Georgia’s Medicaid waiver plan arrived this week. It’s pretty much exactly what many health advocates expected: a plan that will at best cover 50,000 of the over 400,000 who could qualify for Medicaid under a full expansion. As I read the coverage surrounding the release of the waiver plan I was discouraged not because of the number of people still left without coverage (I was ready for that) but that the policy confirms a deep misunderstanding of poverty and what is making people sick in the U.S.

Growing up white and middle class in the Midwest, my understanding of poverty developed implicitly. I don’t remember anyone telling me people living in poverty were lazy or made poor decisions. Rather, success stories and advice provided a narrative of how people born into poverty or lower middle class came into flourishing careers, social status, and economic stability and focused on themes of hard work and education. “Work hard in school so you can get a good job.” “I put myself through college delivering pizza and waiting tables.” “We ate popcorn for dinner a few nights a week during graduate school but the hard work paid off.” The values of hard work and pursuing higher education created a message that poor people could escape poverty simply by working harder. What these stories lacked, often unintentionally, was the acknowledgement of the many factors outside of personal work ethic and discipline needed for success. These stories failed to convey the ways in which social support, housing, race, ethnicity, health, and disability influence opportunities for work, education, and financial stability. After a decade of working with people who fall at and below the poverty line, these narratives have proven false.

Under the waiver, in order to qualify for Medicaid, Georgians must be working, enrolled as a full-time student, or documenting specific qualifying work training or volunteer activities. Do we believe that people who find themselves unemployed and/or living in poverty prefer not to work? Do we believe that dangling access to health care is an effective or ethical way of motivating people to work? On Fridays, the clinic where I work operates a specific program to provide healthcare to people experiencing homelessness. Of the hundreds of people I have met in this program, almost all of them are either working or want to be working. It is not a lack of motivation or drive keeping people from gainful employment. Let me provide a few examples:

Transportation: It is no secret that Atlanta’s public transit system has severe gaps in access. For patients without a car, getting to work often requires a train ride and one or two buses. If any one of these connections gets delayed or canceled, getting to work becomes impossible. I’ve had patients loose jobs because they arrived late due to a bus coming late or a train being cancelled. The problem worsens when people have to move constantly for housing. The landlord doesn’t renew the contract, the housing program funding is eliminated, the 30-day temporary emergency housing shelter limit is up. Each move means more difficulties in transportation. If people move toward the suburbs for more affordable options, they loose transportation to get to jobs in the city. Public transit isn’t cheap. It costs $2.50 for a one-way ride. Working a minimum wage job not only cannot cover the cost of even a studio apartment in Atlanta, it also can’t keep pace with the cost of getting to and from work every day. We can’t expect people to work when we don’t invest in an efficient, affordable public transit option.

Health and Disability: Many of my patients have severe mental and physical disabilities that would prevent anyone from full-time employment. Obtaining disability can take years even with the right resources. One of the essential steps in obtaining disability is having a regular source of healthcare where a provider can document health and disability. This requires time and access to health care. Mike (name changed) has been coming to Good Sam for a few years and his birthday was Friday. He was severely abused as a child and developed anger issues which resulted in imprisonment. He likely had undiagnosed learning disabilities and never finished school. Coming out of prison with severe trauma, a debilitating mental heath condition and no high school education, he isn’t equipped for work. Our psychiatrist remembered it was his birthday and brought him a small gift on Friday. He told her it was the first birthday present he had ever received in his life. He needs Medicaid so he can heal, get his GED, and build a life beyond the trauma he has experienced.

Work opportunities: Jack (name changed) has schizophrenia and until recently was living on the street. He is now in supportive housing and never misses an appointment at the clinic. Given his health condition, he cannot work a full-time job but wants to be a productive citizen and earn money. He found a connection which offers him prep work in a kitchen one day per week. Every day, he walks to the library and checks his email to determine when he is needed because he cannot afford a phone. Then he takes public transit (a train, one bus and then a second bus) to get to the facility. He puts in a full day of work and tells me he loves working there. I can’t image doing that much work before even arriving at a job and yet this work wouldn’t meet the new proposed Medicaid work requirement. Many of the jobs available to people who lack higher education or training, have disabilities, or have criminal records do not provide a living wage, opportunities for growth or financial sustainability. They are working- it’s just not enough.

In addition to the policy’s failure to understand the causes of poverty, the policy misses an opportunity for equity, failing also to recognize the ways in which decades of policy have in many ways caused the current crisis of people without insurance. People of color are disproportionately more likely to be uninsured and live in poverty. From our earliest days as a nation, we have used policy as a tool to disenfranchise groups of people. Through policy, we have authorized systematic racism in which it was legal to treat people differently because of the color of their skin. The impact of legislation like Jim Crow laws didn’t disappear when the legislation was repealed. People of color in the U.S. continue to have lower life expectancy. This is a societal problem and policy can either further perpetuate this disparity or be employed as a tool to correct it.

I have two school-aged children and I want them to do well in school. Let’s say I give one a healthy breakfast, assistance with homework, extracurricular activities, safe playtime, a stable home, a consistent sleep schedule, and quality medical care. Let’s say I send the other to the same school but deprive him of nutrition, sleep, support, play, and safety. I have systematically disadvantaged one over the other. When they get to high school and the first son is thriving and the other is not, it won’t help to tell my second son that if he just works harder I will give him some support. I have to own the damage I have done. As a society, we also have to own the damage our nation has done through unfair policy.

The Medicaid waiver has a long journey ahead but its current form reminds me that we have a long way to go. Health insurance is already structured as a reward for stable employment in this country. What are we going to do about the fact that we have systematically disadvantaged people from achieving either?

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