Wednesday, July 8, 2009

Notes From Underground: How Do We Like Our Poor?

Posted By on Wed, Jul 8, 2009 at 11:04 AM

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Thinking about healthcare issues in the abstract makes my eyes bleed, so if you want sophisticated waxing on healthcare reform and policy, stop reading now! But a recent conversation with a local healthcare professional gave me pause. I was talking to a women's health nurse practitioner working at a women's healthcare clinic in town. I asked how the job was going. She said the bulk of her clients were on TennCare, but that she also saw immigrants and unemployed women who had no insurance at all. She'd noticed something curious: The immigrant women were extremely grateful to have any care at all. The unemployed women--sometimes middle-aged execs who'd recently been laid off from well-paying jobs but were no longer carrying COBRA--were also extremely grateful to have any care at all. Both groups happily paid for their own care based on a sliding pay scale. It was many of the unemployed women on TennCare--those who paid nothing for the visit--who seemed the most entitled and demanding. "They want the best care, all the extra attention," she said. (I'm paraphrasing from memory.) Initial reaction: "Really?" I said. "They're not grateful?" It got me thinking about the presumptions we have about the poor, and the notion that they ought to be grateful for handouts. Those of us who have to pay for our insurance would be grateful to have it for free if we suddenly lost it. But I think there's something psychologically to holding that card in your hand. Free or not, the TennCare member is enrolled in a system that promises them coverage, so they can rightly expect to get the full benefits of that program. They want the annual checkups and medication and attention and the extra tests. They've got the card; the lady next to them doesn't. They went through the system and did the paperwork. (I'm not even talking about or implying that anyone in these cases is necessarily bilking the system, although we know that does happen.) They can expect the care. And when we expect something, we're more likely to ensure we get it. But really I'm just talking about the stigma of poverty. We're a country built on a poor-but-proud mentality in some ways. The poor can earn respect by working hard and with dignity, we seem to say. Expecting handouts is generally looked on with derision. It's almost as if we want to see the kind of grace we think should come with being on the receiving end of that benevolent hand of government charity. All our cultural signals back that up. Shows like Extreme Makeover: Home Edition show needy family after needy family sobbing with joy that anyone would be so kind as to swoop into their lives and solve their problems. That's the viewer payoff: They're poor, and now they have this dream house, and they're super humbled by it. We like our poor humble. If the family took one look at their shiny new home and rolled their eyes and said, "Geez, it's about time," it probably wouldn't have the same punch. Watching the citizens of other countries discuss their universal healthcare, no one ever comes off so much as grateful for the coverage, merely matter-of-fact about their right to receive it. But that's not America. Also, I've been poor--no health insurance, food stamps, trailer parks, the works. Being poor used to seem to mean enduring a very public acknowledgement of your predicament, at least in the small towns and public school systems I went through. Credit was harder to come by, so it was much more difficult to pose as middle class. (Though I've lived in Section 8 housing where everyone else seemed to pay $12 bucks a month in rent but always had really nice electronics.) And this was still a generation who didn't have a fancy swipey thing for food stamps that just looks like a credit card from a distance. You had to paste those suckers onto a little booklet and whip it out in line while everyone looked. And that free lunch program meant you had to pull out your card and have it filled in punch-hole style by the cafeteria lady, while, again, everyone else paid with cash and looked on and tried to figure out where your particular family went wrong. So you learned to act really grateful. It seemed to bring less scorn. I probably just sound like a whiny asshole: Man, back in the day when I was really poor, you had to really act poor, and now poor people don't have to act poor at all! I'm certainly not arguing that poor folks ought to grovel and tear up every time they catch a break--there's enough shame already there, especially with so many people already blaming them for their misfortunes. But I am intrigued by the assumptions that informed my very simple and immediate head-scratch at this woman's comments about some of her patients--and I'm usually your classic bleeding heart when it comes to most social programs. So what's worse? Those women not being grateful, or me thinking they should be?

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