In the swamps of Louisiana, late autumn marks the end of the hurricane and the sugarcane seasons -- a time for removing plywood from windows and burning residues of harvest in the fields. Then begins the season of crayfish and, nine months having passed since the revelry of Mardi Gras, a season of newborn Cajuns. Among the yield of infants in the autumn of 2004 was a boy named Daigan James Plaisance Theriot, and, on the morning of Daigan's thirtieth day of life, he was seated next to a bag of raw chickens in the back of an Oldsmobile Cutlass. His mother, a teen-ager named Alexis, was in front, squeezed between her younger sister and her sister's latest beau, a heavily tattooed man who had just been released from maximum-security prison. The car came down a road that begins with a bayou and ends in dented trailers, and stopped at a small wooden house.
When Alexis's sister leaned into the back seat to fetch the poultry, the young man, grinning, slipped a hand down the back of her jeans. Alexis stared at the couple for a moment, then pushed them aside to pick up Daigan. Alexis's hair was long and streaked with pink, and her face was a knot of frustration. As Daigan began to cry, she crossed the yard denouncing in absentia his father, whom she called Big Head: "If I see him, I will hurt him -- Big Head asking for it now." When she reached the porch, which was crammed with auto parts and porcelain toilets, she fell silent, then forced a smile. Amid the fixtures stood a tall black nurse.
The nurse, Luwana Marts, holds one of the stranger jobs in the Louisiana state bureaucracy: she is a professional nurturer in a program called the Nurse-Family Partnership, which attempts to improve the prospects of destitute babies. A few months earlier, Alexis, eighteen and pregnant, had arrived at a local government office seeking Medicaid for her impending delivery. She ended up with both the Medicaid and Luwana. As a rule, Cajun families don't welcome government intervention, especially when it occurs inside their homes, involves their infants, and means the presence of a dark-skinned person. To some parents, Alexis among them, Luwana was a spy in the house of maternity, and so she now and again had to lie in wait for reluctant beneficiaries.
Alexis maneuvered herself and Daigan past the toilets, from which cacti had started to grow, and pushed open the front door with her hip. She entered a combined living room, dining room, kitchen, laundry, and storage facility that was home to five people, a dying cockatoo named Tweety, and multitudes of flat silver bugs. Luwana followed Alexis, Daigan, little sister, and boyfriend inside. That morning, feeling the onset of flu symptoms, Luwana had decided to avoid contact with the infants she called her "little darlings." In the field, though, calculations of risk were subject to change. She dropped her satchel, slathered her hands with Purell disinfectant, and reached out. Alexis handed over Daigan and wrapped her arms tightly around herself. "So, tell me," the nurse began with practiced tranquility as she scanned a body in a playsuit for damage. "Not the happiest day of your life?"
Alexis and nineteen other girls in Luwana's caseload call her their "nurse-visitor," a term whose genteel ring seldom comports with the details of her job. She is one of eight nurses, all mothers themselves, who work the parishes of Terrebonne and Lafourche, persuading poor first-time mothers-to-be to accept assistance. The Nurse-Family Partnership model is currently being tried in Louisiana and nineteen other states on the basis of promising preliminary results -- results achieved in the face of the nurses' preposterously difficult assignment. In regular visits until a baby is two years old, they try to address, simultaneously, the continual crises of poverty and the class -- transcending anxiety of new maternity: this creature is inexplicable to me. Despite its ambition, the program is rooted in a pessimistic view of the future that awaits an American child born poor -- a sense that the schools, day-care centers, and other institutions available to him may do little to nurture his talents. Shrewder, then, to insulate him by an exercise of uncommon intrusion: building for him, inside his home, a better parent.
Thus, no matter how chaotic the scene -- no matter that Alexis's sister had taken a break from hacking chicken parts by the kitchen sink in order to satisfy the ex-inmate's sexual needs in the next room-Luwana's first task is to create an aura of momentousness around the new baby. As she moves through a household, giving advice about routine building, breast-feeding, and storing shotguns out of reach, she attempts to win over not just a young mother but a typically unwieldy cast of supporting players, from the baby's father to the great-grandmother getting high in a tent behind the house. What Luwana tells each family may seem, on the face of it, fiction: that in this infant enormous possibilities inhere. But such fictions can be strategic, especially in cultures in which the act of becoming a mother is honored far more than what the mother subsequently does for her child.
Alexis, who wore a tight red T-shirt, would have been striking even without the pink improvements she'd made to her caramel-colored hair, and since fifth grade, when she'd lost interest in schoolwork, most of her opportunities had come from men who'd taken note of her looks. Lately, she'd been wishing that she'd had a longer, simpler childhood, but, in the childhood that she had, full hips and breasts and lips had served her well. They served her less well now. To Luwana's questions about Daigan's feeding schedule, she responded monosyllabically while studying her manicured fingers. She'd received the manicure, plus some blue balloons and a chocolate-chip cake, on what she called the "heartful" occasion of Daigan's birth. The days preceding his arrival had not been happy. Alexis lived with her mother and father, a grocery clerk and a construction worker who were in constant conflict. When Alexis was eight months pregnant, the fights grew so fierce that she fled the household altogether. Her recent return testified less to domestic reconciliation than to the impact that a squalling baby has on the sleepover invitations a girl receives.
As Luwana tried to draw Alexis out, the phone rang, and Alexis covered her ears. "I'm guessing this is Daigan's dad who keeps on calling," Luwana said, after the third round of unanswered rings. Alexis met her eyes for an instant, then burst into tears. "O.K., now," the nurse said, "spell it out for Miss Luwana." Between sniffles, the proximate cause of distress became clear. Daigan's father, a sturdy twenty-six-year-old named James, worked on a tugboat on the Mississippi River. That weekend, he would be returning to shore and expected to have sex with Alexis, though she was not healed from childbirth, nor was she using contraception.
"No way!" Luwana said. "Keep your legs closed: embed that in your brain. Tell him to keep his hands to himself. And if you can't stand up for yourself, stand up for Daigan. You've got a lot of work ahead, giving him what he needs. Look around, Alexis. You need another baby in this picture?"
"No," Alexis said dully. Then she brightened: "Miss Luwana, maybe you can write me an excuse note, like for gym?"
Luwana's church friends smiled knowingly when they learned that she worked for the state. They pictured cubicles, potted plants, and cushy hours. She seldom corrected this impression, nor did she say that some mornings, driving her six-year-old Maxima toward some difficult case, she wanted to turn north and spend the rest of her working life in more high-minded quarters. But Luwana's efforts were invigorated by the fact that twenty years ago she was herself a poor, pregnant teen-ager in these swamps. "I know now that there were government programs on the books designed to help girls in my situation, but back then, especially if you were black, you didn't hear about them," she said. She is now thirty-eight, with two sons and a husband who has spent most of his working life in a mill that makes paper cups. It took her fourteen years, between child-rearing and stints as a nurse's aide, to earn a bachelor's degree in nursing. Her state job pays thirty-five thousand dollars a year, half of what she'd make in the emergency room of a private hospital. "Oh, I have my material longings -- every so often I'll throw a pity party for the house I'll never have," she said. "But quite a few of us nurses are working, you could say, in the context of our own memories."
"How he doing?" Alexis asked uneasily, as Luwana's fingers explored Daigan's soft spot.
"You're the mama," Luwana responded. "You tell me."
"He's got a big head like his father," Alexis said under her breath. Then she rallied: "He's not as cranky as he was. And one thing I learned already is how he cries different when he's hungry than when he's wet." Luwana bestowed on Alexis a dazzling smile that she had thus far reserved for Daigan. "Making that distinction is important," she said. "You're listening to him, and in his own way he's explaining what he needs. Pretty soon now he'll be making other sounds, and when he does you'll want to make that noise right back. He'll babble, and then you'll talk to him, and that's how you'll develop his language. Now, what you may also find, around five to eight weeks, is that he'll be crying even more -- it's a normal part of his development, but it can also stress out the mom, so we'll want to be prepared for it. The main thing will be keeping calm. And if you just can't keep calm -- if you find yourself getting all worked up and frustrated -- well, then what?"
"Put him down? So I don't hurt him, shake him, make him brain-dead?"
"Put him down and . . . ?" Luwana drilled her girls hard on this particular point.
"Call someone who isn't upset? Let the baby be, and get help."
Luwana turned to Daigan and clapped. "See, your mama is getting it," she said, using the high-frequency tones that babies hear best. "She's surely going to figure you out."
There was a trick that Luwana relied on to stave off dejection: imagining how a given scene would unfold if she weren't in it. In Alexis's case -- one that, in terms of degree of difficulty, fell roughly in the middle of her caseload -- she knew that slight improvements had already been made. At Luwana's urging, Alexis had stopped drinking and smoking when she was pregnant and had kept her prenatal appointments. So she wasn't incapable of changing her life on Daigan's behalf; the odds were just long.
Sitting cross-legged on the floor now, Luwana sang "Clementine" and made faces at Daigan, and for a moment Alexis studied this demonstration of engagement with her child. But then her gaze drifted over to her sister and the ex-con, who had emerged from the bedroom to chop the rest of the chicken. The young man, whose tattoos included white supremacist ones, put on mirrored sunglasses for this task, a fashion choice that made Alexis giggle. Luwana's primary subject that day was infant attachment, a topic she tailored to fit Alexis's limited attention span. "A funny thing about the axe murderers," she said casually. "Usually something missing in the love link." And, indeed, axe-murdering seemed to register with both Alexis and the former prisoner, who set down his knife and came over. "I need to hear, too -- mines is horrible," he said. "We whup him but since he turned two he don't do nothing we say, probably 'cause his mama on drugs and sleeping around and getting locked up -- well, she's a whore."
"You hit a two-year-old?" Luwana asked, her eyes narrowing. "You teach him how to fight and are surprised when he turns around, starts fighting you?" She then fixed her stare on Alexis, who began examining the brown linoleum floor.
"The love link," Luwana began again. Now the room was still. "It's a cycle. When there's no safe base for the baby -- when you're not meeting his basic needs, satisfying his hunger, keeping him out of harm's way -- there will be no trust, no foundation for love. And that's when you might just get the axe murderer. Maybe sometimes we have a baby and expect that baby to comfort us? Well, sorry, it works the other way around. It's on you now to comfort him, earn his trust, because that's how Daigan is going to learn how to love."
Infant-development strategies, like other forms of social capital, are perversely distributed in America-fetishized in places where babies are fundamentally secure and likely to prosper, undervalued in places where babies are not. The nurse-visiting program aims, in a fashion, at equalization. The territory that Luwana and her colleagues cover begins an hour's drive southwest of New Orleans, down fog-prone highways lined with cypress trees which lead to the Gulf of Mexico. On the shoulders, turkey vultures pause, flicking mud from their wings. Mississippi River sediment shaped this marshy delta, to which eighteenth-century French Acadians, expelled by the British from Nova Scotia, laid a claim not hotly contested. The terrain now occupied by the exiles' descendants is muggy, heavily wooded, and visited so often by hurricanes that Katrina, which made landfall near here, failed to register as a main event. Residents have another, steadier battle with nature, because they've built their lives on one of the fastest-sinking landmasses on earth.
The social demographics are almost as fragile. Louisiana literacy rates are among the nation's lowest; infant mortality and child-poverty rates -- thirty per cent of all children are poor -- are among the very highest; and almost half of all births are to single mothers. Historically, the swamp region's topography isolated it from the rest of the state, but drawbridges and thoroughfares have been erected in recent years, and cane fields now give way to Wal-Marts. Still, idiosyncratic child-rearing beliefs endure: a baby will become constipated if held by a menstruating woman; formula is healthier than breast milk; giving an infant a haircut before his first birthday will stunt his growth and hurt his brain.
The cases that Luwana and her fellow-nurses take typically begin with a referral from a public-health or prenatal clinic: a form indicating the age and address of an expectant mother and the baby's due date. Occasionally, a nurse shows up at the given address to find a mother-to-be converting Sudafed to methamphetamine on a hot plate. Other times, a pregnant girl's father is hostile because he's the probable father of his daughter's child. But the nurse's typical commission is to work with what she finds. And while Luwana believes that some aspects of mothering are instinctual, what she teaches is more like applied science. Her tools include a polystyrene demonstration baby named Dionne, picture books, a raft of developmental checklists, and, above all, her trade's bleak knowledge: babies can get used to almost anything -- as many of those babies' mothers had.
The Nurse-Family Partnership program began twenty-eight years ago as the obsession of a developmental psychologist named David Olds. He is fifty-seven years old, with clear blue eyes and a tendency to fidget not unlike that of Luwana's adolescent mothers. He grew up in a working-class household and as a young man taught in an inner-city day-care center, an experience that led him to suspect that by age four or five some children are already gravely damaged. In the nineteen seventies, after earning a Ph.D. at Cornell under the late child psychologist Urie Bronfenbrenner, he began working with colleagues to translate this grim view into an elaborate scheme of prevention. At the time, scientific knowledge about early brain development and the importance of a child's first years of learning was more limited than it is now. But for Olds, who has one biological child and two adopted children, intuition as much as evidence suggested that the rescue effort should begin before birth, and unfold in the setting where an infant would spend most of his time. As for what sort of person a low-income young woman might trust inside her home, he and his colleagues settled on nurses, who in poor communities have high status and medical expertise that many pregnant women want. In 1978, Olds used a federal grant to test his idea in Elmira, an economically depressed, mostly white community in New York's Southern Tier, which had the highest rates of child abuse and neglect in the state.
"Some policymakers look for cure-alls, which this isn't," said Olds, who continues to study his protocol's effects as the director of the Prevention Research Center for Family and Child Health, at the University of Colorado, in Denver. "We keep refining how we do this as the nurses report back on their experiences, because there's still a lot that we don't know -- for instance, how best to help mothers who are battered or mentally ill." Nonetheless, when he conducted random-assignment evaluations (among the most strenuous tests of a social program's effect) to gauge how the Elmira mothers and children were faring at the completion of the program, he found more improvement than he had expected. One of his chief concerns had been child abuse, and it turned out that children whose mothers had finished the nurse-visiting program were far less likely to be abused or injured than their counterparts in a control group. He also discovered that by the time the nurse-visited children were four, their mothers were more likely to be employed, off public assistance, and in stable relationships with their partners. Evaluations of two subsequent pilot programs-with primarily black families in Memphis and a racially diverse group in Denver-showed less dramatic results against control groups but suggested additional possibilities. By age six, for instance, the nurse-visited Memphis children had larger vocabularies, fewer mental-health problems, and slightly higher I.Q.s. In all three sites, the mothers had fewer subsequent children and longer spaces between them. An economic analysis of the Olds experiment commissioned by the state of Washington concluded that the approach -- which currently costs around four thousand dollars per year per family -- was cost-effective as well, because the children aided by the nurses had required fewer expensive social services such as foster care and hospitalization.
The early optimism surrounding programs meant to help poor children is often dispelled by the rigorous assessments that come later. Children may make startling intellectual and functional gains in the hothouse of a model program -- say, a preschool run by skilled and idealistic teachers -- but those gains tend to vanish when the children move on to their communities' less hospitable institutions. This phenomenon, known as "fade-out," is one of the great frustrations of antipoverty policy, and I was first drawn to Olds's work because his long-term findings seemed to defy the regressive trend. By the time the Elmira children turned fifteen, they were still demonstrably better off than their control group peers. For instance, they'd been arrested far fewer times, one of several findings that inspired the U.S. Department of Justice to cite Olds's infant intervention program as a model for the prevention of juvenile crime. I wondered, however, about the objectivity of the Olds studies, since, regardless of acceptance by peer-reviewed publications like the
Journal of the American Medical Association, he is essentially grading his own work. When I raised specific questions about the long-term outcomes in Elmira, Olds decided to recalculate his data using seven different evaluation methodologies, grasping that such a test might undercut his life's work. He later reported that some of the original findings -- for instance, those about Elmira teen-agers drinking and running away less than their counterparts -- weren't holding up under a preliminary analysis. He was so dismayed by these results that he seemed oblivious of the fact that other evidence of the improved futures of nurse-visited children and their mothers was now about as solid as findings can be when the subject is social policy's impact on human behavior.
The nurse-visitor approach makes some liberals uneasy, because they fear that its focus on good parenting will undermine the fight for decent schools, quality day care, and other institutional supports for poor children. Libertarians recoil at a government-funded program that meddles in private lives, and child-welfare advocates have been frustrated by Olds's restraint. In their view, a "scientifically proven" approach like nurse visiting could have attracted bipartisan support and been widely implemented years ago, if its creator had more emphatically promoted it.
Olds's cautiousness is based not just on a sense of personal fallibility but on what he considers the faltering of Head Start in the late sixties and seventies. A rapid, politically driven expansion inflated public expectation while diluting program standards; by the eighties, conservative policymakers were using Head Start's modest results to justify the rejection of other government antipoverty programs. Olds wants his protocol to expand incrementally, as he fine-tunes it. Currently, thanks to a hodgepodge of public and private funders, nurse visitors in places as diverse as Los Angeles, Fargo, Allentown, Tulsa, and Bedford Stuyvesant serve an annual twenty thousand of the United States' 2.5 million low-income children under the age of two.
Louisiana, where I decided to watch Olds's ideas at work over the course of a year, is one of nurse-visiting's most difficult settings. Legislators there have been sufficiently impressed with the program to more than double its size in four years, with the help of federal Medicaid dollars. But, in a state where nurses often run out of breath when recounting the disadvantages of their clients ("The mom I'm working with now is a sixteen-year-old unmedicated, bipolar rape victim and crack-addicted prostitute with a pattern of threatening to kill her social worker, who recently abandoned her baby at her ex-boyfriend's sister's, and who has an attempted murder charge in another situation -- well, I think I've got all the risk factors," a colleague of Luwana's said one day), nurse-visiting is unlikely to be mistaken for a cure-all.
In the bayou, every schoolchild knows that a shrimp's heart is in its head, and that now it's cheaper to buy that shrimp from China. So last winter, in a neighborhood called Upper Little Caillou, people who once worked on the water were trawling for a service sector niche. On homemade signs in yards, the inventory of salable goods continually evolved: "Shrimp/Alterations/Vinyl Blinds"; "Turtle Meat, Adult Novelties & Bail Bonds." Maggie Lander, a seventeen-year-old client of Luwana's, was among the residents hawking what she imagined rich people might want, such as her mother's cache of Harlequin novels. In the interest of clarity of message, though, the front of her home bore just one sign -- "No smoking" -- on behalf of her one-year-old daughter.
In a few years, Maggie figured, her daughter would perceive the deficiencies of her home, as Maggie did -- understanding, for instance, that a sheet stapled to the ceiling wasn't what people usually meant by an interior wall. But she chose to believe what Luwana had told her: that babies didn't care about the surface of things. Their standards were deeper, Maggie believed, than those of some grownups she knew.
In addition to selling secondhand goods, Maggie worked for a janitorial service. She has a lisp, a vulpine face, and auburn hair that she parts down the middle and often lets fall over her eyes. When Luwana came around, though, Maggie tucked the strands behind her ears, revealing the sallow beauty of a Victorian consumptive. For a half-Mexican, halfNative American schoolmate named Jose Hernandez, the sexual attraction had been intense. It wasn't entirely an accident when, after a year and a half of courtship, she got pregnant.
In the bayou region, which is traditionally Catholic, no doctors admit to performing abortions. Home remedies, though, are highly evolved: blue cohosh root, a belly flop from bed to floor, the placenta-rupturing magic of cocaine. ("Is the baby shaking yet?" practitioners of this late-stage strategy asked when they entered the local emergency room; they knew the drill better than the doctors did.) But most pregnancies here were not terminated; as Maggie's mother liked to say, "God doesn't make mistakes." Maggie concurred with this theory. Still, when Luwana first appeared on her broken front porch, she was relieved to have a fresh pair of eyes on her life.
David Olds and his researchers like findings that can be quantified, and Luwana has learned to report her experiences accordingly. The forms she filled out, however, didn't always capture the extent of a family's despair. The first time she'd come to Maggie's house, she had found an intelligent, underfed tenth grader in her second trimester who was sick with untreated hepatitis B and was also trying to care for her mother, who was bedridden and weighed eighty-two pounds. "I was in another world then, wanting to die," Maggie's mother, whose name is Tammy, recalled. "I'd been played the fool by a man I thought wanted a wife." Though mother and daughter shared malnourishment, depression, and very close quarters, they seemed to exist in separate spheres.
One afternoon before Christmas, the effects of Luwana's yearlong campaign against hopelessness were easy to see. The baby, whose name is Maia, was an exuberant babbler, with a paunch so magisterial that her patchwork jeans were left unbuttoned. Maggie's mother was rounder, too, thanks to antidepressants, and she was working alongside Maggie at the cleaning company. Maggie was buoyed by her recent engagement to Jose, whom Maia plainly adored. He had moved into the house shortly before his daughter's birth, and he, Maggie, and Maia now occupied a sweltering room in the rafters.
As Maggie discussed her low-budget wedding plans with Luwana, she bounced her dark-skinned daughter gently, while her fingers traced shapes on the baby's thigh. Maggie had become a diligent student of child-development technique, reading aloud so often from the parenting handouts Luwana had given her that she got on Jose's nerves. "She's, 'Listen to this on early brain development,' and I'm like 'O.K., I was here when Luwana went over it, I know,' " he said. "But she has to memorize this stuff." Luwana, of course, found the habit agreeable, and privately gave Maggie her highest praise: "The girl's an overcomer." But, in the swamps, a massively improved life is not the same as a good one.
Maggie was now weak from the interferon that Luwana pressed her to take for her hepatitis. Maggie didn't know whether she had caught the disease from the twenty-five-year-old to whom she lost her virginity, at age thirteen, or whether she had been born with it. But the combined pressures of infirmity and maternity had led her to a decision with which Luwana took strong issue: dropping out of school after Maia was born.
"I'm just trying to see that we're taking logical steps here," the nurse said gently. A fiercer iteration of her argument -- that bearing a child as an unmarried teen-ager and failing to finish high school were matchless predictors of lifetime poverty -- had just brought tears to Maggie's eyes. "You have too much to lose, and I know you don't want to clean houses all your life. Remember when I met you? It was one of the first things you said -- how adamant you were about finishing?"
"I will go back, Miss Luwana, I promise," Maggie replied. "It's just now, with my job and Maia doing so many new things -- I don't know. . . ." Luwana's concern with diplomas, career plans, and jobs with benefits wasn't shared by many people Maggie knew. In a sinking region, land and housing came cheap, and dinner could be yanked from the brown water, so uneducated people could in fact "work the odd one," "do for themselves," and get by.
Luwana, like many of her clients, is good at suppressing emotion. Among her cases were a young mother who had attempted suicide in her third trimester, two others who'd been violently abused, and one who was paraplegic and mentally disabled. Maggie's case troubled the nurse differently. She saw in the girl something of her younger self -- "You know, that caged bird singing" -- and feared the potential was going to be lost.
"I mean, I'm not going to be just some dropout," Maggie promised Luwana now, gathering conviction. She reminded the nurse of a pact she'd made with Jose, who worked nights with her on the cleaning crew and spent his days in high school. He'd get his diploma while she took care of Maia, then it would be her turn for school.
"So he's going to be the main one keeping Maia, is that what you're saying?" Luwana said skeptically. "You're going to trust him with her next year when you don't trust him now -- when he doesn't wake up when she's crying?" In the year that Luwana and Maggie had spent together, Luwana had grown alert to the girl's romantic habits of mind.
When Maggie and Jose cleaned houses for lawyers and car dealers, Jose enjoyed discoveries of drug stashes and signs of affairs. "Wife large," he'd say with a broken-toothed smile, brandishing a find. "Panties behind the trash can in the bathroom, petite." Maggie preferred to dwell on other evidence. "I like dirty kitchens more than the fancy spotless ones," she said, "because in the dirty ones you can picture the homey wife and the father and kids all eating together and talking like a family." She hoped to replicate this scenario with Jose and Maia.
"Let's see," she said one day of the family life she had personally experienced. "In the last few years, we stayed in that trailer park we couldn't afford, then the little blue house we couldn't afford, either -- had to give it back. Then a trailer park, then my auntie's trailer when we couldn't afford the trailer, then back to the trailer park, then straight to a little bitty camper behind my aunt's trailer -- now,
that was tiny, you walk in the door, there's a mattress and a table and that's it. Then we moved in with my uncle, then with my mom's boyfriend, then back to the trailer park, then back to the boyfriend, then back to my uncle, and then here."
Luwana had bettered her own circumstances with the help of caring teachers and strong parents, neither of which Maggie seemed to have. Her father, an illiterate as well as an addict, beat her mother when Maggie was young, and then his neck was broken in a car wreck. Afterward, he got sober, found religion, and separated from Tammy. Both parents are devoted to Maggie, but their leverage is minimal. "I hear Luwana saying to Maggie, 'It's not about you, you're making decisions for your daughter now,' " Tammy once said, "and I can almost see it on the tip of Maggie's tongue, 'But you didn't, Mom. You didn't look out for me.' " Tammy thought often about a day, shortly before Maggie got pregnant, when her daughter told her she was suicidal. "I didn't want to hear it," Tammy said. "I just wanted to believe that Maggie was the one thing in my lousy life I'd done right." Now Maggie considered Maia one thing that she was doing right.
Copyright 2006, The New Yorker
Expanding Medicaid Is Best Financial Option for States
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June 3, 2013
States that choose not to expand Medicaid under federal health care reform will leave millions of their residents without health insurance and increase spending, at least in the short term, on the cost of treating uninsured residents, according to a new RAND Corporation study.
If 14 states decide not to expand Medicaid under the Affordable Care Act as intended by their governors, those state governments collectively will spend $1 billion more on uncompensated care in 2016 than they would if Medicaid is expanded.
In addition, those 14 state governments would forgo $8.4 billion annually in federal payments and an additional 3.6 million people will be left uninsured, according to findings published in the June edition of the journal Health Affairs.
“Our analysis shows it's in the best economic interests of states to expand Medicaid under the terms of the federal Affordable Care Act,” said Carter Price, the study's lead author and a mathematician at RAND, a nonprofit research organization.
“States that do not expand Medicaid will not receive the full benefit of the savings that will result from providing less uncompensated care,” Price said. “Furthermore, these states will still be subject to the taxes, fees and other revenue provisions of the Affordable Care Act, without reaping the benefit of the additional federal spending which will costs those states economically.”
Price and study co-author Christine Eibner used the RAND COMPARE microsimulation model to estimate the likely effects if 14 states choose not to expand Medicaid under federal health care reform. Among the measures studied are the impacts of Medicaid expansion on insurance coverage, federal payments into the states and state spending on care for the uninsured.
The states studied are Alabama, Georgia, Idaho, Iowa, Louisiana, Maine, Mississippi, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Texas and Wisconsin. Although governors in additional states oppose expanding Medicaid, the 14 states in the study were the first whose governors said they would not expand Medicaid. At the time of the analysis, these were seen as the least likely to expand Medicaid.
Last summer's U.S. Supreme Court ruling on the Affordable Care Act gave states the ability to block the law's expansion of Medicaid, the federal-state program that provides health insurance to low-income families. The Affordable Care Act provides support to expand Medicaid to include families that earn up to 138 percent of the federal poverty level.
The federal government will pay a much larger share of costs for the Medicaid expansion than it does for current Medicaid enrollees. It will cover 100 percent of the costs for expanding Medicaid beginning in 2014 through 2016, and then gradually decrease support to 90 percent of costs beginning in 2020. The federal government currently pays an average of 57 percent of the cost of Medicaid.
The RAND study found that the cost to states for expanding Medicaid generally would be lower than the expense state and local governments will face for providing uncompensated care to uninsured residents after implementation of the Affordable Care Act.
Researchers estimate that increased insurance coverage triggered by health reform will reduce state and local spending on uncompensated medical care by as much as $18.1 billion annually across all states. Those savings may continue beyond 2020, when the states' share of Medicaid costs plateaus.
“State policymakers should be aware that if they do not expand Medicaid, fewer people will have health insurance, and that will trigger higher state and local spending for uncompensated medical care,” Price said. “Choosing to not expand Medicaid may turn out to be the more-costly path for state and local governments.”
The study suggests that changes could be made to the Affordable Care Act to help some people targeted by the Medicaid expansion to get health insurance coverage through other means. Those options include a smaller expansion of Medicaid or changes in the new state insurance exchanges to allow more poor people to purchase private health insurance.
The RAND study shows the alternatives could help provide health insurance to some people targeted by the Medicaid expansion. But none of the options examined would provide health coverage to as many people as full Medicaid expansion.
Researchers also outline how failing to expand Medicaid could have more than financial consequences. Based on earlier research showing that past expansions of Medicaid has led to decreases in deaths, the study estimates that an additional 19,000 deaths could occur annually if the 14 states studied do not expand Medicaid.
Support for the study was provided by RAND's Investment in People and Ideas program, which combines philanthropic contributions from individuals, foundations, and private-sector firms with earnings from RAND's endowment and operations to support research on issues that reach beyond the scope of traditional client sponsorship.
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