A Medicaid Story

As we have learned the hard way, a lot of people in this country have an incredibly narrow view of Medicaid and what it does. They understand that it provides coverage for health services such as physicals and hospitalizations, but don’t realize that it covers a much larger scope of care: behavioral health; violence prevention; and case management to name a few. Many didn’t fully appreciate the incredible reach of Medicaid given that many states don’t refer to it as such, including here in Massachusetts where we call it MassHealth. I have come to realize — more than a day late and a whole lot of Medicaid dollars short — that so many Americans are woefully uninformed about this critical service. And because of that, cannot comprehend what is being lost as Donald Trump guts it as a part of his budget bill.

But before I go further I need to share a preamble, a heads up, and a confession. The preamble: before I came to the work of gun violence prevention over six years ago I spent my entire adult life providing trauma services to adults and children impacted by domestic and sexual violence. This included working with kids in the aftermath of a domestic violence homicide. Their stories of profound trauma sit with me until this day, and likely will for the rest of my days. I’ve been thinking a great deal about these kids as the Trump administration slashes funding to violence prevention, and I thought about them again as the debate about the gigantic awful bill raged on.

Here is one of those stories, and here is the heads up. Before you read on, please know that it’s not a happy story. It’s one you might want to skip if reading about a lethal incident of domestic violence and the child left behind would be upsetting for you.

And now the confession. I wish I had told this story a long time ago. More on that in a bit.

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Jessica (not her actual name) was a middle schooler who came home from school one day to find the door to her apartment ajar. She walked in calling her mom’s name, and found her on the floor bleeding. She called 911, but tragically her mom was already dead, shot and killed by the boyfriend she had just broken up with. A too familiar story for those of us in domestic violence work, and an unfathomable trauma for this child. When kids go through an experience like this, they are forever changed. They never get to be the same kid they were before the violence happened. And this was certainly the case for this girl.

Along with a colleague, I started working with Jessica the day after the homicide happened. We supported her at the funeral, and provided intensive clinical and case management support immediately afterwards. We saw her through living temporarily with one family member and then moving in with a different family member, who then became her permanent guardian. We supported her guardian with the task of parenting a child he didn’t know well, a child who had just experienced an unspeakable trauma. Months later, we got her enrolled in an overnight camp, took her shopping for supplies, and I drove her out to the camp location to give her a hug and pep talk her into this new experience. Over our time together, we talked about everything from missing her mom to getting her period for the first time — a really hard milestone for a motherless girl.

We also did a ton of advocacy with her school. To be clear, even before her mother’s death, Jessica struggled at school and her school struggled with her. The school sure tried to shower her with love after the homicide, but like any other under-resourced school with over-crowded classes, they only had so much bandwidth for her particular needs. As the issues for Jessica at school escalated, my colleague and I had regular phone contact and meetings with school staff. Our goal was to ensure that every person at the school see her not as a bad kid, but as a kid that bad things had happened to. We also worked hard with Jessica to see the staff at her school not as enemies, but as a part of her team.

This was a kid who, without her mom, felt very alone in the world. I was glad at least that my colleague and I could be there for her. There was no way our care could replace her mother’s, but at least she saw people working hard on her behalf.

You can probably see where this is going. Our services were covered by Medicaid. Did Medicaid pay for everything we did? Nope. Not even close, honestly. But it did pay for hours and hours of therapy, and a pretty large chunk of the case management services. We could bill parent contact hours for our work with her dad and collateral contact hours for the meetings with school officials. It was a source of funding that enabled a tiny community based organization to provide a very traumatized kid with comprehensive support at a most critical moment. It was a lifeline.

No one goes into this work thinking they will be compensated well. And Medicaid doesn’t reimburse nearly enough for the kinds of services I am describing. But it sure helps keep the lights on and the phones ringing for a whole lot of programs. And it also helps keep the doors open for kids like Jessica, who need both open doors and open arms to receive them in the aftermath of traumatic loss.

I, along with so many of you, watched in horror as Trump’s budget bill moved forward. There are a lot of kids at risk of losing their coverage because of this bill — kids who need everything from a physical to trauma-informed behavioral health. And there are many organizations that need Medicaid as a funding source so that they can be there for kids like Jessica. Too many people don’t realize that Medicaid pays for therapy after surviving violence, services for the families of victims, and violence intervention programs in hospitals, schools, and in the community. It doesn’t pay well, but it’s a part of the safety net we weave together to make sure all of these programs can continue to do their life saving work.

I am telling this story because I don’t know any other way to describe the enormity of the harm caused by this bill. I tell it because there are real people who will lose access to services that are direly needed for their health — and for their healing after violence. Those that celebrated the passage of this bill seemed to have this gotcha attitude about people on Medicaid, like this would teach them a lesson. Some of their language held a very accusatory tone, almost blaming people for needing Medicaid in the first place. This includes Speaker Mike Johnson, who claimed that “4.8 million people will not lose their Medicaid unless they choose to do so.” But here’s my question: exactly what choices do kids like Jessica get to make here?

I tell this story because I didn’t hear these narratives during the whole conversation about Medicaid. I am realizing now — too late — that most people didn’t understand the role Medicaid plays in the larger social safety net. They just had no idea that Medicaid is a part of what helps fund domestic violence, rape crisis, and gun violence prevention programs. That it’s a part of what keeps the doors open, the lights on, and the phones ringing.

So I needed to tell this story. Because I needed you to know.

I only kick myself for not telling the story sooner. Not because I think my one voice with my very small platform would have stopped the passage of this bill. But violence thrives in silence and at the end of the day I want to make sure I am pretty damn loud. And I hope you will be loud too.