Speaking Notes

PADM 5791

February 3, 2010

Dr. Neubauer

WHERE WE ARE

We are in Chapter 3 now on Medicaid.

I plan to distribute the midterm exam on the 17 of February to be returned completed on Feb. 24.

Chapter 2 -- (History of) Health Care Policy in the United States

Medicaid has been variously referred to a workhorse, Pac Man and as a monster. The other metaphor that comes to my mind is, perhaps, a "hot potato."

It was created in the wake of the creation of Medicare in the 1960s and basically is considered a welfare program financed (and shaped) jointly by the national government and the state governments.

This is a "heavy" chapter with a lot of material in it.

My own family-of-origin experiences -- thankful that Medicaid in Georgia made nursing-home care available for my parents.

· Difficult admissions processes involving hospital discharge planners

· Having to relocate my grandmother on occasion

· The nursing homes evaluating their prospective clients -- "not too bad"

· The computer-generated letters threatening to discontinue care

Medicaid "issues"

· The stigma of being perceived of as a welfare program

· Not wanting to nurture and perpetuate dependency

· Eligibility driven -- and the numbers are going up and up -- disabled and elderly and others

· Being an open-ended "budget breaker" for state governments

· Having to ration care by any other name

· Being managed different among the states and variations on coverage among the states

· Being "gamed" by everyone involved given the importance of outcomes and the dollars involved

· Not attractive to providers who have a choice because of relatively low reimbursement rates.

· Maze of eligibility rules, questions regarding fairness, and holes in the "safety net."

· "Can state governments contain the rising cost of the Medicaid program and still provide increased access and high-quality care to the poor?" (textbook page 97)

Generally speaking, political leaders who are Democrats are more likely to favor spending for Medicaid than are Republican political leaders

Generally speaking, Democrats probably more favor that it be administered from Washington D.C. rather than administered (differently) by the 50 state governments.

States have the option of "bundling more things into" Medicaid (and tapping into federal matching money in the process).

Under Republican presidents the push has been to DECENTRALIZE the administration of Medicaid and under Democratic presidents the push has been to introduce MANDATES into the program. This "one-two punch" puts the states in a bind.

When states start to "strong arm" providers they get sued. As a consequence money winds up being paid to attorneys rather than to physicians and hospitals.

I think many believe that Medicaid "needs a home" and that the preferred home is at the national level of government.

· Who's the boss?

· Who's the goat (i.e. bears the burdens of administration and provision of services)?

· Who pays the bills?

There are at least two ways to characterize the decentralized administration of what could otherwise be national programs.

· Wasteful, duplicative, unfair and perhaps incompetent.

· "Laboratories of democracy" in which good ideas become notices and adopted by other states.

The larger a program is (geographically and in terms of range of program activities) the MORE COMPLEX its administration becomes. At some point the program is at risk of IMPLOSION. The question becomes does the complexity of a program like Medicaid exceed the ADMINISTRATIVE CAPACITIES of a state's government? The answer can certainly be, "yes." In such a situation AUTOMATION may only serve to feed crisis. Perhaps Medicaid has the qualities of a "perfect storm" -- a world of hurt, impossible sets of constraints, and maze of rules and procedures.

THE PROBLEM IS that it is unlikely that Medicaid could be better administered at the national level. One of the major reasons why national health care legislation has not passed is because of the perceived inability of "the federal bureaucracy" to get it right. I am sure that something can be learned from the experiences of veterans with the VA medical care system

THE CHALLENGE OF LONG-TERM CARE

· Very few people are not poor in the face of the possible need for long-term care.

· As families become "career mobile" the fabric of family care systems becomes weaker.

· Long term care is not easy to "package" and sell as an insurance instrument.

· The demographics are presently against us.

· It is just not acceptable for people to freeze to death on the streets in a nation in which others have vast wealth.

· Existing models of long-term care do not scale well because they are labor intensive.

· Technologies offer only incomplete solutions.

· Hospice care (on the extreme end of the need for long-term care) can itself be costly.

THE OPPORTUNITIES OF PROGRAMS FOR CHILDREN

· Prenatal and preventive care for children is known to be COST EFFECTIVE. To not provide such services is a FALSE ECONOMY.

· There are important POSITIVE EXTERNALITIES associated with spending for children.

PROVIDING CARE FOR MEDICALLY NEEDY PERSONS

· People do not intentionally choose to become disabled or otherwise to have exceptional medical needs.

· Many people are the victims of environmental and other hazards that they did not personally create and that they (often) cannot easily avoid.

· Having said that, HEALTHY BEHAVIORS and avoidance of avoidable risks is in everyone's interest -- individually and collectively.

· ONLY A SMALL PORTION OF THE ENTIRE COSTS OF MODERN MEDICAL CARE CAN BE PUSHED ONTO POOR PEOPLE.

· COPAYMENTS make sense for people who are not poor in terms of discouraging unneeded medical attention and medications.

· But for poor people, copayments are only likely to discourage/prevent people getting the kinds of care THAT SAVES MONEY IN THE LONG RUN. Such requirements are likely to be FALSE ECONOMIES.

THE BURDEN OF "PUSHBALL"

· Much of the cost of our present systems (including Medicaid) go for "overhead" activities that DO NOT PROVIDE MEDICAL CARE in and of themselves.

· The more different kinds of "players" there are in the system the more likely that resources will be expended playing "pushball" rather than providing needed services.

CONCLUSION

The problem is too large and complex for state-based solutions. (textbook, page 125)

"Solutions" tend to be short term and patch work in nature. (textbook, page 126)

The program cannot continue on its present course. (textbook, page 126)

What does one do when you can't get there incrementally and it is also impossible to make major changes? WHAT MUST HAPPEN BEFORE NOT MAKING A MAJOR CHANGE BECOMES THE IMPOSSIBILITY?