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Wednesday, October 24, 2012  

Saying Goodbye

My column in the newest issue of Let's Talk is about living with, and parting from, our foster daughter of more than two years. Some of it will be familiar to people who have read my writing on the policy issues pertaining to foster care:

From WIC coupons (about $40 each month) to asthma medications to periodic caseworker visits to check on her care, Sophia’s life was continually touched by government programs. And they are precisely the kinds of programs that have been under budgetary attack, at the state and federal level, since the economic meltdown of 2008-09 and especially the Republican wave of 2010. As I write this, the nation’s pundit class has been hailing the courage and seriousness of a vice-presidential candidate whose primary claim to fame is a budget proposal that cuts $800 billion in Medicaid and another $130 billion in nutrition programs over ten years. Half of Medicaid’s recipients are children, and the SNAP and WIC food stamp programs overwhelmingly serve families with children. His stated rationale for this dramatic budgetary shift is the danger that there will be too many “takers” like Sophia living at the expense of high-income “makers.” That such sentiments are even breathed in a society supposedly shaped by the ethics of the Bible ought to shock and horrify us.
Other parts I've had some difficulty expressing until now:

I found it very difficult to mimic the habits of parenting that were so closely fused with our oxytocin-fueled connection to our biological son when all I could feel was exhaustion or despair. But very quickly one comes to understand that the failing is all one’s own; there is no blaming a one-year-old for behaviors that vex you beyond patience, there is only the need to pray and practice for more patience.

And as time went on, the emotions filled in the space that was marked out, however imperfectly, by our attempt to act as if we loved this girl. The deep-dark humor of our sleepless early weeks and months with Sophia gave way to affection that was as fierce and powerful as if she’d been our own. Steadfast love, I came to see — switching to an Old Testament concept — is much more about the steadfastness than the love, at least when speaking from our modern emotional lexicon. The gift of love is added, so to say, to perseverance. It was a grace for which I will forever be grateful.

And speaking of Medicaid, it is perhaps the great under-discussed issue of the race. The candidates have been eager in some areas to amplify their disagreements or to obfuscate them, but Medicaid policy is one area of genuine, clear, and consequential disagreement that has gotten very little airtime. 

Romney and Ryan have recently taken to mentioning the program, largely in an attempt to soft-pedal their actual plan. Right now, Medicaid is a program for the poor and for long-term nursing care paid for jointly by the federal government and the states based on the number of enrollees and the cost of their approved treatments (I'm sure it's very complicated, but that's the gist of it). When the number of eligible enrollees rises--such as during a recession--its costs increase, and they increase along with the inflation in medical costs (it's cheaper than Medicare and much cheaper than private insurance, but its costs rise along with everyone else's).

Romney's plan is first to repeal the program's expansion under Obamacare, kicking 19 million otherwise-insured people off the program (whcih, remember, is cheaper than private insurance). Then he plans to cap the budget for Medicaid, so that it is no longer determined based on eligibility and health costs but rather on inflation plus 1%. Then he wants to turn those capped dollars over to the states to do with as they think best. This means in the first instance very meaningful real-dollar cuts to the program, since health costs rise faster than inflation plus 1%. In the second instance, it means that states will be free to fiddle with eligibility rules or covered procedures in order to keep their own share of the costs down. Romney talks as if states have magical efficiency-finding powers, but they don't. The upshot will be some combination of people getting dropped from the program's rolls and per-enrollee spending declining. How much? Well, $1.7 trillion relative to current law. The Kaiser Foundation gamed out some possible scenarios if you're interested in the bloody details. Yglesias points out that nursing care is likely to get hit hardest because it's much harder to make efficiency gains there. 

But in any event, Medicaid doesn't cover a whole lot of people who aren't children, seniors, or moms. As the rates it pays to doctors get squeezed, it will get harder for everyone in the program to get care, even if they remain eligible. This is, I am not afraid to say, a moral issue. Romney and Ryan see a program that spends too much money on health insurance for the very poor and imposes an immoral financial burden on people who are very wealthy. It's not the only issue in the race, by any means, and it's not the only one with a sharp moral edge. But it's an issue I've been close to for a while now, and I am more aware of the impact of it than, I daresay, most of the people who cover this dispiriting little hobble toward the White House. Please consider it seriously and inform yourselves, because Medicaid is a very important program. 

posted by Benjamin Dueholm | 11:43 PM
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