The Working Poor (50 page)

The financing method perpetuates the inequities: The schools that have more money provide a superior education, which helps children improve their earning power so they can live in communities that have more to spend on public education. This, in turn, accentuates the racial divide, for public schools have been resegregated since the late 1980s, thanks in large measure to rulings by conservative judges installed by Republican presidents and Senates. One-sixth of the country’s black students now attend virtually all non-white schools, many of which are impoverished, and only one-seventh of the whites attend multiracial schools, defined as those with 10 percent or more minority enrollment.
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Breaking the pernicious pattern by funding schools on a statewide or nationwide basis would not end racial segregation, but it would be a step toward redistributing resources. But then, every solution creates at least one new problem. Money comes with strings attached. The ideal of pooling taxpayers’ involuntary contributions at higher levels of government to convey it equitably down the line collides with the powerful devotion in this land to local control—and to privilege. Vouchers for private schools undermine the separation of church and state and draw resources away from public schools.

Furthermore, not every ailment can be relieved by money. Even if teachers were paid in accordance with their essential value to society, even if there were enough of them to keep classes small and instruction somewhat individualized, even if they had sufficient books and microscopes and maps, not all the problems that children carry into school would go away. At some place along the continuum of difficulties, our skills weaken. We do not know how to address all those troubles that young people face. However, we do know how to do much more than we choose to do. Our insufficient will has not carried us even close to that twilight region where our competence fades.

The same can be said of every burden that weighs on the working poor. We know how to promote home ownership and make decent apartments affordable, but we don’t do enough of it. We know a great deal about how to treat alcoholism and drug addiction, but we don’t provide enough facilities to accommodate all who need and crave the help. That is also true of depression and other mental illness.

We know very well that many who work at the edge of poverty fall between the cracks of health insurance plans, earning too much to qualify for Medicaid and too little to buy private coverage. We have made only a partial response. Since 1998 government has filled much of the gap with the State Children’s Health Insurance Program (SCHIP), which provides federal matching grants to states that cover children at 100 to 200 percent of the poverty level—or higher, as in New Jersey, which extends coverage up to 350 percent. Few states have chosen to insure parents, however, and reduced tax revenues in a recession make that even less likely to happen. (The program’s annual federal budget of $4 billion is roughly the cost of a new aircraft carrier.) Furthermore, nearly a quarter of all uninsured children are ineligible for public coverage, a huge failing that could be changed by federal largess. Then, too, one-quarter of poor children who qualify for Medicaid are not enrolled, either because their parents don’t want government help, are deterred by complex application procedures, or simply don’t know that the children are entitled to benefits. We have not even had the will to spend extra money for outreach workers to get those kids insured. The same can be said for other support: Only one-third of the households in poverty receive food stamps or subsidized housing.

The larger debate over the country’s patchwork health insurance system, which leaves 47 million uncovered, touches on all the big questions about government’s role, the private sector’s fairness, and the class structure of America. Employer-based policies may be the worst conceivable way to organize coverage. They drive up companies’ labor costs, force workers into badly run health maintenance organizations, and create pools of insured so small for some firms that a single employee’s cancer diagnosis can send premiums shooting through the roof for everyone. In an age of high mobility, workers bounce from one to another plan as they change jobs, often enduring months without protection. We don’t get our auto insurance through our workplaces, and we shouldn’t get our medical insurance that way either.

But do we have the skill to solve this? Can we craft a form of universal coverage without stifling efficiency and scientific enterprise? Despite fears about government suffocating the private sector, the opposite has happened in research and development, where soaring federal funding has stimulated a similar growth of private investment. The question is whether the same would happen if a single-payer system of medical insurance were created. The single payer would be the federal government, funding the plan
through taxes, as it does now to insure 40 million elderly through Medicare and 50 million poor through Medicaid. That would provide basic care for everyone, regardless of income. You could even call it Basicare.

There are fears that this would lead to rationing of a kind, as in Canada and England. Some Canadians have experienced long waits in getting such treatment as chemotherapy after breast surgery, for example. In spreading finite medical assets more evenly throughout the population, would Basicare also deprive the wealthy of their privileged access to boundless supplies of specialists, high-tech testing, and advanced remedies? Would it constitute “socialized medicine” and sap the profit motive that drives research and draws talent into the profession? Many doctors who resent government regulation of their fees now refuse to see Medicaid and Medicare patients because the payments are so low—or they charge the elderly rich annual subscription fees to compensate for Medicare reimbursements.

The private alternative, however, has brought the nations medical system to the brink of catastrophe. Insurance companies exact wildly escalating payments from the public, indulge in exorbitant payoffs to their executives, execute dangerous denials of treatment, and reinforce a class-based hierarchy of care that damages the health of Americans with lesser means. Just as government has gradually entered the insurance business through Medicare, Medicaid, and SCHIP, it can’t shrink from further involvement without neglecting its duty to the general welfare. Until a single-payer system becomes politically acceptable, some form of federal-private interaction through subsidies and regulation is a must.

Here is where we need the will to develop the skill to have it both ways: to guarantee the benefits without smothering individual choice or medical initiative. That would be quite an achievement for a nation so steeped in aversion to big government yet so idealistic in the pursuit of social justice. Surely this would happen if members of Congress, who enjoy one of the country’s best insurance plans, faced the difficulties of Caroline Payne, who had to halt back treatment after being dropped from Medicaid; or Lisa Brooks, whose credit rating was ruined by an HMO that refused to pay for an ambulance; or those malnourished kids at the clinics in Boston and Baltimore.

We know what an unhealthy early childhood does to a growing human being. Neuroscience and other areas of research have taught us about the intricate relationships between the biological and the cognitive, between early nurturing and later functioning. Our understanding
of the problems is ahead of the skills we have acquired to solve them, and the skills are ahead of our will to act. Across the country we have developed a multitude of early-intervention programs, many founded on sound concepts. But those that are underfunded and run by undertrained staff set an unhappy pattern: The project receives inadequate resources, which leads to its want of success, which causes it to be abandoned as a failed approach.

Parents’ handicaps in raising their children lie along that continuum between the correctable and the unmanageable. At the most accessible end of the spectrum, mothers and fathers may simply lack informed techniques of parenting that can be taught in classes or individual counseling. Plenty of well-to-do parents pay for such training; low-income parents may find sporadic help without charge through social agencies. Parents learn such skills as how to encourage their children rather than focus on their wrongdoing, how to do joint problem-solving and help kids make their own choices, how to manage anger, how to administer discipline sensibly, how to listen and express empathy, and how to achieve mutual respect.

At the distant end of the continuum, though, where serious personality disorders and disrupted families affect parenting, our skills are weaker. Some parents carry such profound disturbance from their own upbringing that lessons and advice don’t have much impact. We have not figured out how to curb sexual abuse, for example, other than by removing children to foster families, which are not always model households themselves. These are concerns that cut across class lines.

Given the decisive nature of the earliest years, why doesn’t American society muster its most ingenious efforts to guide parents and safeguard children? The successful programs are described with recurring terms: “comprehensive,” “intensive,” and “highly professional.” Another should be “expensive.” When you have highly professional specialists in medicine, psychology, and child development focusing on a family the way a trauma team huddles over a patient in surgery, you run up very high bills.

Can the wealthiest country in the world afford to pay? You bet we can, especially if those at the top are willing to sacrifice a little. It might even save us money elsewhere in our social welfare budgets, as suggested by the results of the federal Infant Health and Development Program, a clinical trial aimed at premature babies. From birth through age three, 985 children in eight locations across the country were bombarded with attention from pediatricians, social workers, home visitors, and others who monitored
their health, referred families to services, provided educational child care, and the like. At three, the kids had higher IQ scores, larger vocabularies, and fewer behavioral problems than children who had not received the services.
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In other words, when we do it right, it works. “And everywhere we’ve tried to do it on the cheap, everywhere we’ve tried to cut a corner, we end up spending money with no appreciable results,” said Representative George Miller of California, who was chairman of the House Select Committee on Children, Youth, and Families.
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We have known all this for a long time. He made the observation in the 1980s.

Even our extensive efforts don’t reach enough children. Head Start, the preschool program for the poor, is funded at an annual amount worth the price of one and a half new aircraft carriers. It enrolls only 60 percent of the youngsters who are eligible, according to the Children’s Defense Fund, and its teachers, only half of whom are required to have a college degree, earn an average of just $22,000 a year. The Bush administration has shaken up the program by announcing plans to require it to push reading for preschoolers, a policy disputed as unwise by many educators. Early Head Start, begun in 1995 to tackle the critical years from birth to three, has been deemed effective by preliminary studies, but it touches only 5 percent of the nation’s eligible children. Meanwhile, government policies operate at cross-purposes by ratcheting up the work requirement imposed on welfare mothers without raising funds for child care. We don’t even do what we know how to do.

To appraise a society, examine its ability to be self-correcting. When grievous wrongs are done or endemic suffering exposed, when injustice is discovered or opportunity denied, watch the institutions of government and business and charity. Their response is an index of a nation’s health and of a people’s strength.

The United States possesses agile mechanisms for discerning troubling truths and adjusting toward reform. We have done so against racial discrimination, environmental degradation, corporate malfeasance, misguided foreign policy, police brutality, and domestic poverty. The fact that all these ills remain, many of them less virulent than a half century ago, testifies to both the challenge and the accomplishment. If the ideal is high enough, it is never quite attained. If the striving is sufficiently intense, it
never runs to completion; at best, it yields success after success indefinitely. That should be our mission against poverty in working America.

If a single cause were identified, a remedy might be readily designed. It would fit neatly into a liberal or a conservative prescription. If either the system’s exploitation or the victims’ irresponsibility were to blame, one or the other side of the debate would be satisfied. If the reasons were merely corporate greed or government indifference or impoverished schools, then liberal solutions would suffice. If the causes were only the personal failures of parents and children, teachers and workers, then conservative views would hold. But “repression is a seamless garment,” as Salman Rushdie wrote. This is repression of a kind, and it lacks the clear boundaries that would define the beginning and the end of accountability. In the fields of North Carolina, the migrants are driven by Mexico’s destitution and drawn by America’s promise. They are indentured to coyotes and
contratistas.
They are warehoused in squalor and paid a pittance by growers, by wholesalers, by supermarket chains, and by shoppers who enjoy low prices for the cucumbers and tomatoes that the migrants harvest. When accountability is spread so broadly and diffused, it seems to cease to exist. The opposite is true. It may look as if nobody is accountable. In fact, everybody is.

The liberal-conservative divide is not only about how big government should be; it is also about what government should do. Liberalism is the use of the state for some purposes; conservatism is the use of the state for other purposes. Just as liberal Democrats call for increasing grants and programs for the poor, “social conservatives” among Republicans want big government to give or withhold money to promote marriage, dictate local education policies, discourage child-bearing by mothers on welfare, and subsidize religious institutions’ moralistic efforts to combat indigence.