"Medicaid expansion" represents the crown jewel in a destructive and insidious process of separating the responsibility for health and health-care outcomes from the authority to set health system policies and priorities. The mechanism has nothing to do with the merits of "what" expansion portends to accomplish but the "who" and "how" of its implementation.
Resources to support all health-care endeavors are obtained through the labor of local individuals. Some of these resources are "redistributed" among individuals and communities to help poorer individuals and communities in need. That is a "political," not a "health" decision. It is not the subject of this column, nor is the "social justice" and "human compassion" worthiness of providing health insurance coverage for a particular segment of the population.
Health and Human Services Secretary Kathleen Sebelius put it best in a March 22 USA Today interview. Commenting on why she thought most states would come on board, she said "governors are ... beginning to understand the economic advantages of Medicaid expansion." Put somewhat differently, even if expansion is not the most prudent course to improve health status, access and quality in one's state, economically the taxpayers would like to get back some of the funds they have paid into the federal coffers.
For centuries, public and private organizations at the local, state, federal and international levels have engaged in various activities to assist the less fortunate to maintain or improve their health status through promoting and providing education and access to health-care services.
Medicaid expansion caps a massively expanding process dating back at least to the 1970s whereby states and local communities have sought and accepted federal money for every conceivable endeavor, often based primarily not on health need, priority, effectiveness or efficiency, but the economic advantages. Meaningful oversight and review of such endeavors are usually nonexistent as long as the economic advantages, i.e., continued funding, persist.
Some of these endeavors are extremely cost-effective and efficient operations that optimally reach their target populations, contributing to health access, quality and status improvements. Others are fragmented, poorly run, bureaucratic, inefficient and ineffective operations that provide little health cost-benefit. Both yield the same "economic advantages."
Each day I read multiple accounts of impending doom in the health research, educational, disease surveillance/control and delivery sectors because of resource shortages. I cannot separate bureaucratic, lobbying whines from true accounts of potential calamity.
I am especially concerned about pleas from the elderly covered by Medicare Advantage and special clinics and programs serving populations with special challenges. Several California programs, such as the Santa Ana Latino Health Access clinic and its unique "promotora" outreach service, claim they have been targeted for heavy cuts from local and state sources, somewhat based on the theoretical resources that will be available through Medicaid. Evaluating the concerns of "disproportionate share" facilities that no longer will receive direct funding is another issue.
Most state and local communities have little meaningful capacity or desire to seriously evaluate and prioritize current health operations and activities to ascertain the quality, cost-effectiveness and efficiency of each. They have little ability or will to separate important, high-functioning entities (and their corresponding service populations) who will seriously be hurt by resource reductions from inefficient, bloated and poor quality endeavors that few would miss. Cutting any of them will have the same negative "economic advantage."
Rather than giving local communities incentive to develop these capabilities, Medicaid expansion encourages them to continue to evaluate health programs based upon "economic advantage," not upon their responsibility to assure their populations are provided the most needed services in the most effective and efficient manner. That is a shame.Felsen, of Great Cacapon, is a retired public health physician.