Health is a right.

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Author: David Parrella
Date: Mar. 2008
From: Policy & Practice(Vol. 66, Issue 1)
Publisher: American Public Human Services Association
Document Type: Article
Length: 1,111 words
Content Level: (Level 5)
Lexile Measure: 1310L

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Public Health and Medicaid? To many people, this can seem like an unlikely pairing. Rival moieties within the same caln. The survey and certification people vs. The claims payers. The kinder, gentler world of under-funded preventive care vs.the bloated Tyrannosaurus Rex.

Yet the bean counters and the health care hippies actually do promote a common agenda. The public health world is rapidly evolving from the Nurse Ratched regulators of the last century to the Amazon guardians of quality health-care delivery. At the same time, Medicaid has been transformed from a giant ATM machine into one of the largest, most sophisticated purchasers of health care in the nation. Both camps have more to learn from each other in the pursuit of the common goal of quality accessible health care for all Americans.

After all, Medicaid is collectively the largest and most expensive health insurance system in the country. And many of the biggest cost drivers are the result of the kinds care can most effectively manage. Unfortunately, healthcare prevention has yet to produce an alternative existence to a life in poverty, or at least the grinding treadmill of low-wage existence that our clients trudge through, with all of the adverse affects of bad diet, bad behaviors and bad access to health care that come along with it.

What can Medicaid do in the interim to keep Americans healthy?

* Medicaid is the dominant financer of the care provided to our most vulnerable populations. Almost half of children under the age of 19, 40 percent of newborns and two-thirds of the recipients of long-term care, whetherin the home or in an institution, receive their health care under Medicaid.

* Medicaid is the last, best hope of the safety net system, a system that serves Americans who may not even be eligible for Medicaid. Unless the current administration in Washington succeeds in its recent campaign against case management, rehabilitative services, public hospital and medical education, Medicaid will continue to be the financial bulwark for programs that serve persons with cognitive, behavioral and physical disabilities and, indirectly at least, the uncounted mass of Americans who crowd into the safety net sites who are not eligible for any program. Federally Qualified Health Centers, teaching hospitals, and children's hospitals would be hard pressed to keep their doors open based solely on the largess of the commercial health-care system.

* Medicaid is the not-so-secret glue that holds the seamy underside of the so-called health-care system together. Strange funding categories like hospital disproportionate share, emergency medical assistance, school-based child health, certified public expenditures, interagency transfers and the like are all on the most wanted list at the Centers for Medicare and Medicaid Services. But they pay the bills that no one else wants for care they reluctantly provide to those individuals the system tries hard not to recognize. It costs money not to rely completely on the kindness of strangers to care for the uninsured.

* Medicaid will bear the costs of the aging of the baby-boom generation. Self-indulgent to a fair thee well, my generation is already consuming vast quantities of health-care dollars in an effort to remain wrinkle free and sexually aroused. We haven't even begun to pay for the accumulated costs of a misspent youth. Long-term care, are you ready to rock?

So if Medicaid is going to be the ultimate recipient of adverse risk, are we already beyond hope of investing more in public health? What is the benefit of that investment to Medicaid directors who must deal with immediate budget cuts in an impending recession rather than making prudent decisions to lessen the burden for Medicaid directors of the future?

The reason is, in the absence of such an investment, we have seen the future, and it doesn't work.

* We need a healthy workforce in the future, if for no other reason than to take care of us. When I speak to students, I tell them they should get angry and get engaged because our lifestyle decisions are going to keep them working longer for less. We don't want them questioning their obligations to us, so someday we're just going to have to do the right thing and give them coverage, whether we like it or not. To do so, we're going to have to maximize the public-health contribution to disease prevention in order to make it even marginally affordable. The social and biological costs of not doing so would be too horrible to contemplate. We're not that stupid.

* Prevention works. Immunizations, fluoridation and lifestyle changes do reduce the incidence and severity of disease. Health, and not health care, it turns out, is cheap.

* Activities that support quality health care delivery and reduce waste do result in better outcomes.

* Surge capacity in the current system is a myth. All you need to do to see the evidence of that is to visit your local emergency room in a semi-large city on a Saturday night. In case of a pandemic event or a bioterrorist attack, most of our urban health-care centers would more closely resemble lower Manhattan under attack by a giant reptile in Cloverfield than they would some orderly disaster drill coordinated by your local health department. The current war on states to reduce funding for the safety net could, in the end, endanger national security.

* Our mothers were right. Happy people are healthy people. Academic studies have shown time and again that people with a smile on their face and a song in their heart smoke less, exercise more and are less likely to be obese and depressed. Behavioral health programs, including prevention programs long suspect in the eyes of Medicaid, should be the Smiley "Have a Nice Day" Happy Face of the new health-care system. Why let the pharmaceutical companies have all the fun?

And so my esteemed colleagues, Medicaid, public health and human services can and must work together if we're ever going to get this right. Maybe it's the early effects of senile dementia, amplified by a happy and satisfying personal life as I tiptoe past the residue of midlife, but I think we are going to get it right this time. Don't listen to the cynics who say that universal coverage is unattainable. It may not be universal coverage under the traditional Medicaid rules, and that's OK. Medicaid will always be there for some of the population. But the other 50 million Americans may need something else that builds on their own as-yet-unanswered pleas to be healthy as part of the pursuit of happiness. Health, and not necessarily health care, is a right, not a privilege.

David Parrella is the Medicaid director in Connecticut.

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Gale Document Number: GALE|A179082270