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The Medicaid Mess

March 10, 2011

I’m going to the interim session of the Texas Academy of Family Physicians this weekend. It’s always renewing for me to talk with my colleagues who are committed to caring for their patients in trying times, who come from big towns and small.

I’m sure one of the big topics will be the impending budget shortfall of the State of Texas, which is to the tune of $10-$20 billion dollars. Like the rest of healthcare in the U.S., the cost to Texas for its share of Medicaid has grown much faster than general inflation or other revenues — 9% per year from 1998 to 2008. Medicaid accounts for about 28% of the entire state budget.

The legislature has to balance the budget so programs have to be cut. I’m afraid once again the legislature will be unable to deal with the uncomfortable realities directly, but will talk around the issues so as to not appear too offensive or harsh.

They’ll probably reduce fees to doctors and hospitals, lower income thresholds of eligibility and say they are only eliminating fraud, waste, and abuse.

The reality is they’ll worsen the soft rationing that comes when few doctors or other providers are willing to take Medicaid patients, and the hard rationing that comes when families that make more than some percentage of the federal poverty level lose their coverage.

The worse part of rationing is it means the available dollars aren’t used for the greatest effect. A patient who qualifies for Medicaid is ultimately eligible to receive round after round of futile chemotherapy, weeks in an ICU, and unlimited trips to the ER, while the patient who barely makes too much gets no assistance for their painful gallstones, migraine headaches, or chronic diseases.

If the legislature (and more importantly the voters) just had the cajones to admit care for low income citizens is rationed, then develop Texas-centric approaches to use the available dollars to achieve the most health for the most people, the shortages would at least have a larger sense of fairness. Is this asking too much?

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