Writings and observations

In the absence of perfection

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A few years back, when Idaho legislators debated whether to establish a state insurance exchange program under the Affordable Care Act, I criticized most of them for an obsession, not with the health of uninsured Idahoans, but with the perceived evils of the federal government.

Today, the exchange in Idaho is established, popular, heavily used and without doubt saving lives and improving health. Debate has nonetheless continued over what to do about the 78,000 Idahoans who earn too little to qualify for participation in the exchange and get payment help for health care – if at all – through a state and local government catastrophic health program, which pays hospitals for some emergency care no one else will compensate. The answer adopted by 31 states, and proposed by many in Idaho, is to allow expansion of Medicaid to cover the 78,000.

After four years of that debate, some progress: At least now, they’re talking to a significant degree about health care. Progress should be noted where it happens.

But don’t consider the progress, even after four years with a good, working example right in front of them, too spectacular.

The most recent discussion of Medicaid expansion came in an interim legislative committee on August 29. The pro side included savings of many millions of dollars (now paid out in expensive emergency medical care costs) to state and local governments, clear help for the health of many Idahoans and overwhelmingly positive public comments to legislative and others panels over four years. And on the other side?

Senator Steve Thayn said he doubts federal rules on food stamps or Medicaid encourages people to become productive. “If we’re really, truly looking at an Idaho solution, we need to look at what we can do with Idaho money, Idaho rules, and what we can do to change the cost of medical care.”

What is that exactly – we’d all love to know – and if there are such options why has no one found them in the last four years?

Representative Judy Boyle of Midvale: “I think we’ve heard of some other [non-Medicaid] options. … I think we can come up with a really good solution that fits Idaho.”

What sort of options? There’s a non-profit from Seattle that arranges for free care for some low-income people. And a lone (apparently) Idaho Falls physician who takes no insurance payments, just charges very low rates and keeps his overhead down. Interesting instances both, but if you ask why they’re not more widespread – nothing in the Affordable Care Act or other law is stopping them – you’ve halfway answered your question. Or just ask your local hospital or physician why they’re not doing it this way. Their responses would run much longer than this column, but probably point out the many costs, services and risks left addressed by operating essentially as a pure charity.

Limiting costs is a great thing to do, would be smart to bear in mind, and must be part of where health care planning goes in the years to come, but it won’t be easy. Finding ways to do it everywhere in the health care system would be useful work for lawmakers and others for years to come.

In the meantime, 78,000 Idahoans are stuck in a holding pattern of being without health care coverage except the most expensive kind (in crisis condition in hospital emergency rooms) which when paid for at all is paid by local taxpayers or by hospitals who pass on the costs to everyone else. It is a nonsensical system, both in terms of finance and health. The most positive spin for not improving it seems to be that some people insist on finding perfectly satisfying answers, in opposition to merely fostering public health and saving lives.

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