Build Back Better

      I know—we don’t usually think about the federal or state government in terms of developing a “problem solving” process or methodology. But we do know that there are generally a number of steps involved in implementing such a process. There is a basic five-step problem-solving process used to effectively manage and run a successful organization.

Here goes:

     Since Congress and state government rarely (or never) follow any of the five steps and only rarely even conduct oversight hearings on a problem or solution at the legislative level, we rely on others (generally the media) to answer the question: did the legislative “solution” solve the identified problem? In fact, it is not always clear that the problem has been stated clearly or specifically, that the legislators differentiated fact from opinion, or that anyone has identified the underlying causes of the problem.

     So this week, the Reader has identified a number of issues or problems and is focusing on whether the solution is likely to solve the problem.

     First, Government Technology newsletter on August 20 asked the question, Will the Infrastructure Bill Fix America’s Broadband Issues? The $65 billion devoted to broadband has two primary buckets: $42 billion in grants to states for broadband infrastructure and $14 billion to extend the Emergency Broadband Benefit (EBB) for low-income citizens. Experts had a positive reaction to the $42 billion for infrastructure—and that it could largely resolve the challenge of people not having a network at their home (broadband availability). If the problem is identified as broadband affordability or the “digital divide”, we will still have tens of millions of Americans who cannot afford broadband. The $14 billion aimed to address affordability will go to some “good local companies” and municipalities, but much of the funding will go to organizations that have monopolies on portions of the Internet market. The extension of the EBB program might help more people but the program’s monthly Internet bill discount will be decreased from $50 to $30.

     Advocates would have liked the bill to address affordability in rural areas by including a funding preference for cooperatives. Others commented that precision agriculture and telehealth will need higher uploads speeds and urged that we instead invest in scalable infrastructure to meet the present and future needs of those not now being served. Some advocates urged that the federal government make EBB a permanent program in order to meet affordability needs throughout the country. How do we answer the question about meeting the needs for broadband? It depends upon how you define the problem(s). It should result in greater broadband availability (but unlikely to provide speeds that meet all present and future needs) and does not appear to do enough to deal with the equally important problem of broadband affordability. Let’s see if federal ARPA funds Virginia has allocated to broadband better assist those who have the greatest needs.

     Second, let’s look at the major problem of food insecurity. The Washington Post column today Census data suggests America’s hunger problem may be waning, but food assistance continues to top pre-pandemic levels tells us that food insecurity still has a long way to go before returning to pre-pandemic levels. The most recent Census household pulse survey says that self-reported food insecurity was at its lowest levels since the start of the pandemic for households with children. But SNAP enrollment is still way up—two million more than last year and six million more than in 2019. And food banks are still seeing dramatically more need than pre-pandemic. The Bureau of Labor Statistics says that the cost of many grocery items, including beef, poultry, eggs and dairy, continues to go up as it has for more than one year.

     Ongoing need is part of the reason the Biden Administration increased food assistance benefits last week, the largest increase to SNAP on record. Feeding America, a network of 200 food banks around the country, distributed 10 percent less food in the second quarter of this year compared with the peak of the pandemic last year. But food distribution is still 40 percent higher than the same period in 2019.

     A Food Bank executive said, “now we’re thinking about the impacts for us. Enhanced unemployment won’t be there for much longer, nor will the peace of mind of people knowing that they won’t get evicted. That will continue to make SNAP the first line of defense.” Another Food Bank executive reported, “It’s important to remember that pre-pandemic, the number of food insecure was way too high. With the delta variant, and with kids back in school and more kids being quarantined, we suspect we’ve got an interesting 60 days in front of us. It’s a marathon, but one where we don’t know where the end is.”

     Another executive was concerned that “the boost in SNAP benefits is to be applauded, but it still leaves gaps that will have low-income Americans turning to food banks.”

     The Census data indicating that food insecurity improved for the week ending August 2 appears to be reflecting federal aid programs that are buoying low-income families with children. They received the child tax credit, while families without children reported just a slight dip in food-insecurity levels. The summer Pandemic-EBT program is slated to end in September, and the final child tax credit payments go out in December, so neither will be long-term boosts for American families, even as grocery prices continue to soar. As federal and state pandemic health declarations expire, many Americans who were getting hundreds of dollars more in SNAP payments through an emergency benefit will see that money disappear. While the SNAP benefit increase is a good way to sustain income support for poorer households, it does not guarantee improved nutrition. America’s dietary health is burdened by too much consumption of unhealthy foods, much of which can be purchased with SNAP benefits.

     So how do we answer the question about whether America’s hunger problem is waning or is still a serious situation that could get worse as pandemic benefits disappear and food banks continue to see increased demand? It depends upon how you define the problem(s) and where you set the baseline. My bottom line is that food insecurity and food nutrition remain among our most serious problems and have negative consequential impacts on the lives of children and families. I support the policy changes recommended by No Kid Hungry, a national advocacy organization that identifies about 13 million children still at risk of hunger in the US. They urge Congress to make the Summer Electronic Benefits Transfer (EBT) program nationwide and permanent. That will get more food to children when schools are out of session. They support expanding the Community Eligibility Provision (CEP), which allows our highest poverty schools and districts to serve breakfast and lunch at no cost to all enrolled students without collecting household applications. And they are lobbying for extension of the enhanced Child Tax Credit and making those benefits permanent. Congress has the power to make drastic improvements to the lives of our nation’s children. We should support these changes that we know will improve the situation for millions of families.

     Third, Virginia’s adult dental care Medicaid benefit went into effect July 1. 2021. The eligible population includes adults who are 21 years of age and older and enrolled in Medicaid or FAMIS. Services include diagnostic, preventive, restorative, endodontics, periodontics, oral surgery and other general services. So what is the problem? A guest column in Virginia Mercury on August 17, 2021 reads: 750,000 Virginians are eligible for a new health care benefit. Now let’s make it happen. More dentists needed. The article was written by Steve Pollock, president and CEO of DentaQuest, the organization that administers to Medicaid dental benefit in Virginia.

     For adults who receive Medicaid coverage, access to oral health care was previously limited to emergency care only. It certainly wasn’t a great way to manage dental care for already underserved people, and it was also bad economic policy. For many Medicaid-eligible adults, not being able to visit a dentist for routine, preventive care led to serious oral diseases, which frequently landed them in emergency departments across Virginia. In 2018, this population accounted for 19,000 oral health-related emergency department visits. Because emergency departments are not equipped to treat dental issues, the patient frequently left without any treatment beyond temporary pain relief, and taxpayer dollars were wasted on a hospital visit where no real care was delivered.

     While expanding coverage is a necessary and excellent first step, it only creates theoretical access to care if we don’t do the hard work to make it a reality. To truly create opportunities for adults covered by Medicaid, Pollock says that we need more dentists to enroll as Medicaid providers. As of now, more than 1900 dentists have signed up as Medicaid providers. Pollock recognizes that poor oral health has a direct link to higher risks of chronic illnesses, including diabetes, cardiovascular disease, hypertension and asthma. It also increases risk of suffering a stroke and leads to greater instances of depression and other mental health illnesses. Access to oral care health also assists with employability, and enable health systems to provide more equitable integrated care to Medicaid members. Pollock concludes, “Put simply, this new law is a potential game changer for a population that is too frequently left behind by out health care policies. Now, it’s up to us to make it a reality.”

     There is a lesson to be learned here, but one that we should have learned from other significant changes in health care like the Affordable Care Act. Enacting legislation is one step in a longer process. Our leaders in state government recognized the importance of added this critical coverage into law and into the state budget. And we should be grateful for their leadership. Outreach to Medicaid members as well as recruitment of dentists to sign up as Medicaid providers are the next two key steps in the problem-solving process. Most successful organizations understand the need to implement and follow up on the solution and to set up outcome measures and monitoring and evaluation of long-term results. Community action has a role to play in outreach to Medicaid members and can work with others in the community to encourage dentists to sign up as Medicaid providers.

     I hope these examples are helpful as we look at other legislative and administrative solutions to problems and determine which priorities are most worthy of our support based on analysis and review.

Jim Schuyler VACAP