The United States has a gun problem, and the United States has a racial justice problem. When the two collide the results are too often tragic and horrible. The events of the past week, unfolding in real time before a country still in shock and mourning over the mass killings in Orlando, further underscore this terrible reality (as if any further emphasis was needed). Last week, a peaceful demonstration in Dallas protesting the deaths of two more black men at the hands of police was turned into a scene of violence and chaos in which five police officers were killed and several more officers and civilians were wounded in what appears to have been a retaliatory attack by a lone gunman.
As Baltimore’s Health Commissioner noted in her recent op-ed, what makes these repeated violent incidents doubly tragic is that we have the means to prevent many of them. These interventions must include not only sensible gun control policies, but also tackle upstream public health interventions that have wider implications for addressing persistent racial inequality in the U.S. As Surgeon General Vivek Murthy argued, the real challenge is to “reduce the origins and impetus for violence in the first place.”
The medical community is increasingly recognizing gun violence as a public health problem, and some professional bodies, such as the American Academy of Family Physicians and the American Medical Student Association, have also specifically called out police violence. Unfortunately, political roadblocks to effective action remain firmly entrenched. Only a couple of weeks ago, House Democrats staged a sit-in as an effort to bring gun control measures to the floor. Instead of bringing a bill to the floor, the House Republican leadership is busy debating how to discipline the Democrats for their protest.
Meanwhile, as the toll of gun violence steadily mounts, the ban on using federal funds to research gun violence remains in place. Medical leaders are raising their voices to overturn the ban. Let’s hope their call is heeded soon.
“State Flexibility” a Code Word for Gutting the Medicaid Program
While the House Republicans have put forward an outline that ostensibly replaces the ACA, some analysts have concluded that “the real target of the proposal is the gutting of Medicaid.” The Republican outline repeats the tired assertion that, “…governors and state legislatures are closer to patients in their states and know better than Washington bureaucrats where there are unmet needs and… all states should have more flexibility to adapt their Medicaid programs, to better design benefit packages in a way that better meets the needs of their state populations.” Really? Let’s look closer.
Consider first that despite the fact that covering hundreds of thousands of people made newly eligible for Medicaid by the ACA would costs states almost nothing – and, in many cases, would actually save money – nineteen states have still so far refused to do so. But, unfortunately, there is much more. For example, it took a lawsuit against the state of Washington, as well as pressure from CMS, to get many states to cover new Hepatitis C medications for most beneficiaries, and some states are still dragging their feet. If states had more “flexibility” to deny treatment, can there be any doubt that many would do so? Similarly, it took a lawsuit based on the legal right to treatment to get the state of Florida to make improvements to its Medicaid program for children. And the list goes on. The Missouri legislature recently voted to charge Medicaid recipients for missed appointments, though Governor Nixon vetoed the bill. Governor Bevin in Kentucky is seeking to impose extensive lock-out periods for beneficiaries who fall behind on their premiums and Texas is refusing to cover certain services for children with autism despite a federal directive requiring them to do so.
Now remember that all of these proposed state actions (and all of the inaction on coverage) are occurring in the context of both guaranteed federal matching funds for states and significant legal protections for beneficiaries. Consider what would happen if both of these were removed. These and other ideas that have emanated recently from some states are the best possible argument for why states should not be given carte blanche to redesign their Medicaid programs.