CHARLESTON, W.Va. -- I was surprised at mention of Wellsville, N.Y.'s Jones Memorial Hospital in the first section of the Sunday Jan. 5 Washington Post. Over a half century ago my father played a major role in the construction of this modern hospital in my old hometown of about 7,000 in the dairy farming region of western New York.
The town was a major winner in the "fiscal cliff" legislative lottery. Not only had the bill granted one-year relief to the town's seniors and physicians by postponing a scheduled 27 percent reduction in Medicare physician reimbursements but -- because the hospital had fewer than 100 beds -- it received a one-year reprieve from a scheduled $450,000 cut in federal hospital funding. Also extended were federal milk subsidies to supplement the income of local dairy farmers.
The front page The Journal in Martinsburg on Jan. 5 reported a much more somber account of a federal funding lottery loser and citizens who feared for the future of an Eastern Panhandle program that serves sexual abuse and domestic violence victims.
A recent Washington Post editorial, responding to a federal food safety report, averred it is essential we invest over an additional $ 1.3 billion a year ($200 million in FDA oversight and $1.1 billion in food processing and handling). Whether in the form of taxes, user fees or direct costs, this will require consumers pay more to improve food safety. Some question if it is worth it.
Although central funding decisions affecting these activities portend serious consequences for "real" individuals and local communities, fiscally they represent minor skirmishes compared to the debate over Medicaid expansion. The issue is whether states should accept federal funds (covering about 1/2 the administrative cost of implementation and 100 percent of health cost until about 2019, and 90 percent thereafter) to expand Medicaid.
Some state governors have been accused of depriving low-income individuals access to health services by declining to participate because of political considerations related to their opposition to the Affordable Care Act (ACA). The reality is that states with governors of all political persuasions were making major cuts in the Medicaid program before ACA expansion in order to avoid bankruptcy.
Governors Fallin of Oklahoma and Scott of Florida are among those who believe they can provide health services for the expansion population at much lower cost to both the federal government and their respective states by not participating. Governors Hickenlooper of Colorado and Martinez of New Mexico are among those who will participate claiming their analysis reveals that certain cost savings, improved health status and projected increased health-care jobs (and associated taxation) will save their respective states money and improve access and care.
The Los Angeles Times reports that California's progressive Governor Brown is concerned about the cost of expansion, despite a UCLA-UC Berkeley study model that suggests there could be decreased State costs and higher tax revenues. However, the authors themselves admit the projections are based upon shaky assumptions and few federal programs from the past promising savings produced them.
Even ignoring the scheduled 2014 ACA sales tax on private insurance policies, the promised savings in premiums for such policies (by reducing "cost-shifting" for uncompensated care) is not likely to occur, with double digit percentage increases already projected areas this year.
In the midst of this controversy, the New York Times (Jan. 10) reports on a study by the Institute of Medicine and National Research Council which reveals that despite far greater spending, Americans die earlier and are less healthy than those in peer countries. Other than survival from cancer, there is little that Medicaid expansion will do to alter this equation. The main contributors include violence, teen and high risk pregnancies, obesity, STDs and substance abuse.
Perhaps Georgia has the best idea. They plan to finagle their State bed/provider tax to generate more State "match" money from the federal government so that they can return the tax to health providers with the federal "match" bonus. Possibly, the funds that previously supported the Martinsburg violence program will be used to reward Georgia. This federally sanctioned "gaming" of the system that rewards those who contribute to expanding the size and power of federal government by manipulative redistribution of funds among states concerns me.
We seem to forget the interconnected and interdependent nature of Yin-Yang. Federal funds are generated from taxes paid by individuals from individual states and local communities. Is it prudent to deny the citizens of these states and local jurisdictions a share (indexed for poverty and disease burden, if desired) of what they contributed to support the programs and delivery mechanisms they genuinely believe will most effectively and efficiently contribute to improved health status?
Perhaps, Senator Lamar Alexander's recent suggestion that we revive a 20-year-old proposal that the federal government runs Medicaid and the states runs education deserves a serious look. Separating decision "authority" from outcome "responsibility" works poorly.
Felsen, of Capon Bridge, is a retired public health physician.