by Georgia Center for Opportunity | Apr 24, 2015
Today, poor children in America have a limited shot at moving up the economic ladder into the middle or upper class. A study in 2012 by the Pew Charitable Trust shows that “[t]hose born at the top and bottom of the income ladder are likely to stay there as adults.” Further, “More than 40 percent of Americans raised in the bottom quintile of the family income ladder remain stuck there as adults, and 70 percent remain below the middle.”
In terms of economic mobility, America is losing its identity as the “land of opportunity.”
In January 2014, Raj Chetty, Nathaniel Hendren, Patrick Kline, and Emmanuel Saez, economists from Harvard and Berkeley, released a study with interesting insights regarding this issue of upward mobility. Their study explores community characteristics that foster upward mobility for lower-income children. The study measures two outcomes: absolute mobility, or the way children progress up the income ladder into adulthood, and relative mobility, or the income disparity between children who grew up rich and poor in the same community as they reach adulthood.
The researchers in the study looked at households in “commuting zones,” or what are basically metropolitan areas, in order to compare the economic mobility of children in various communities. Interestingly, they found that kids who grow up in certain metropolitan areas are far more likely to climb into the top two-fifths of American household income distribution than kids from families with the same relative income from other metropolitan areas. This led them to look into what the specific community factors are that foster opportunity. Their research reveals some very telling patterns:
1. Family Structure
The single most important factor in communities that foster economic mobility is family structure. Chetty et al. found that children raised in communities with high percentages of single mothers are significantly less likely to achieve both absolute and relative mobility. As such, “[c]hildren of married parents…have higher rates of upward mobility if they live in communities with fewer single parents.”
What makes this finding particularly significant is that this is the first major study showing that rates of single parenthood at the community level are linked to children’s economic prospects over the course of their lives. Previous research has shown that children raised by two married parents are significantly more likely to climb the income ladder, but this is the first serious study to show that lower-income kids from both single and married-parent families are more likely to flourish if they are in a community with high shares of two-parent families.
2. Racial & Economic Segregation
Second, they found that children raised in communities that are racially and economically segregated – that is, communities that cluster lots of poor kids together – are less likely to achieve economic mobility. In fact, segregation and family structure are the only two community characteristics that had a consistent correlation with upward mobility in their study.
It is helpful to think of racial and economic segregation as isolation – that is marginalization from both the mainstream economy and the norms that allow middle-income people to flourish. These norms are often contagions that go unnoticed and unmentioned in middle-to-upper-class communities. What is missing for so many children stuck in cycles of poverty is social inclusion, which overlaps with the third factor.
3. Social Capital
Social Capital often goes unmentioned in conversations about economic mobility because it is so difficult to capture in social-scientific terms. Moreover, social capital highlights how complex and connected poverty is because it cannot be separated out from other community factors. The methodology of social scientists encourages that complex problems be broken down into distinct elements to make it easier to analyze and tweak through targeted programs. But to address the problem of social capital is to enter into the complexity of poverty and see how approaches that ignore social capital actually rob disadvantaged groups of the coherence of their experience.
Here is why social capital is so important: You could have two people with exactly the same income who actually live very different lives based on the different social networks they have. For some, achieving upward mobility is a perfectly compatible, even expected, progression within their networks and lifelong relationships. Being a part of their family and maintaining strong relationships with loved ones basically means moving up the economic and social ladder. When hard times hit, they have the support structure they need to get back on their feet. For others, achieving upward mobility means separating themselves from family and loved ones, which may cause them to lack the connections and support they need to withstand an economic crisis.
The breakdown of the social bonds in American communities actually hurts the poor the most. Many people talk about inequality, but this study shows that the problem is not inequality but a lack of economic and social inclusion. Social capital is intertwined with family structure since adults in two-parent families have a much easier time devoting themselves to the kinds of activities that build social capital in a neighborhood. Social capital is also closely correlated to access to quality schools, which leads to the fourth community factor that fosters upward mobility.
4. Access to Quality Schools
Though it is certainly not a new finding, Chetty and his colleagues found that poor kids are far more likely to succeed if they have access to high quality education. Though the study does not mention the need for school choice, it is clearly a necessity by the fact that too many schools are providing a poor education to children who have no other options available to them.
GCO believes that the best and most effective way to provide access to high quality education for children from low-income households is through a variety of school choice initiatives, particularly Education Savings Accounts (ESAs) and Tuition Tax Credit Programs. Throwing more money at failing schools that lack competition and the ability to innovate is not the solution.
Conclusion
The study by Chetty et al. has a lot of other interesting findings worthy of consideration, but the four community characteristics that have been mentioned – two-parent families, racial and economic integration, social capital, and access to quality schools – are the ones with the strongest and most consistent correlation with upward mobility. These factors help to set those cloistered and marginalized from mainstream norms on a pathway to opportunity.
At GCO, we are committed to addressing limited social mobility in Georgia. We seek to identify barriers to opportunity and promote legislative, policy, and community solutions that allow people to achieve middle class by middle age. Our hope is that Georgia and America at large will once again become a “land of opportunity” for all people.
by Kimberly Sawatka | Dec 3, 2014
For many, December is a much awaited time of the year. While the holidays can issue in a frenzy of shopping and preparations, extended time away from school and work provide the prefect opportunity to relax and catch up with loved ones. Beyond the presents that may be given or the lights that may decorate our homes, fellowship with family, friends, and neighbors is what renews us during the holidays.
For me, the holidays have always been a time of celebration shared between the generations of my family. As a child I looked forward to going to my great-grandmother’s house. Preparing for the yearly family gathering, I would watch her whip up marvelous holiday delights. I would listen to her stories about Christmas when she was a girl. Once aunts, uncles, and cousins arrived, I loved the hum of the house filled with conversation and holiday cheer. It is the traditions shared with me in my youth that I still look forward to as an adult.
Keeping in mind what makes the season bright for you and finding fun ways to share time with others will surely make this the most meaningful and memorable holiday yet.
5 Activities to Try This Holiday Season
- Family book club: This year, select a book for the whole family to read over the holiday. Meeting weekly to discuss the plot, character development, and personal feelings about the story will not only help bring everyone together, but also help the kids (and adults!) keep their reading and critical thinking skills sharp over the break. Time spent discussing readings with family is also a special way to learn new things about each other.
- Holiday letter-writing: Nothing brightens a person’s spirits like receiving a hand written letter. Share season’s greetings by sending warm holiday messages to your neighbors, friends, or family members. Additionally, have the kids handwrite a letter to Santa Claus, send thank you cards for gifts received, or keep a holiday journal. These are all great ways to practice writing skills over the break.
- Christmas Caroling: Unfortunately, I haven’t seen a caroler in years! However, nothing makes me happier than to join-in (albeit off key) songs like Silent Night and the Twelve Days of Christmas. Revive the holiday tradition this year by starting a caroling circle of your own.
- Community service: Because the holidays are not only about what we receive, but what we give back, experiences such as working at a local food bank or collecting donations for less fortunate families provide the opportunity to build a stronger sense of community. Embrace the spirit of the holidays through volunteer work.
- Start a new tradition: Traditions provide a sense of closeness with your family and inclusion in a wider community, both contributing to developing a positive self-identity. This year I am happily starting a new holiday tradition with my siblings. Since Christmas is now one of the rare occasions we are all home together, we decided to make each other ornaments for our Christmas trees. Find a new family activity that will allow you to learn from and about those close to you.
This holiday season don’t just catch up on your Netflix list. Whether getting out to ice skate, reading in front of the fire, or helping a neighbor out, make this a meaningful time by celebrating what matter the most: love shared and good will exhibited.
by Georgia Center for Opportunity | Jul 24, 2014
This is the sixth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, the third explained the impact of uninsurance, the fourth focused on Medicaid and the Affordable Care Act, and the fifth highlighted challenges to expanding access to healthcare.
While there are significant challenges to providing low-income uninsured Georgians with quality healthcare, there are cost-efficient, state-based solutions Georgia can implement in the short-term that can positively impact health outcomes for Georgians in the coverage gap.
Provide State Government Support for Georgia’s Charity Clinics
The state’s 96 clinics served more than 183,000 unique patients and saved the state over $200 million in 2012 while not receiving any state funding. However, other state governments do financially support their charity clinics. Virginia provides $3.5 million to its 53 clinics; Ohio gives $435,000 for 46 clinics; West Virginia provides $4.3 million to 11 clinics; and South Carolina recently approved $2 million for 51 clinics.[i]
The state’s existing charity clinics have the capacity to serve more patients, but funding and unnecessary state restrictions limit their ability to meet their full potential. The Georgia Charitable Care Network requested a $2 million appropriation from the Georgia legislature in 2014.[ii] Since clinics’ can provide $7 worth of services for every $1 spent, this relatively small amount of government funding would allow clinics to be open more hours and serve an estimated 100,000 additional patients.[iii] With the increase in funds, the expansion in capacity could take place at many clinics with little delay, providing much needed care to Georgia’s most vulnerable citizens. However, funding for Georgia’s charity clinics was not included in the state’s FY 2015 budget.
While a $2 million appropriation would allow Georgia’s current clinics to serve more patients, over 40 percent of counties do not have a charity clinic. A larger appropriation would allow for the Georgia Charitable Care Network to help underserved communities open new clinics. Since many rural areas have limited access to care, new clinics could have a significant impact on communities across the state.
In 2015, the state should provide $10 million in funding to support the dramatic expansion of current clinics and the creation of new ones in underserved communities. Compared to the $2.1 billion cost of Medicaid expansion over ten years, this appropriation is affordable for the state and sustainable in the long-term while still expanding access to quality healthcare to a significant portion of the state’s low-income uninsured population.
Expand Telemedicine into Charity Clinics
Telemedicine is the provision of care through real-time interactive communication between the patient and provider from one site to another via electronic communications. The electronic communication – which usually includes at least video and audio – allows a provider to care for a patient at a different location. Telemedicine can be used to provide primary and specialty care, remote patient monitoring, and medical education. Care through telemedicine can take place at hospitals, clinics, community health centers, nursing homes, and schools.[iv]
Telemedicine has improved access to care for many individuals – especially those in rural areas that have a physician shortage – because instead of traveling across the state to see a provider, a patient can go to a local clinic or hospital and be connected with a provider located anywhere in the state. Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better management of chronic diseases, reduced travel times, shared health professional staffing, and fewer or shorter hospital stays.[v]
Georgia has one of the most robust and developed telemedicine networks in the country, but Georgia’s charity clinics are not currently using telemedicine. Utilizing telemedicine in the clinics would enhance their ability to deliver services. Setting up telemedicine presentation sites in charity clinics would allow providers to volunteer their time at clinics across the state without leaving their office. This would be especially beneficial to individuals who live in rural areas and often do not have access to specialty care.
Charity clinics currently do not have the capital to purchase the technology and infrastructure required for telemedicine, which is relatively inexpensive given the benefit it provides.[vi] The Georgia legislature should include funding to pilot the use of telemedicine in its charity clinic appropriation.
Modernize Nurse Practitioner Laws and Regulations
Many nurse practitioners and other mid-level providers deliver care to patients at charity clinics as employees or volunteers. However, the ability of NPs to provide care is limited by Georgia’s restrictive laws and regulations.
Georgia should join the one-third of states that provide full practice authority to NPs. By implementing the licensing model recommended by the National Council of State Boards of Nursing and the Institute of Medicine, NPs will be able to provide the high level of care that they are educated and prepared to provide at charity clinics and other healthcare facilities across the state.[vii]
While many physician associations have opposed these reforms, a 2012 study found no evidence of differences in primary care physician earnings between states that provide NPs with full practice authority and those that maintain practice barriers.[viii] Since the literature on NPs finds no reason to be concerned with the quality of care provided by NPs and it should not impact Georgia’s physicians’ earnings, there is little to no reason for the state to continue to limit the care NPs can provide.
Reinstate Sales Tax Exemption for Charity Clinics
Many healthcare providers are exempt from the payment of Georgia’s sales and use tax, including licensed nonprofit in-patient general hospitals, mental hospitals, nursing homes, and hospices.[ix] From 2008 to 2010, Georgia’s volunteer health clinics were also exempt from Georgia sales tax on medical and office supplies and other purchases.[x]
Given the amount and quality of care charity clinics deliver and the savings this care provides to the state, Georgia should reinstate the sales tax exemption to provide the clinics with more resources to serve individuals in need of care.
Replace the Lost Federal DSH Funds with State Dollars
Many hospitals have expressed concern about the upcoming loss of DSH funds. In 2016, Georgia hospitals will lose an estimated $26 million in federal funds for uncompensated care. The federal funding loss increases to $40 million in 2017 and $111 million in 2018.[xi]
DSH funds are an important source of revenue for many of the state’s hospitals, and the federal reduction could cause some of the hospitals to cut services or completely close. To support this essential component of the state’s safety-net, the state should replace the lost federal funding. Since implementing the above recommendations to support the state’s charity clinics and other state and federal health policies could reduce the amount of uncompensated care provided by hospitals, the state may not need to replace the full amount of lost federal funding. Thus, the state should work with hospitals to identify the amount of uncompensated care they provide and to calculate the amount of state funding needed for hospitals to maintain services.
[i] Georgia Charitable Care Network, “Partners in Georgia’s Safety Net.”
[ii] John Sparks, “Stabilizing the Healthcare Safety Net: A Partnership with Free and Charitable Clinics,” Georgia Charitable Care Network, Presentation to Georgia General Assembly Joint Study Committee on Medicaid Reform, November 18, 2013, video of testimony found at http://www.house.ga.gov/Committees/en-US/MedicaidReform.aspx.
[iii] GCO interview with Donna Lopper, Georgia Charitable Care Network, December 9, 2013.
[vi] GCO interview with Jeffrey Kesler, Georgia Partnership for Telehealth, March 13, 2014.
[xi] Georgia Hospital Association, Hospitals 101, 28.
by Georgia Center for Opportunity | Jul 22, 2014
This is the fifth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, the third explained the impact of uninsurance, and the fourth focused on Medicaid and the Affordable Care Act.
Georgia faces many challenges and barriers to expanding access to quality healthcare for low-income uninsured individuals, particularly for those in the Medicaid expansion coverage gap.
State Fiscal Constraints
Preliminary estimates projected that providing Medicaid to newly eligible adults through the expansion would cost the state approximately $2.1 billion from 2014 to 2023. Since the federal government covers 100 percent of the cost for the first three years and then slowly reduces its contribution until it is set at 90 percent in 2020, expansion is projected to first cost the state about $120 million in 2017. In 2023, the final year of the projection, state costs will have risen to almost $406 million.[i]
Governor Deal and other state leaders maintain that the state cannot afford Medicaid expansion and have expressed serious concerns that the federal government will be unable to live up to its obligations under Medicaid expansion. Therefore, any policy or program that would improve access to healthcare for low-income uninsured Georgians must cost significantly less than Medicaid expansion and must rely upon state-based sources of funding.
Physician Shortage
Georgia ranked 41st in the country in active physicians and 44th in primary care physicians per capita in 2010.[ii] According to the U.S. Department of Health & Human Services, almost 2 million Georgians live in a “Primary Care Health Professional Shortage Area,” meaning there are a low number of primary health professionals relative to the population.[iii] In 2010, 31 of Georgia’s 159 counties did not have an internal medicine physician; 63 did not have a pediatrician; 79 did not have an OB/GYN; and 66 did not have a general surgeon.[iv]
Georgia’s Fiscal Year 2015 budget allocates $2 million in additional funds to develop new graduate medical education programs to train residents.[v] While an important step, the state must continue to pursue efforts to address its shortage of primary care providers. Without more providers, many Georgians may not have access to primary care, even if they have health insurance coverage.
Limits to Nurse Practitioner Scope of Practice
Nurse practitioners (NPs) are an important provider of primary care across the country. In many states, NPs evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments. A literature review by the National Governor’s Association found that most studies show that NPs provide comparable care to physicians and achieve equal or higher satisfaction rates among their patients. The review did not find any studies that raised concerns about the quality of care offered by NPs.[vi]
Georgia’s laws and regulations for NPs are more restrictive than almost any other state. A 2007 study ranked Georgia’s NP regulations 48th in the country because the state’s NP limitations affect patients’ freedom to choose providers and NPs ability to provide primary care.[vii] Georgia’s restrictions include requiring NPs to be supervised by a physician and to have a collaborative agreement with a physician or a physician’s supervisor/delegation in order to prescribe drugs. These limitations do not exist in over one-third of states.[viii]
Fiscal Challenges of Safety-net Hospitals
Hospitals that serve a large number of Medicaid and low-income uninsured patients receive state and federally funded supplemental payments from state Medicaid programs. Called disproportionate share hospital (DSH) payments, the funding offsets the disadvantaged financial situation of hospitals that provide large amounts of uncompensated care to uninsured individuals and serve a substantial number of patients in the relatively low-paying Medicaid program.[ix]
The ACA was expected to reduce the number of uninsured individuals and, therefore, reduce hospital uncompensated care costs. This would create less need for DSH payments. Thus, the ACA required annual aggregate reductions in federal DSH funding from FY 2014 through FY 2020.
In 2011, almost 40 percent of Georgia hospitals lost money. Rural hospitals are in an even worse financial situation as 55 percent had negative total margins.[x] Given their financial struggles, Georgia hospitals have expressed concern regarding the DSH reduction. Since Georgia does not plan to expand Medicaid, the reduction in DSH payments would not be offset by an increase in revenue through having more patients being covered by Medicaid. Thus, the hospitals are likely to receive less funding, while the demand for uncompensated care is expected to persist.
[i] Georgia Department of Community Health, “Preliminary Estimate on the Impact of Federal Health Care Reform on the Georgia’s Medicaid and PeachCare Program,” Handout, April 2012.
[v] Governor Nathan Deal, Office of the Governor, “Deal: Budget includes half a billion dollars in k-12 education,” Press Release, April 28, 2014, accessed May 23, 2014, https://gov.georgia.gov/press-releases/2014-04-28/deal-budget-includes-half-billion-dollars-k-12-education.
by Georgia Center for Opportunity | Jul 18, 2014
This is the fourth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, and the third explained the impact of uninsurance.
Medicaid is the country’s main public health insurance program for low-income families and individuals, including children, parents, pregnant women, seniors, and people with disabilities. A joint federal/state program, the federal government sets mandatory eligibility groups and general guidelines for benefits, while states establish individual eligibility criteria within federal standards.
The Georgia Department of Community Health projects that over 1.8 million Georgians will enroll in Medicaid and PeachCare in 2014 – 18.56 percent of the state population. The Department estimates that the state will spend $2.85 billion on these programs – 15.57 percent of state revenue. The federal government will cover the remaining $6.65 billion for a total expenditure of $9.5 billion. [i]
In 2010, Congress passed and President Obama signed into law the Patient Protection and Affordable Care Act (Affordable Care Act or ACA). The expansion of Medicaid eligibility to all nonelderly adults who make up to 138 percent of FPL is a major component of the law. In 2012, the Supreme Court found the ACA’s Medicaid expansion to be unconstitutionally coercive of states. As a result of the ruling, expanding Medicaid is now optional for states.
Georgia Governor Nathan Deal and the General Assembly have chosen not to expand Medicaid because of the cost to the state and unsustainability of the federal contribution.
An estimated 534,000 uninsured adults in Georgia making less than 100 percent of the federal poverty level fall in the expansion “coverage gap.” These uninsured individuals would be newly eligible for Medicaid under the expansion but will likely continue to have limited access to affordable health coverage without a change in the state’s expansion decision or other health policy changes. [ii]
GCO’s new healthcare access report focuses on identifying sustainable solutions to improve healthcare for these individuals.
[i] Clyde L. Reese III and Jerry Dubberly, “Georgia Medicaid and PeachCare for Kids,” Georgia Department of Community Health, Presentation to Georgia General Assembly Joint Study Committee on Medicaid Reform, August 28, 2013, 11, 33, http://www.house.ga.gov/Documents/CommitteeDocuments/2013/MedicaidReform/DCH%20PP%20Presentation_Medicaid%20Reform%20Study%20Committee_082813.pdf.
[ii] Genevieve M. Kenney et al., “Opting in to the Medicaid Expansion under the ACA: Who Are the Uninsured Adults Who Could Gain Health Insurance Coverage?,” Timely Analysis of Immediate Health Policy Issues, Robert Wood Johnson Foundation and Urban Institute, August 2012, 18, http://www.urban.org/UploadedPDF/412630-opting-in-medicaid.pdf.
by Georgia Center for Opportunity | Jul 16, 2014
This is the third entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report and the second entry looked at Georgia’s healthcare safety net.
The lack of access to affordable care contributes to many individuals going without important services. Uninsured individuals in Georgia are nearly four times less likely than the insured to have had a routine check-up in the past two years[i] and are more likely to experience avoidable hospitalizations for conditions such as pneumonia, diabetes, and asthma.[ii] In 2011, 36 percent of low-income adults in Georgia reported that they went without care because of cost in the past year. Only two states had a higher percentage of individuals going without care.[iii]
Uninsured individuals are financially costly for taxpayers and the insured as well. In 2013, uninsured individuals across the country spent an estimated $25.8 billion out-of-pocket on medical care and received between $74.9 billion and $84.9 billion in uncompensated care. About 60 percent of the uncompensated care spending was provided by hospitals, 26.4 percent by publicly supported community providers, and 14 percent by office-based physicians who provided in-kind services or charity care.[iv]
Providers also attempt to recover their losses from providing uncompensated care to uninsured patients and those covered by government programs that pay below cost, such as Medicare and Medicaid, by increasing charges for those with private insurance. The higher prices charged to private insurance are passed on to families and business through higher premiums.
Estimates vary on how much cost shifting occurs. One study estimates that cost shifting through increased premiums and other similar strategies accounts for about 2.4 percent of private health insurance costs,[v] while another study estimates that uncompensated care cost shifting makes up 7.7 percent of private insurance costs.[vi] If the higher estimates are accurate, the uninsured population is costing the average Georgia individual $330 and the average family $900 per year in higher premiums.[vii]
[i] Patricia Ketsche et al., The Uninsured in Georgia, Georgia Health Policy Center, Issue Brief, November 2008, http://www.issuelab.org/resource/uninsured_in_georgia_2008.
[ii] John O’Looney, Louis Kudon, interand Glenn M. Landers, Avoidable Hospitalizations in Georgia: An Analysis of the Potential for Strategic Action, Georgia Health Policy Center, January 2005, http://ghpc.gsu.edu/sites/default/files/documents/ghpc/community_public_health/Avoidable_Hospitalizations_11-29-07_FINAL.pdf.
[iv] Teresa A. Coughlin et al., “An Estimated $84.9 Billion In Uncompensated Care Was Provided In 2013; ACA Payment Cuts Could Challenge Providers,” Health Affairs 33 (2014): 810, http://content.healthaffairs.org/content/33/5/807.abstract?=right.
[v] Coughlin et al., “An Estimated $84.9 Billion In Uncompensated Care,” 812.
Page 26 of 27« First«...1020...2324252627»
