replacing Medicaid for the disabled and those not requiring long-term nursing care. Long-term care should be removed from states and replaced with a new federal Medicare Part E.

The profit motive, with the need to constantly increase profits to attract Wall Street investment or keep stock prices growing will lead to an ever increasing number of people who will be considered uninsurable, thus relying on the public option.

Most healthcare systems will provide services to both comprehensive insurance beneficiaries, the retired, the disabled and those with the public option. In other words, Medicare for All is our future, with the only exception being firms abandoning the system and providing their own doctors while making arrangements with local hospitals and specialists - essentially creating local HMOs. 

The major issue here is funding, although more efficiency will reduce prices. Costs are already minimized by the for profit and by governmental medical care (which often uses for profit networks). To repeat, with a shout THE ISSUE IS PRICE, NOT COST!

The problem with the Affordable Care Act is that much of its funding came from taxes on capital gains and income falling on the top third of taxpayers. In other words, the upper and upper-middle classes. IRS data shows that about half of Adjusted Gross Income for these classes is from non-wage income. Membership in these classes is limited to the top 4% of taxpayers.

This is politically unacceptable, as the multiple attempts to repeal the ACA have shown. Broad based taxes are necessary and should be bipartisan. Any political promise to the contrary must be broken. No votes will be lost to either party by doing so. Few members of the middle or working classes will shift their allegiance to the other party because of tax policy changes. 

Members of the current majority party will simply not give up on their political home because their taxes go up. One of the key reasons for party identification among frequent voters is economic policy - not the details but a belief in who should be taxed. Progressives will never join the Republican Party for a campaign promise not kept.

The stupidest myth in American history is the belief that anyone held George H.W. Bush to account for breaking his “no new taxes” pledge. They did not vote for Perot because of it - his voters were sending a message to the entire system and drew from both parties. If anyone believes that any Bush voter shifted to Bill Clinton for violating the NNT pledge, I have a collection of bridges over the Potomac you may be interested in purchasing.

Payroll taxes are regressive, so they should not be used to fund the public option, et al. Indeed, all Medicare taxation should be shifted to a less regressive consumption tax. This tax is less regressive because it takes from profit and wages in equal measure. Taxing only wages or only capital leads to either too much progressivity or too little.

The only question is how to collect these taxes. If it is more important to give exporters (and overseas customers) an economic break, the standard border adjustable goods and services tax is best. 

To preserve the private option - either for comprehensive insurance or employer-provided care - a subtraction (aka net business receipts) value added tax is best. Such a tax should also include distribution of (more generous) child tax credits. 

Paying these taxes through employers, rather than the Internal Revenue Service, corrects the economic failure that simply relying on privately negotiated wages creates while taking away the “stink of welfare” found in the American Recovery Plan Act’s distribution mechanism.

The provisions in the Affordable Care Act creating surtaxes to fund healthcare must be repealed, as should both dividend, interest and capital gains taxation (as well as rent) currently collected through personal income taxes. Instead, tax transactions, rather than people at the same rate now paid for the highest rate for  long-term capital gains. The current rate (including ACA taxes) is just short of 23.8%. The proposed rate is 28.8% (adding proposed surtaxes for high incomes).

Much money is spent on campaign contributions to continue going back and forth between these rates. I have little hope for compromise - although splitting the difference between 26% and 27% seems reasonable.

What would such a tax pay for, if not healthcare? Fund the military - especially overseas deployments which serve our security and economic interests abroad, repayment of the Social Security Trust Fund and begin funding Net Interest rather than rolling it over into new debt. The international economic system can only favor the Dollar and U.S. Debt for so long. Every empire falls. The question is, who will lose the most if American debt becomes worthless? 

Using data from the Federal Reserve Survey of Consumer Finance, the top 10% of households indirectly hold 56% of debt held in Federal Reserve and Bank Assets and Long Term Investments and 77% of mutual fund and direct debt holdings. According to the Pareto Rule, half of each of these fund pools is owned by the top 1% of households. They have the most to lose if the debt crashes. Use an Asset Value Added Tax (on transactions) to decrease what is becoming an unworkable level of debt. 

Attachment: Single Payer

Attachment: Tax Reform