by Gail Collins
Maybe what Texas has been working on is really the recipe for still more, still worse, national economic inequality. The state has a massive number of badly educated adults prepared to work for very low wages, plus laws that make it next to impossible for labor to organize and press for better salaries, plus a tax system that favors the wealthy. What’s not to like?
“We’ve got a split economy,” says Christopher King, the economics professor. He’s sitting on the porch of a nice café that overlooks Lake Austin and features gourmet coffee and upscale muffins. King is drawing a picture from Kurt Vonnegut’s Player Piano, of a world divided between the elite scientists and the miserable masses. “It’s a vision I can see without squinting too hard,” he says, waving a fork. “Dell [Computers] isn’t growing here. They’ve shifted their assembly overseas. Some of the design stuff is here. Everybody else is baking these muffins.”
11
The Other Side of the Coin
“From the perspective of a disembodied soul”
Policy wonks have always described Texas as “low tax, low service.” While the state’s leaders like to brag about the first part, they don’t generally broadcast the rest. There are no signs announcing, “Welcome to Texas. You Won’t Pay Much and You’ll Get What You Pay For.” But it’s hardly a secret.
If we’re looking at Texas as a model of the empty-place vision of how to succeed, it seems only fair to look at both sides of the coin. Some Texans, particularly the wealthy, pay low taxes. But virtually no one gets much support from the state. Even if they’re poor. Or need services.
When that famous California what-are-we-doing-wrong delegation made its trek through Texas, one of the many, many people the lawmakers talked to was Representative Mark Strama, a Democrat from Austin. “I told them, maybe a better way to look at this is through the prism of what John Rawls called the veil of ignorance,” Strama recalled. “You should look at public policy questions from the perspective of a disembodied soul that doesn’t know the body with which it’s going to incorporate.”
John Rawls was an American moral philosopher, and I think we can all assume this is the only time he ever came up during any event related to the Texas legislature.
This was the test Strama was posing: if you got to pick the place where you were born, would you be less enthusiastic about Texas if you had no idea if you were going to be a future software entrepreneur or a future teenage unwed mother? “Your chances of being employed in Texas are three to four percentage points better than if you’re in California,” Strama continued. “Your chances of not having a doctor when you need one are substantially higher, too. If your soul happens to be born in a body that doesn’t work below the waist, or that doesn’t have vision, the chances that you’ll have a meaningful life are probably better in California.”
Despite this unique opportunity to combine a visit with Rick Perry and a discussion of the veil of ignorance on the same trip, the delegation was not all that thrilled with Strama’s presentation. “What I remember is one of the guys interrupting me and rejecting the premise because he didn’t like the outcome. He said: ‘That’s an argument for the welfare state!’ ”
“Everything’s bigger in Texas, including our poverty and hunger”
One of the high points of every session of the Texas legislature is the release of “Texas on the Brink,” a production of the liberal-leaning Legislative Study Group in the house of representatives, which compares their state to the other 49 in categories ranging from average hourly earnings of production workers on manufacturing payrolls (38th) to percentage of the population who visit a dentist (46th). Unless you’re the sort of person who roots for your state to make it to the top in number of executions, the report is never happy tidings. “Texas has the highest percentage of uninsured children in the nation,” the 2011 report read. “Texas is dead last in the percentage of residents with their high school diploma and near last in SAT scores. Texas has America’s dirtiest air.” Also the dirtiest water, if you’re talking amount of toxic chemicals released into it. Texas has the lowest percentage of pregnant women who get prenatal care in the first trimester. It ranks fourth worst when it comes to the percentage of children living in poverty, and second worst in the percentage of the population with “food insecurity,” which basically means not having enough to eat. “Everything’s bigger in Texas, including our poverty and hunger problems,” said Paige Phelps of the West Texas Food Bank, who pointed out that in one west Texas county, Presidio, more than 44 percent of children don’t always have enough food to meet their basic needs.
This is very bad news for more of the country than just Texas. The dirty air does tend to flow elsewhere. The people entering the workforce without a high school diploma are going to be a drag on the entire national economy. And if we’re citizens of this country, it’s hard to be comfortable about pregnant American women who aren’t being cared for by a doctor, or children who don’t know where their next meal is coming from.
“This report makes for some interesting trivia, but if Texas is such a horrible place, why have 4.5 million people moved here in the last decade?” retorted Arlene Wohlgemuth, who was the executive director of the conservative think tank the Texas Public Policy Foundation, when “Texas on the Brink” was released. You may remember her as a leading architect of that social services privatization hell.
“We’re not going to find out about it, either”
When we think about what a low-service state fails to do, we tend to focus on social services. But there are a lot of other things that we instinctively expect to be taken care of, and Texas doesn’t. Necessarily. In all cases.
For instance, there’s the matter of weather-tracking. Weather is no small matter in Texas, which actually has some of the worst in the country, what with hurricanes, floods, droughts, and wildfires. In 2011, it was hit by a killer dry spell that decimated much of the farmland in the state, and half the population was awake nights worrying about how long this would last.
Yet Texas spends virtually nothing trying to keep track of weather and climate data. The Houston Chronicle noted that “the Texas state climatologist has a staff of three part-time students. The Oklahoma Climatological Survey has a staff of forty-eight scientists and technicians and sophisticated data collection in every county in the state.” You do not think of Oklahoma as a big spender when it comes to state services. Yet Oklahoma manages to cough up enough cash to try to figure out where the next disasters are going to strike, and warn its citizens about what might happen and how to prepare for it.
Or on doctor-tracking. In 2011, reporters from the Duluth News Tribune decided to write a “Where is he now?” about a former Minnesota surgeon who had left the state after being disciplined by the Minnesota Board of Medical Practice for “unprofessional and unethical conduct.” During their investigation, they determined that although the Texas Medical Board was supposed to review a doctor’s disciplinary history every two years during license renewal, it did not make use of the National Practitioner Data Bank, which keeps track of such things. A spokesperson for the Texas Medical Board said that would be too expensive for the state, because the Data Bank charges a fee.
“If the doctor doesn’t want to tell us and is not truthful when he renews his license, then we’re not going to find out about it either,” she said.
“Things start to look like rationing”
Still, the low-service-state story is mainly about things that happen to the poor and helpless. Let’s start with mental illness. If you’re poor and mentally ill in Texas, you had better be suffering from schizophrenia, bipolar disorder, or severe depression, because those are the only conditions the state is really prepared to treat. Most mental health care for low-income Texans comes through thirty-nine community mental health centers and in 2003, when the state was having one of its regular budget crises, the legislature decided to reduce the number of eligible patients—an initiative that seems to have permanently nailed down the fiftieth place spot
for per capita mental health spending. “When you have more need than resources, things start to look like rationing,” said David Evans, the CEO of Austin Travis County Integral Care, which runs the community mental health center and related services. The state gives the organization funding to care for about 3,000 adults, but in 2011, it was serving 6,800.
It’s kind of ironic that Texas Republicans were bounding up and down, denouncing the Obama health care plan as “rationing,” when so much of it was already going on back in their home state. (Senator John Cornyn, the up-and-coming power in the Texas congressional delegation, urged the country to “resist the movement toward a single-payer socialized system that will inevitably lead to rationing and a lower standard of care for most people.”) But, as we’ve noted before, irony is a commodity not in short supply in the Lone Star State.
Under the new state order, unless a victim of mental illness was threatening to harm himself or others, the centers weren’t supposed to treat people who weren’t schizophrenic, bipolar, or suffering from severe depression. In theory, that would leave lots more resources available to victims of the three covered conditions. In 2009, the Department of State Health Services did a study to see how the changes were going. They found that even people suffering from schizophrenia, bipolar disorder, or severe depression were sometimes waiting more than a year to get treatment.
Texans with mental illness were estimated to be eight times more likely to end up in jail than in a mental hospital. That ranked as the forty-eighth worst odds among the states. (Thank you, Nevada and Arizona.) “The largest psychiatric facility in the state of Texas is not a hospital or a clinic or an outpatient center. It’s the Harris County jail, which treats and houses, on a daily basis, about 2,500 mentally ill people,” reported Patricia Kilday Hart in Texas Monthly.
Poor people with severe mental illness are supposed to be sent to one of the state’s mental hospitals, but there are only forty-three of them, and 5,450 psychiatric care beds, for a state of over 25 million people. A patient in distress may wind up being transported hundreds of miles to get care—if there’s care available anywhere. “We have days when there are no beds available anywhere in the state,” Evans said. “Then the only choice becomes, stay too long in the emergency room, or be taken to jail, or in an untenable family situation, or become homeless.”
Of all the many, many horror stories that haunt Evans, one of the worst is that matter of the mentally ill person who winds up being picked up by the cops: “The individual goes to jail, but might not be competent to stand trial. Folks have averaged something like thirty-seven days in jail, in psychiatric distress.” Texas has a history of class action suits filed by advocacy groups on behalf of mentally disturbed prisoners, and Evans is torn between rooting for their successes and worrying that if the jailed mentally ill are put at the front of the line for treatment, other people with an equally desperate need will have to wait still longer.
“Treatment works; recovery is possible,” he said. “But the real hope lies in access on demand.”
“I was there two and a half days
waiting for treatment”
There’s a support group meeting in a church on the west side of San Antonio. The sponsor is C.O.P.S./Metro Alliance, a local community organization. The subject is jobs. Nobody in attendance seems to have heard of the Texas Miracle.
A young father has lost his construction job (“hard labor but good money”) and worries about the stress on his wife and family. A middle-aged woman with a background in data processing just visited the unemployment office and was depressed when she saw that the notices for available jobs appeared to be the same ones that had been hanging there when she last visited two years before. A balding man who had worked in civil service for eighteen years was let go four months ago and had gone back to living with his mother. A woman who had worked cleaning motel rooms (“they pay you for twenty minutes a room”) quit when she realized her child care bills were higher than her salary.
The one theme that runs through all their stories is lack of health insurance. “She worries because I’m not insured,” says the man who works construction, gesturing to his wife, who seems to be near tears. “But my health is okay for now.”
“I’m diabetic,” says the woman who worked in data processing. “Can I afford to buy my medicine? Definitely not.” The former civil service employee needs medication for depression that costs $500 a month.
Lack of health insurance is a common problem in the families of unemployed people around the country. It’s just that in Texas it’s bigger. Way, way bigger, since 26 percent of the people there are uninsured—including a third of all working-age adults. It’s the highest proportion in the country and Texas, as we’ve been reminded quite a bit, is a really large state. We’re talking more than 6.2 million uninsured Americans. Americans who will grow up—and grow old—with untreated and chronic conditions like diabetes and asthma. Some of them will then move to other states where their built-up medical issues will become the problem of emergency rooms in Chicago or Atlanta or Denver.
One of the reasons so few Texans have health insurance is the much-touted business-friendly culture that shies away from the idea that employers have any responsibility to their workers beyond the occasional paycheck. Another is that the state is second from the bottom in its spending on Medicaid. (Pressed on this matter during the presidential campaign, Perry alternately blamed federal bureaucracy and Washington’s unwillingness to hand over all the Medicaid funds in a block grant for Texas to use as it saw fit.) If a working mother with two children makes $5,000 a year, she can’t qualify for Medicaid coverage.
Texas isn’t the only state attempting to keep everybody but indigent adults off Medicaid. Four states make the cutoff even lower—Arkansas, Alabama, Louisiana, and Missouri. That’s very tough on the residents of those states, but even if you add all four together you are talking about less than half the uninsured people wandering around Texas, perhaps trying to control their tubercular symptoms with cough syrup. (Also, we have not been having a national debate about whether the country could create more jobs if everybody else behaved more like Louisiana or Arkansas.) On the other hand, there are also states working under the assumption that everybody is better off when as many people as possible are insured. In Minnesota, the most liberal place in the nation when it comes to Medicaid eligibility, that working parent’s income just has to be below $41,043.
What do all those uninsured Texans do when they get sick? If they live in an urban area, the most likely recourse is the county hospital, which is obliged to treat everyone who comes in the door, although it reserves the right to charge the people who don’t qualify for free treatment.
“When the bill comes, I don’t open it,” admitted Amira, one of the participants at the C.O.P.S./Metro Alliance community meeting. A widow with four kids, she’s studying to become a nurse.
The quality and efficiency of health care provided to uninsured patients varies from city to city. In rural areas, the nearest hospital that will provide treatment can be hours away. In San Antonio, if the stories at the community meeting are any indication, anyone who tries to use the emergency room as their physician will pay in waiting time. “I went to the emergency room when I was very sick,” Amira tells the group. “I was there two and a half days waiting for treatment. It’s terrible not to have insurance and be in Texas.”
No matter how great the hospital’s effort, it falls short of the vast, uninsured demand. Harris County, which encompasses the city of Houston, has a county hospital system that runs three public hospitals and thirteen clinics. The county also has a $1.2 billion budget, much of which comes from local property taxes. Nevertheless, uninsured patients complain about waiting weeks or months to get a clinic appointment.
The biggest worry for the health care professionals, however, is the people who never show up at all.
“Honestly what keeps us up at night,” said David Lopez, the CEO of the Harris County Hospital
District, “is that you have 1.2 million people who are uninsured. As busy as we are, if we were to count noses it’s about 325,000 uninsured people a year. That means the balance aren’t being seen.” And the ones who do come in often delay the visit so long that their problems have become acute. “Cornell has asked to send residents down here because the pathology we see is great for teaching purposes,” Lopez reported.
If you’re a young doctor in search of unusual cases, however, the place to go in Texas is the colonias—about 2,300 extremely poor communities along the border, some of which lack running water, solid waste disposal, and paved roads. Some have rates of tuberculosis four times the national rate, and there are seldom-seen-in-this-country diseases like dengue fever and leprosy. Most of the residents are citizens—uninsured citizens. Once a year Operation Lone Star, a training exercise run by the state and the military, provides free basic medical and dental treatment in the colonias, and people sometimes wait overnight to get a place in line.
Here’s what all this means to the rest of us: We’ve got untreated carriers of communicable diseases, along with many, many people with untreated chronic conditions. All of them have every right, as Americans, to move to other states and present themselves to the local emergency room or state-funded clinic. Maybe they’ve moved to Minnesota, which makes so much effort to provide health care for every family that needs it. Minnesota didn’t create their untreated-diabetes problems, but Minnesotans might have to pay to treat them.
You’d think the fairest thing would be for the country to come up with a plan that makes sure everyone has health insurance. Then people who have the capacity to pay for their coverage will have to do so. Those who don’t will get help. No matter where Americans are living, they’ll get an equal chance at proper medical treatment. And then when our citizens move from state to state, they won’t be bringing their untreated health problems along with them.
