Saturday, June 28, 2014

Are the working poor any better off under Obamacare? Will they pay their premium?

How many people  have actually gotten health care coverage under Obamacare?  It is hard to say.  The Administration said 8 million enrolled but we don't know how many of those paid their premium. Also the Administration has not released numbers in over two months, so they must be embarrassing or they would be crowing. This article makes an informed calculation that the number is less than 4 million: Obamacare Exchanges Are ‘Disappointing’ With Fewer Than 4 Million Newly Insured. The Government Hoped for 26 Million.

No doubt some people who needed health insurance are now covered under Obamacare. Those probably most benefiting are the middle-class people  with pre-existing conditions. There have no doubt been winners and losers under the program.

One thing I have not seen discussed anywhere is that those who previously did not have health insurance did not, not have health care. Among the working poor, having insurance may not make them any better off.  I have worked with low-income people in one way or the other most of my adult life.  In my experience, few low income people go without health care. If they earn too much for Teencare, there is a safety net. They often are served at a United Community Health Service facility for their primary care such as the Vanderbilt Clinic at Vine Hill. These programs have a sliding fee program making care affordable. Here is what the Vine Hill clinic says about their program:

Vine Hill Clinic offers a full range of primary care services, including chronic disease management, pediatrics, social work services, and preventative services such as annual physicals, well child exams and immunizations. Our clinic also offers basic dental services to our patients such as cleanings, fillings and extractions. Our Medical Staff who specialize in pediatric and adult care are here to serve you. Patients are encouraged to schedule an appointment. "Walk-in" and Open Access appointments are available each day. Open Access appointments are similar to “walk-in” appointments, except Open Access appointments are available for scheduling starting at 8:00 am for that day. This way you can come in at your appointment time and it will prevent you from having to wait very long to be seen. Medicare, Medicaid (TennCare) and most private insurance is accepted. Discounts are available for those without health/dental insurance who meet income guidelines. Patients can also obtain low cost or free prescriptions and most lab tests provided on site are discounted or free.
There is also a program called "Bridges to Care" that is much better than Obamacare. I have encountered several people using this program. I know someone who has had heart problems and various other health issues and has had all of her health care cost paid for under this program.

Also, the emergency room is a source of care for people with no insurance. Part of the logic of Obamacare is that reliance on the emergency room by the uninsured is driving up health care cost.  No doubt that is true.  But I predict that we will see little decline in emergency room use unless some disincentives are put in place to discourage emergency room use. Those who now rely on the emergency room for non-emergency care could use a health clinic now, instead of the emergency room. I was around when TennCare was an expansive health care program, not just Medicaid like it is now.  Under the old TennCare, the working poor still relied on the emergency room.  Part of the reason is that the working poor often work jobs where it is difficult to take off work for a doctors appointment and the emergency room is open 24 hours a day. Part of it may simply be habit.

There are no doubt many admirable hard working responsible working poor people.  But there is also a way of thinking that accompanies poverty in our welfare state. Middle class people or the working poor with middle class values would be mortified if they could not make their car payment and a car was repossessed. It is not uncommon to hear something like this from a poor person: "I bought that car, and I hadn't had it six months until the transmission started slipping, so I just stopped making the payments and said, 'you can come get it.'" They say this with pride.  They do not view a repossession of a car as a failure.

Not all, and I don't know the percentage, but I know it is a common attitude among the poor that they do not think about debt the same way middle class people do.  They do not worry about $50,000 of medical bills. They have no assets and get by day by day.  They are not going to go without cable TV to pay a hospital bill.

I don't doubt that many of the people now covered by Obamacare will make sure they maintain their insurance premiums and will be grateful to have health insurance.  When it come to the working poor, I am not so sure. Even it they made that first insurance premium payment, if they must choose between a new Titans starter jacket and making that second insurance payment, many of them will choose the new Titans jacket.

The income tax penalty is not going to make a lot of difference either. They just do not think that far ahead. They have never learned delayed gratification. Also, many of them either legitimately don't pay taxes or have learned how to cheat on their taxes so they don't pay taxes.  As the penalty increases, no doubt the working poor with middle class values and the middle class will be motivated to comply and avoid the penalty, but not the working poor with lower class values.

Instead of just comparing the number of people who now have insurance who before did not have insurance, I think a better measure of the success of Obamacare is how many people now have health care or much better health care than they did before Obamacare. I bet it is not many.  A less comprehensive approach to changing the health care delivery system, could have helped those few.

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