- Cullman, Alabama

September 17, 2012

The Health Care Funding Debate: A longer perspective

The Cullman Times

CULLMAN — As we Alabamians approach an opportunity to vote on using Trust Fund monies to bail out the General Fund over the next three years it occurs to me that many voters may lack a long-term perspective on this issue, especially as it involves the State's ability to continue Medicaid funding. Recently I was surprised to learn that some of my younger physician colleagues are unaware of this history.

From the inception of our country until after World War I doctors and hospitals provided care and patients paid for services as they could. Services were rather meager compared to what large medical centers can provide today. The prices charged were much smaller as well. A glance at the historical displays at Cullman Regional Medical Center supports this. About the time of World War II hospitals noted that poor people could not afford health care and that wealthy people could not pay for health care in catastrophic situations. They formed an association where members paid a little every month and if they needed care it would be provided at their hospital. Doctors got on board with this scheme as well. Thus was born Blue Cross (for hospitals) and Blue Shield (for doctors). The concept was widely popular and the health insurance industry blossomed.

In the 1960s, the U.S. Government sought to provide care for poor senior citizens and developed Medicare. Medicare would provide poor seniors with health care and the cost would be borne by a tax on workers, much like Social Security. President Lyndon Johnson desired to provide all poor people with the same kind of health care. It was thought too costly for the federal government to provide alone and so a very loose plan was passed to provide this care. The cost would be shared by the federal government and the states. This was the beginning of Medicaid.

In the ensuing years, health insurers paid hospitals on what was called "cost-plus". The hospitals added up their costs, tacked on a small profit, and the health insurance companies paid the bills. There were no incentives to control costs. At the same time Medicare became wildly successful. What was once a program for poor seniors became mandatory for those over age 65. Medicaid was growing as well. Experts who studied health care warned that health care costs were growing beyond reasonable limits. They warned that spending on Medicare and Medicaid were growing as well.

In the 1980s, I was a student at the UAB School of Public Health. Daily we explored and discussed the problems with health care funding and expenditures. In the 1980s, we were warned of the tremendous growth in monies spent on health care. Experts wondered why Americans spent more than some countries and had poorer health. Some pointed out that 90 percent of Medicare's money was spent on only 10 percent of those eligible in the last 14 days of their lives. They also warned that costs would be unsustainable if they continued as they were doing.

Public Health officials and others have sought to warn the government. In these 30 to 40 years both Republicans and Democrats have failed to alter our country's health care destiny. Now almost every state is burdened by Medicaid. It is the single largest budget item for many states. Alabama is not the only state struggling to meet its obligation. What was once a program for the marginal poor is now the only means of health care for almost half of our state's children. It covers many elderly in nursing homes. It is no longer a safety net; it is a way of life.

Our elected officials, whom we voters had hoped would become leaders and statesmen, have no solution to this problem. They cannot fix it. They have only sought to delay the inevitable by three years as they propose we "borrow" from the Trust Fund to prop up the General Fund. If this money is not "borrowed" then prisons will close, nursing homes will close, doctors' offices will close, the poor and those in rural areas will largely be without health care. If we "borrow" the money, then this problem will not be upon us for three more years. The politicians have failed to provide leadership out of this dire situation. They have returned the choice to the voters.

Voters have a dismal Hobson's choice to make. They can bring down health care as we know it, open prison gates, empty nursing homes, and curtail rural transit systems by voting "no". By voting "yes" they can perpetuate an out-of-control inflated bureaucracy led by men who proclaim that they have no solutions for our woes, but only for three more years.

Our country's entitlements have become more than our government can provide. The status quo cannot persist. There is simply not enough money. Our state is in a similar position. A different path must be chosen.

To vote “no” Sept. 18, is a heartless and cruel choice which will surely cause suffering for many. Let the reluctant voter who votes “yes” not forget that this choice only gives us 1, 095 days in which to find a permanent solution. Sadly, our current officials have failed us. May wise and stalwart leaders emerge quickly to assume the helm.

Mark K. Addison, M.D., M.P.H.