Abstract
The week before I sat down to read this book, I was on my way to a conference, driving through a small town in western Massachusetts that hugs a narrow road leading to the turnpike. Preoccupied with the gathering on the other end of my travels, I only barely averted a horrendous accident. A driver coming at me from the opposite direction turned left across the bow of my car without warning. Had I not reflexively slammed on the brakes, I could easily have plowed head-first into that car. This kind of “what if” sets the heart pounding.
But it was a mild moment compared to the experience of the author of Trapped in America’s Safety Net, Andrea Campbell, who takes us on a harrowing passage through the bowels of means-tested, bottom-tier, catastrophic health coverage. Campbell, a professor of political science at MIT and noted expert on inequality and social policy, embarked on that journey in order to help her sister-in-law, Marcella Wager, who was involved in a devastating hit-and-run car accident that left her permanently paralyzed from the neck down. Campbell brings the reader on a depressing, infuriating, and powerful tour of the worst the United States has to deliver in the way of care for citizens who have been seriously injured. Through the eyes of her brother’s family, she spares nothing in exploring how rules set up to ensure that fraud and freeloading are held to a minimum expose hard-working families and helpless victims to extraordinary indignities and wrenching insecurity just when they are most in need of support.
Had I been less fortunate and found myself in Marcella’s condition, my health and disability insurance would have protected most of my income, covered my hospital stay almost in full (minus a fairly modest deductible), and ensured that I retained my assets (home and retirement accounts). I would have been able to concentrate on my survival without worrying that my children would be dragged into sudden poverty. But Marcella and her husband, Dave Campbell, have endured almost the opposite experience. Because Marcella did not have health coverage of any kind at the time of her accident, she has been pushed down into the lowest tier of insurance—California’s Medicaid program for the poor—which is relentless in its means testing. Assets must be drained; family cannot step up to help lest that assistance be monetized in ways that threaten the asset bar; waiting periods place her health in jeopardy; essential prescription medications are rationed; and when Marcella finally lays her hands on health care, the reimbursement rates are so low that she cannot find a physician nearby.
Seven months pregnant at the time of the accident, Marcella’s infant was miraculously spared injury. But little Logan is growing up in a household that has to choose between his mother’s healthcare and any chance of getting back on track toward a middle-class life. The harder Dave works to support his family, the more perilous their lives become, since his earnings threaten her insurance coverage. And the fact that they are a young family just makes matters worse: they face years of these unholy options.
Marcella’s misfortune has prompted Andrea Campbell to describe in detail the vagaries of the American welfare state. Five characteristics are particularly salient. First, our safety net is heavily reliant on private provision of essential protections, which means one’s status as a worker/earner (how long, how much, for how generous a firm) exerts an extraordinary level of control over how good our benefits are, from pensions to health care. Second, we spend a lot of time and money trying to detect fraud and prevent the “undeserving” from putting their grubby hands on any part of the safety net. We seem to care more about this free-rider problem than we do about the fate of those who, through no fault of their own, have been gravely injured and need care. Third, we seem to be content to watch children and working-age citizens suffer while pouring money into care for the elderly. No one wants to deny older people their dignity; but our indifference to the legitimate needs of children like Logan and his working-age parents is indefensible, but very real. Fourth, even our welfare-state success stories are shot through with holes. My insurance would take care of my hospital costs, but virtually no one is insured against the exorbitant expenses incurred by 24/7 personal care, which is what a quadriplegic needs to survive.
Finally, Campbell’s detailed description of benefit programs shows just how powerful regional differences are in determining the strength of the safety net. States that are legendary for tight-fistedness in social spending, especially in the South, are even more meager when it comes to the health needs of accident victims (or the ordinary needs of poor children, for that matter). States that are more generous on social spending are also better places, if one can even think in these terms, to have a catastrophic accident. “Nowhere else do social assistance payments differ by a 4-to-1 ratio from one part of the country to another,” Campbell tells us, “when the cost of living difference is only 1.4-to-1.”
Trapped in America’s Safety Net is really two books in one. Its most compelling theme sticks closely to the experience of the severely disabled and shows how variations in state policy subject them to different degrees of hardship, make it variously harder or easier to retain middle-class assets, or regard them with compassion or suspicion. The second book within this book takes us on an excursion through the entire welfare system, from education to pensions, from TANF to food stamps. Here the book is a useful compendium, offered by an expert, but is less tightly connected to the central story and hence sometimes reads as though it was added on. Teachers looking for a primer on the insanities of the American welfare state will find this broader agenda an accessible account for their students. Those who want Campbell to drive the muckraking argument home will find the more narrowly construed story of inequity and tragedy more compelling.
In the end, the reader is bound to come away from this book feeling two parts anger and two parts embarrassment at being a citizen in a country that is so wealthy and so ungenerous, bound in red tape, suspicious of those in need, and downright mean.