In this issue, the implications of repealing the ACA and what replacement might look like, a look back at Martin Luther King and poverty, and philanthropy trends for 2017.
Let's start with a cartoon from Clay Bennett of the Chattanooga Times:
Many healthcare watchers have some gripe with the Affordable Care Act. It was a hot mess of legislation that twisted and turned with the aim lowering costs and covering as many people without current coverage as possible. It survived numerous legal challenges since passing in 2010 but is likely to die in 2017 with the GOP-controlled Congress and making a new attempt to repeal it.
There are many experts, as Politifact explains here, that go into great details about what repeal would mean without a replace strategy for the insurance industry, the federal budget and folks who have started to reap the benefits of expanded coverage. However, these arguments just skate by the challenges of people who have little choice in decisions about health and economic prosperity. According to some studies, medical expenses ranks as one of the highest reasons for filing for bankruptcy. As the New York Times recently reported:
In the new poll, conducted by The New York Times and the Kaiser Family Foundation, roughly 20 percent of people under age 65 with health insurance nonetheless reported having problems paying their medical bills over the last year. By comparison, 53 percent of people without insurance said the same.
These financial vulnerabilities reflect the high costs of health care in the United States, the most expensive place in the world to get sick. They also highlight a substantial shift in the nature of health insurance. Since the late 1990s, insurance plans have begun asking their customers to pay an increasingly greater share of their bills out of pocket though rising deductibles and co-payments...
The health law has led to a decline in the number of Americans suffering financial stress from health problems, thanks to the new options for receiving coverage, especially for the poor. But the problem is still widespread, touching roughly a quarter of Americans under 65, when the insured and uninsured are looked at together.
Late last year Kaiser noted that poor people still face one of the most daunting coverage gaps:
As of September 2016, 19 states had not expanded their programs. Medicaid eligibility for adults in states that did not expand their programs is quite limited: the median income limit for parents in 2016 is just 44% of poverty, or an annual income of $8,870 a year for a family of three, and in nearly all states not expanding, childless adults remain ineligible.2 Further, because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults fall into a “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits (Figure 1).
Poor people also often also face life-long health challenges that coincide with being poor USAToday's Lisa Eposita reported:
Between 10 and nearly 15 years – that's the difference in life expectancy between the poorest and richest people in the United States, according to findings just published online in the medical journal JAMA. In the huge, long-term study encompassing 1.4 billion Americans, researchers matched income levels and mortality data between 1999 and 2014 to reach their conclusion...Gaps like this come as no surprise to Dr. James Duffee, who's been a community pediatrician in Springfield, Ohio, for more than 20 years, serving mostly low-income children and families. "Poverty is a negative, independent factor that influences lifelong health," he says. "Through the science of toxic stress, we understand that early childhood adversity and poverty is a factor that affects not only brain architecture and [neurologic and endocrine] function, but affects the probability of lifelong illness, including cardiac disease and diabetes."
U.S. News recently reported on poverty's impact on child mental health that may be of interest.
Meanwhile, though a number of people worry their will be no replacement for the law, some scholars are discussing what might take shape such as the American Enterprise Institute's James Scarpetta in the National Review:
It should be self-evident, and not at all controversial to acknowledge, that health insurance is a necessity of modern life. Only the very affluent can afford to pay the cost of treating many forms of cancer without health insurance, and no one is immune from cancer, or a costly accident for that matter. Moreover, households with low incomes will never be able to pay the premiums for health insurance without governmental assistance.
The GOP must accept these realities and address them head-on in a replacement plan. In fact, Republicans should endeavor to have more Americans enrolled in health insurance that provides protection against high medical expenses than would have occurred in the future under the ACA.
His suggestions include:
Grandfathering of existing ACA coverage. Low-income households that are now enrolled in ACA-subsidized coverage or in Medicaid due the ACA’s expansion of that program should be allowed to stay in the coverage they now have indefinitely.
Acceptance and clarification of Medicaid’s role as the safety-net insurance program. The GOP should seek to reach a compromise on the level of income below which households in all states would be eligible for insurance coverage.
Tax credits for households above Medicaid eligibility without access to employer coverage. The ACA imposed a poorly designed 40 percent excise tax — the so-called “Cadillac tax” — on employer plans with high premiums. The GOP should replace this tax with a more rational upper limit on the tax preference for employer-paid premiums.
Promotion of more-flexible Health Savings Accounts. HSAs provide a tax-preferred vehicle for families to set aside resources to pay for expenses not covered by insurance.
Back in 2012, CNN's Stephanie Siek highlighted that toward the end of Martin Luther King's life he attempted to pivot the Civil Rights Movement toward poverty:
In a speech in Grosse Pointe, Michigan, less than a month before his assassination, King spoke of unemployment statistics that belied the long-term unemployment in the black community. But he made clear that employment was not turning out to be a ticket out of poverty. He made the same point in a number of similar speeches in the months before and after.
"The problem of unemployment is not the only problem," King said. "There is a problem of underemployment, and there are thousands and thousands, I would say millions of people in the Negro community who are poverty-stricken – not because they are not working, but because they receive wages so low that they cannot begin to function in the main stream of the economic life of our nation. Most of the poverty-stricken people of America are persons who are working every day, and they end up getting part-time wages for full-time work."
Over at the Center on Budget and Policy Priorities, Nicolas Johnson and Arloc Sherman look at inequality and what it means given the holiday celebrating Martin Luther King:
This concentration of wealth and income means that while a small fraction of households are flourishing, too many Americans of all backgrounds lack basics: stable and affordable housing, access to good jobs, proximity to public transportation, and affordable health insurance and child care. Too many don’t live near good schools or have access to an affordable college education.
For every American who’s living paycheck to paycheck these are significant obstacles.
And the reality is that today, as in King’s time, low-income communities of color face particularly infuriating and imposing barriers such as job discrimination, harsh immigration policies, housing instability, and underfunded schools. King emphasized that many White Americans also faced poverty and disadvantage, and that all groups would make greater progress by working together for change. This is why he called for a “grand alliance” between the races. But he did not pretend the challenges for the races were identical; while a problem like youth unemployment was widespread for both races, he firmly noted, the unemployment rate was much higher for Black youth than White youth.
Michael Goldstein takes a stab at trying to imagine what of speech Martin Luther King might give today:
Today I don’t know that I would organize another march, because I have learned something else. And so have you, but it takes courage to even allow the thought. The decades of marching, protesting, demanding justice had their place, and they will have their place. But you must move beyond demanding economic and social and environmental and international justice from those who cannot give it, cannot permit it, can only feel threatened by what they perceive as the subversiveness of the demand for it...
Ask yourselves, how do we build a single organization that can advocate for all the needs of the people and the planet, and which fights not only against what the promoters of another agenda thrust in your faces, but works for its own positive program, a program that arises out of love for all of Creation and all beings within it? What is that organization’s strategy — over the years it will take to build the groundswell of direct action that will bring it to power — what, you must ask, is its strategy for washing away misinformation and false ideologies with truth, truth, and more truth? How will you use every one of those battles you are forced to fight to not only ameliorate the worst abuses in the short run, but to build the movement for the deepest change and to re-learn the power of united action, a lesson that we learned through doing 50 years ago?
Speak of social justice, a recent Public News Service report says that little of the new money flowing into philanthropic endeavors is finding its way to social justice:
The National Committee for Responsive Philanthropy (NCRP) report says between 2003 and 2013, which included the Great Recession, the assets of the country's grant-making foundations increased by more than $320 billion.
But report author Ryan Schlegel says little of that new money reached those who suffered the most during that same decade.
"While grant-making from the 1,000 largest foundations in the United States for under-served communities grew by a little bit, about 5 percentage points, grant-making for social justice philanthropy was stagnant," he points out.
Over at Inside Philanthropy we have a look at the way in which the Walmart Foundation is changing:
Once upon a time, the Walmart Foundation mainly existed to sprinkle small donations far and wide in the communities where it operated. It still makes a blizzard of these grants every year, and the foundation has the longest 990 of any charitable organization that we know of. But the real action is around a series of strategic initiatives with many moving parts, mixing grantmaking with other tools—and munificence mixing with self-interest.
The foundation's work around employment is a great example. As we've reported, Walmart has big plans for advancing job mobility and economic opportunity by investing in work skills and career readiness. It's doing this through traditional grantmaking, but also through changes in its labor management practices to build better opportunity ladders.
This work advances multiple goals. The foundation is doing some strong grantmaking to front-line groups helping low-income workers get ahead, but it's also investing in human capital to bolster its labor needs, similar to big banks giving money to maintain a pipeline of tellers and branch staff, or how tech companies are investing in STEM education. Of course, Walmart's new efforts to promote mobility are aimed at countering one of the most common charges leveled at the company, which is that it only provides dead-end jobs.
In the Denver Post, Bruce deBoskey looks at philanthropy's trends to watch for 2017. They include: reduced tax incentives for giving; more support of constitutional principles and women's rights; and more minority donors. He also says watch for more money from a smaller group of wealthier donors:
Charities are increasingly relying on larger and larger donations from smaller numbers of high-income, high-wealth donors, while receiving shrinking amounts of revenue from the vast population of donors at lower and middle income levels, according to a new report, “Gilded Giving — Top-Heavy Giving in an Age of Extreme Inequality.”
The report also says a growing inequity in charitable giving may hold risks not only for nonprofits themselves, but for the nation as a whole.
According to the report: “Risks to charitable sector organizations include increased volatility and unpredictability in funding; … an increased need to shift toward major-donor cultivation; and an increased bias toward funding larger or heavily major-donor-directed boutique organizations and projects. The increasing power of a small number of donors also increases the potential for mission distortion.”
Similarly, Triple Pundit's James Serino also offers ups a few other philanthropy trends for the new year, including growing influence of donor-advised funds and more focus on impact measurement:
Reporting that goes beyond simple outputs to measuring actual outcomes will become a must in 2017, particularly with the availability of technology that enables such measurement and reporting.
Another factor to consider over the coming year is measurement against the Sustainable Development Goals (SDGs). These 17 Goals and 169 targets set forth by the United Nations seek to end poverty and hunger, achieve gender equality, and provide quality education for all, amongst other goals addressing the economic, social and environmental dimensions of sustainable development by the year 2030.
Whilst the predecessor to the SDGs, the Millennium Development Goals, focused on developing countries, the SDGs apply to and have been adopted by both developed and developing countries around the globe, including the United States. Therefore, funders will be encouraged to increasingly connect their efforts to the SDGs, both within domestic grant-making and globally.
Will fighting fake news be a target for philanthropy? Inside Philanthropy looks a five-year gift from Craiglist founder Craig Newmark to help the Poynter Institute help others verify and fact check. You also might be interested to know that Cornell University was the final beneficiary of Atlantic Philanthropies funder Charles Feeney. The school received $7million.