In particular I want to deal in a fact-based but highly individualized manner with the many ways in which our society (specifically in Delaware) not only declares war on poor people, but conspires through a variety of governmental and private-sector actions, to keep them safely impoverished while blaming them for their own condition. The stories I am going to tell you are true, and based on a person close to me, whose identity I'm going to protect. I'll change names and some other identifying information, but the misadventures of this individual will be absolutely factual.
I'll call her Stella. She's not the perfect poster-child human being, but then who is? Currently in her early 30s, she was abused (both physically and sexually) as a child; she has severe Learning Disabilities but by dint of great effort graduated high school and is functionally literate (if barely); she suffers from PTSD from the abuse, is Bi-Polar, and has chronic depression.
Until the middle of last year, Stella has always worked. The high-school counselor from the Division of Voc Rehab (and this is the ONLY good thing I will say about this division, ever) was excellent and made sure she ended up with a Home Health Care certificate right after graduating high school. Later she managed (thanks to Del Tech in Dover, with a great big raspberry to Del Tech in Wilmington) to get a Certified Nursing Assistant credential. She originally aspired to move up to something like an LPN slot, but she just doesn't (and won't ever be able to) read well enough.
Stella started working in high school because she wanted a car. Worked fast food for three years, rising to become a Shift Manager, never (this was the late 1990s) making more than $8.50/hour, which ain't too bad for teenagers.
Out of school, she started working as a Home Health Aide for a visiting nurse outfit--one of those where you go to people's houses. Despite being willing to work as much as possible, she soon discovered that (a) they will fire you if they find you moonlighting for another company; and (b) they are dead determined that you will never get more than about 20-22 hours per week because benefits they don't even want to think about. (Oh, and while you're thinking about it, these jobs paid then $8.50-$10.00/hour with a lot of driving that you never got compensated for.)
After a couple years, tired of the driving and the never knowing what she'd walk into at a client's house, Stella moved into working as an aide at a nursing home that was pretending to be an assisted-living facility. We have a lot of them in Delaware. They pretend to be assisted-living facilities because that way they can use one RN to boss around a bunch of Residential Care Aides who aren't CNAs (as they would have to be in a real nursing home) and who get paid $3.00-4.00 less per hour. Put that over 12-15 people and the difference adds up on the bottom line if not the quality of care.
Eventually Stella managed to acquire her CNA and went to work at a real (if really low-rent) nursing home, full-time, supposedly with benefits. She stayed there for four years, occasionally winning excellence awards, until (as we will see in a later chapter) getting the shaft last year. Other items you need to know: since age 21, when she has had health insurance it has been Medicaid (we'll discuss those economics in a subsequent chapter); at various times she's been on Food Assistance (another jungle); and she had a child in her early twenties.
So, roughly, you got the picture?
Here's installment number one:
The State of Delaware does not want people to get on, or even stay on, Medicaid.
I'm not kidding. You can talk all you want about Medicaid expansion, or the people at DHSS and DPH who talk about extending services, but at no time in the past decade have there been fewer than 28,000 people in DE who were eligible for Medicaid but not covered.
First, getting on: this requires a plethora of documentation that most people who need the service do not have--at least not readily available. Birth certificates. Social Security cards. Two most recent pay stubs. This all sounds simple, right? Ah, but you haven't met the Delaware Medicaid bureaucracy.
Take the two most recent pay stubs. Stella went to the Medicaid office over in Newark and presented them. It was a Wednesday, and she was to be paid that Friday. So she brought the two prior pay stubs based on the day she applied. But there was a hiccup in the processing, so the case worker didn't submit her documents until the next Monday. At that point the reviewer noted that her last pay date should have been the Friday two days after she applied, and ruled that she had not provided the two necessary pay stubs, and denied the application on that basis.
(You've got this, right? On the day she applied she gave them the two most recent pay stubs, and she was denied based on a pay stub she had not yet received.)
Did they call her? No. She received a Notification of Termination of Benefits (a great concept, terminating benefits she'd never received), with three pages of instructions on how to appeal the termination. She tried to call her case worker. In case you did not know it, Medicaid case workers in Delaware DO NOT EVER return phone calls from the numbers listed on these notices; most will claim that they never got them. Eventually Stella took a day off from work (that she could not afford) to go sit again in the Medicaid office for THREE HOURS to be told by another worker (hers had the day off) that she had to file an appeal, because she couldn't file a new application until 30 days after her Termination, so if she didn't file an appeal she wouldn't be eligible to re-apply for at least another month, and very possibly two.
So, the appeal. There's this wonderful form that tells you in very plain English to put down why you think the decision to terminate the benefits you never received was in error. Unfortunately, Stella discovered when she got back home to fill it out, there's one thing missing from the form:
The address of where to send the appeal.
Nobody answers the phone. Take another hour to go back to the office WHERE THEY WON'T ACCEPT THE FORM because IT MUST BE MAILED IN, but they'll finally give her the address, while telling her, "You should have asked for that the last time you were here."
Three weeks later the appeal is granted, but Stella is not covered by Medicaid, just given the ability to immediately apply again (with TWO NEW PAY STUBS since she might have come into millions--who knows?--in the last month), which she does again ...
... and gets terminated again. This time they tell her that providing the birth certificate for her child is not sufficient and that she must re-apply and PHYSICALLY BRING THE CHILD to the Medicaid Office.
She then goes through another two-week delay in getting coverage because they find the father's name (all of a sudden) on the birth certificate and now (on the third time around!) demand all the custody and child support papers (he is at that point $25,000 behind in his payments) for yet another application.
Three weeks later she finally gets coverage. But don't think that solves anything.
Three weeks after she gets her coverage, she gets another document in the mail. It seems that she got covered first in mid-August, and everybody on Medicaid has to completely re-certify their eligibility four times a year, every year. September is a recertification month, and no matter how many days you have or have not been on Medicaid (in Stella's case three weeks) you have to PROVIDE ALL YOUR DOCUMENTATION ALL OVER AGAIN. Or they throw you off. And then you're only on for three more months.
There is an important corollary to all this bureaucratic rigamarole, which makes it apparently more palatable to pay salaries and benefits to morons who don't answer phones or provide return addresses than to provide health-care benefits ...
You see, this Medicaid runaround would eventually cost Stella the best job she ever had.
Why? Remember I told you that Stella suffers from PTSD, is Bi-Polar, and chronically Depressed?
Well, in order to keep functioning, Stella needs to stay on a really steady diet of anti-depressants and even anti-psychotics that over-the-counter without prescription assistance cost in total around $1,300/month. After about 3-4 days without the meds, Stella becomes withdrawn and moody. Within a week she's seriously depressed, has wide mood swings, and starts into really erratic behavior. In two weeks ... let's just say (and we'll find out later in detail) it's not pretty.
Nor is she capable of working at that point.
You may think to yourself, why am I (joe taxpayer) forking out $1,300 a month to keep some low-rent chick working a just-above minimum wage job in anti-depressants? Let me spell it out to you:
1. With them, she's working and earning at least most of her living. That's critical. We're talking somebody here with a strong work ethic, and a burning desire NOT to be dependent.
2. Without them, in a month, she's going to be hospitalized (whether she has insurance or not, because she's potentially a danger to self and others) and that's going to cost you (joe taxpayer) at the very least $2,500 PER DAY. Got that? Six days of hospitalization (which, if you know anything about mental health institutions is the bare minimum for stabilizing somebody in Stella's condition) equals the cost of ONE YEAR'S MEDICATIONS.
Oh, there are programs to get the meds for free or low cost. The one from the manufacturer has a 17-page application that must be counter-signed by your employer, two doctors, and a pharmacist; requires an additional ten pages of medical records appended; and takes 6-8 weeks for the company to process. I've talked to more than a dozen psychologists and psychiatrists in Delaware, and NONE of them have EVER seen ANYBODY meet the requirements for this supposed program.
There is exactly ONE free clinic in the Wilmington area where you might be able to find a psychiatrist who can get you an emergency two-week supply of these meds at little or no charge if you don't have insurance. Of course you have to be able to get there, and you have to be able to land one of the few available appointments, or just wait six hours for the possibility that somebody MIGHT OR MIGHT NOT be able to see you today without an appointment. (There are only two days a week that you are allowed to do this. No guarantees.)
Over a fourteen-year period of always working, Stella never made more than than $25,000 in any given year (and remember, she's got a child) and was usually in the $16-17,000 range. In those fourteen years, Medicaid canceled her coverage for periods ranging from two weeks to four months on TWENTY-ONE DIFFERENT OCCASIONS.
When the gap was 2-4 weeks or less, Stella found ways to stretch her meds, or help getting them from family or friends, or even (exactly twice!) the free clinic.
But then, about a year ago, Medicaid cut her off for nearly six months ...
What happened then was not pretty.