10 August 2006

Communitarian Thinking II

I received some feedback in regard to my post on Communitarian Thinking, where I called for big picture, wholistic thinking about several social problems:

1. Public housing officials there want to evict single mothers than their children from public housing if they don't get a job or start an education program, even though this plunges those people immediately into vagrantdom, creating a new problem.

2. Failure to address recidivism in the criminal justice system with prevention, and the related problem of failing to devote sufficient resources to those at very high risk of becoming involved in the criminal justice system in the future (e.g. high school dropouts with a history of disciplinary problems in school.)

3. Failing to note that it is cheaper for the health system as a whole to have everyone insured, so that providers aren't overwhelmed with bad debt from emergency cases and so that people get cheap preventative care from low cost providers like an office based medical practice, rather than getting expensive care from emergency rooms once problems are acute.

My reader poses a couple of groups of questions:
Regarding the public housing policy that was being adopted in Atlanta, GA, I wonder what you feel would be a better solution? While I feel that eviction is a pretty extreme solution, I wonder if there were any details you left out?

I have a friend (no, really,) who was a resident of Alaska. When she was quite young she became a single mother, through poor choices, and then became a client of the Social Services Department. It seems their policy there is to give clients two years of support, during which time they will pay tuition, child care, housing, and board. At the end of the two year period there support is withdrawn. This allows a person (not just a woman,) the opportunity to get at least an Associates degree (or some technical certificate) in the field of their choice while having total support. This sounds like a pretty sweet deal to me, having supported myself while going to school full time. Perhaps this would be a better policy for GA. I know I would certainly support a nation wide policy of this type, and would be happy to suggest this type of policy to any state official. Does this sound like a better long term plan to you?
The plan you describe in Alaska is national policy, it is part of the welfare reform system adopted in the Clinton administration, and the public housing issue in Georgia probably has similar roots.

In fact, the name of the program was changed from Aid to Families with Dependent Children (AFDC) to Temporary Aid to Needy Families (TANF), to reflect the major overhaul of the program involved.

For lots of people, temporary help, and someone pointing them towards opportunities to improve themselves is all they need. In the same way, the federal health care law COBRA, which allows people to continue to receive health care from their employers who eighteen months or so, at their own expense, has problem materially reduced the ranks of the uninsured in the American middle class.

But, this isn't a perfect and complete solution. There are some people who, while not having any particular disability you could identify in a medical text, are simply disfunctional and marginally employable. They may be cantankerous, or mean, or unreliable, or whatever. Often they have subclinical level mental health problems, developmental disabilities (i.e. low grade retardation), or under so much stress that they have lost their ability to think straight for a while.

Welfare reform was based on something of a law and economics model that came to the conclusion that if you create strong incentives for people to get themselves off welfare fairly soon, that they will respond to those incentives, find jobs, and be better off than they would have been on welfare and in public housing. And, this, along with a healthy economy following the enactment of welfare reform had the intended effect. Many people responded to the incentives, got off welfare and are better for it.

Some people can't. And, the incentives aren't universal. One of the bigger barriers to leaving welfare has turned out to be that many people who can work, are not qualified to get jobs that actually provide health insurance, and have health problems. Thus, leaving welfare means losing Medicaid, which means being worse off with a job than they were on welfare.

Rather than taking a hard line approach with the hard core welfare dependent who are unemployed, and evicting them, and punishing dependent children for having parents who have trouble getting their act together, we would be better advised to create a new program, call it "Sustained Intervention For Treatment of Economic Realities" (SIFTER). The program might be on a model of a guardianship and conservatorship relationship, where a case worker receives funds to provide the family with its needs, but has control over how those funds are spent and have a more hands on, high intervention role in the beneficiary's life.

Maybe the problem is poor budgeting or spending too much money on booze and drugs. Maybe the solution is to have necessities like rent, utilities, car payments or bus passes, and so on deducted from welfare checks and paid directly, and have food money deposited directly to a food stamp card, leaving that person only a small allowance in cash every week. Some people have the money management abilities of preteens, even if they can otherwise function, and without money to waste, they can act more responsibly.

If a case worker felt that a beneficiary was unemployable in a competitive market situation, the case worker might formula a plan suited to the person's abilities that makes maximum use of what they are able to do. Maybe this person can only do work economically worth $3 a hour when the minimum wage is $5.85. People in the program could still be placed and the program would receive the compensation to be held in trust for the beneficiary. Maybe the person is capable of taking care of their own kids and did tolerably O.K. as a homemaker, but has utterly failed in the world of work. Maybe for that person, staying home with the kids is a more sound choice than putting the kids in daycare and getting a job that pays little more than the cost of daycare.

Everyone who has made it to two years would be given a choice. Get out, or enter SIFTER. Many would still leave, because they value their own freedom. Some would welcome having few decisions to make in life and receiving more attention. No additional forms would be required other than a one page opt in or opt out form -- those would have been filled out upon entry to TANF, and any new forms could be completed by a case worker.

This way, at the very least, until the children in the family reached adulthood, beneficiaries wouldn't just be left to starve and die on the streets when left to their own devices. The adult beneficiary might never become independent of welfare. But, protecting the children from becoming homeless and hungry, and instead putting them into an environment where their family situation was constantly monitored and the basics of life were made available to them providing stability, could keep the system from spawning a new generation of traumatized people.
Regarding your ideas on health insurance, and it being cheaper for everyone to be insured vs. emergency treatment, I can tell you that some people just do not act in a responsible proactive manner when it comes to their health. I work in a rural Emergency Room, and the number of people that I personally see each day that has no primary care physician and is on Medicaide is astounding. The majority of these patients do not believe in preventative medicine. They do not have a regular Dr. that they see because they wait until they are sick to try to get into see a Dr. and then have to wait, and so do not go. They come to the ER, not the emergent clinic, because they know that we do not turn anyone away, and that we seldom collect the co-pay that is supposed to be required. I would venture to guess that the majority of these patients also smoke cigarettes and drink alcohol.

One of the reasons people come to the emergency room is because few doctors take Medicaid, doctors are scarce as it is in most rural areas and not all of them take Medicaid, and so receiving other kinds of care is hard.

If everyone had health care coverage, and a certain amount of money was invested in educating people about how to use it, this could change. I think that people would go to, for example, a public clinic, which could be self-supporting if everyone had health insurance, similiar to an urgent care center, if they knew about it and it could handle walk ins, at a much lower cost than an E.R., if they could have coverage for that. Waits at E.R.s for non-emergency situations discourage people too. If the two were located close to each other, and everyone had health insurance, it would be much easier for an E.R. to say: "You don't have an emergency, the urgent care is down the block.", and a few disappointments like that would have people going to the right place. A bill in the mail for inappropriate usage might also help teach people, working class people with no health insurance -- although the truly destitute might not care.

And, while some of the 14% of people who don't have health insurance wouldn't get preventative care, many, particularly young, basically together people with families and starter jobs, would, even if vagrants still might not.
Don't get me wrong - I don't think these things should be illegal, rather I think that these people have made some really poor life choices and continue to do so by choosing alcohol and cigarettes and pet food and cell phones over healthcare and dental care and excercise.
For single, able bodied people, one program model I think would work would also have a guardian and conservator model. Beneficiaries who sign up would have a guaranteed part time job, in exchange for a dorm room style single occupancy hotel accommodation, a food stamp or cafeteria card, and a small allowance. They would simply have to show up at a work site 25 hours or so a week, their pay would go directly to the program, and a municipal or county official would be in charge of figuring out whatever the government could use having done that was most useful and within their skill set.

Some days the required work might be grounds work, another day it might be filing, another day it might be data entry, another day it might be janitorial work, or preparing for a county fair. Some days it would basically be make work, some days it would be valuable. The point is not that it makes economic sense as a job, but that people have a minimum wage job guaranteed and a guaranteed bare bones way to spend that money to survive.

Every able bodied adult would have a "no excuses" fall back position. No able bodies single adult could say "I have to be homeless because I can't find a job and can't find a place I can afford to live."

Some people would choose to be vagrants anyway, but many wouldn't if they had a simple alternative.
The town I live in has no public transportation - it's not really necessary since you can ride your bicycle from one end of town to the other in about 15 minutes - yet more of these folks use the local taxi service than any other population in town. I can't afford a taxi on a daily basis - how can they? It maddens me to see this over and over again.
Many poor people use taxis to get groceries because they don't have cars, and can't afford them, and can't carry groceries on foot or on a bike. If society doesn't provide public transportation people have to do something. Another option is to widely provide bikes with baskets big enough for trips like that.
I thought when I got out of low income property management I would get away from this clientele, but find I am faced by the same folks every day. Many of them are 2nd and 3rd generation medicaide/social services clients. I would love to know how to stop this cycle.
Often the adults are beyond escaping from the cycle. It is a matter of providing care, not changing people profoundly. Children who get a decent, stable life with their necessities met growing up can escape.


Jude said...

In my case, I am poor in large part because of my mental illness. I haven't gone on welfare, although some months we've squeaked by on a little over $800. I have a friend in the UK who is also mentally ill with many of the same problems, and she has had an entirely different experience than I have. For example, in the UK, she has had free phone therapy for the past three years. She was finally able to get a job that she can handle, but she received help until that point, even though it took years. I briefly received voc rehab money to pay for therapy, but that money ran out. I have a master's degree and other advanced training, but getting a job in a rural area is tricky, especially one that I can handle without getting too stressed out or with a phone phobia. The only reason we aren't homeless is because I own my house without a mortgage. I don't think there are any solutions in the U.S. for people like me. I went to a doctor for anxiety meds to use only when I attended one of my kids' school functions. I had insurance then, but because of my deductible, the appointment cost $130.00 which I paid off over 6 months. I never filled the prescription because I couldn't afford it. Preventitive medicine isn't an option when you're supporting a family of three on so little money. There's some help--LEAP, for example, CHP plus, a large tax refund each spring which I stretch out as long as possible, and free school lunches. But there isn't the kind of help that would provide a real solution because that would require some sort of unified societal support that doesn't exist in the U.S.

Anyway, this was a great essay. Thanks for writing it and having such a good blog.

Andrew Oh-Willeke said...

There is no doubt that universal health care would cost money. A while ago, I estimated the cost at about $80 billion a year nationwide.

Expanded post-two year period welfare would cost money too . . . not as much as you'd guess, because the vast majority of welfare recipients receive benefits for less than two years, but certainly some. Without running numbers, I'd guess in the low tens of billions of dollars a year.

But, the current system has costs too . . . big ones. Private health insurance subsidizes vast sums of uninsured patient care through bad debt now. Hospitals and doctors spend considerable sums hiring people to screen patients to see if they have health insurance and reject those who don't, which wouldn't be necessary.

Not providing someone with prescription drugs when they were merely poor (and hence not Medicaid eligibile) causing them to suffer more serious conditions, as a result of not getting drugs, costs Medicaid money down the road.

And, in the case of welfare, the price is paid both in homeless shelters, and more importantly, in the cost of prisons and welfare for a generation of screwed up kids.

I don't think that in the long run we save any money with our current approach, and spending perhaps $100 billion a year for these programs, while not chump change, isn't huge compared to the size of the national budget.