Affordable Health Care? Half the Population Can't Afford Anything!

SOME NUMBERS: ninety million, thirty-seven million, fifteen million.

Ninety million is the number of people—30 percent of the population—who have incomes below twice the poverty line, or below about $35,000 for a family of three. These people are not “poor,” but much research shows that this is the minimum income they need to pay their bills and go to a doctor if they have to without worrying about what other necessities they will have to forgo. (And this is true even if they have insurance, what with deductibles and coinsurance.) These ninety million present critically important policy issues that are not being addressed fully.

Thirty-seven million is the number of people who were poor in 2007 (the last year for which we have data) by the flawed definition we use to measure poverty in America—around $17,000 for a family of three and $21,000-plus for a family of four. Try to live on those incomes anywhere in this country—unless your home is abnormally inexpensive and you can grow your own food. No doubt the thirty-seven million figure increased substantially in 2008 (the numbers for the previous year are released around Labor Day) and will go up even more in 2009. Predictions are that the number of people living in poverty in 2009 will be forty-five to fifty million. That should be very troubling.

Even so, fifteen million is the number I want to emphasize here. That is the number of people who live in “extreme poverty,” who have incomes below half the poverty line or below about $8,500 for a family of three. This group represents about 5 percent of the population, a shockingly high proportion in my estimation, and it rose by about three million during the current decade. That so many people have such low incomes is testimony to our evident belief that there should be no basic income floor in American society.

I stress those in extreme poverty as a critical facet of our policy discussion because of the large number of former welfare recipients, women with their children, who have ended up with neither welfare nor a job, and also have not obtained disability benefits, have not gotten married or have not moved in with a partner, or have not been helped by an extended family. These women and children may comprise as many as two million people and are clearly a major ingredient in the increase in extreme poverty during the current decade. I call them “out out out”—out of welfare, out of work, and out of any other major source of legal support.

THERE ARE FOUR SETS of families to be served by a universal single payer health care system at no cost: (1) those with heads (single mothers, typically) who need temporary help in getting back on their feet due to a family breakup or who, during a recession, have exhausted unemployment insurance and may be out of work for an indefinite period; (2) those in which parents have low-income jobs, whether part-time or seasonal, and need an income supplement beyond the little or nothing they receive from the Earned Income Tax Credit; (3) those where an adult member can work outside the home but needs help while she gets appropriate education or training; and (4) those where the parents are not in a position to work because they live too far from available jobs, are caring for chronically ill children or elderly relatives, or have personal problems that make them functionally but not legally disabled and not good candidates for work.

The first group is for the most part noncontroversial, although there are states where even people who are clearly in what is only a temporary bad patch are turned away. The second group should, again, not be a subject of great controversy, but many who apply for help are not helped. Worse, people who have gotten a modest welfare check to supplement low-wage work may discover later on that the check, small as it was, counted against their time limit. With regard to the third group, TANF policy has actually gotten worse. One lesson of the 1996 law is that there are people with multiple barriers to succeeding in the workplace who can nonetheless succeed if they get more individualized attention. The 2006 reauthorization of the law went in the other direction, mandating more stringent work requirements that make no allowance for the extra assistance some women need in order to get and hold a job. The fourth group is obviously the most controversial, since the whole design of the TANF law is unfriendly to the idea that there are people who should be permitted to continue indefinitely to receive cash assistance. But this idea, while it would apply to at least 6 million people, is critically important if we are going to create basic protection for the poorest of the poor.