Debates on how the federal and state governments should spend money on healthcare are constantly being discussed by experts on both sides, and this has been the case since government healthcare was first conceived.
This week, Jonathan P. Leider, a Ph.D. Candidate in Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, gave a talk called “How Much Should We Spend on Health Care?” for the first annual Bioethics Day hosted by the Hopkins Undergraduate Bioethics Society.
The talk focused on the U.S. healthcare system, and aimed to discuss with the audience the various aspects that complicate the healthcare system for providers and consumers both.
The U.S. healthcare system consists of a patchwork of public and private health care systems. The payers in the U.S. healthcare system include Medicaid, Medicare and other providers including employer-sponsored health insurance as well as insurance from the individual market.
“We have a mishmash of payers and providers that form a ‘patchwork quilt,’” Leider said. Mostly, the providers consist of private hospitals, practices and clinics.
Interestingly, the only group in the U.S. that gets served by a single payer & provider system is the VA system for veterans.
In the past, state and federal government budget cuts to healthcare funding have led to varying degrees of public uproar.
In the case of Medicaid, how its funds are accrued and distributed depends on both the state and federal government, and can depend on the various needs of other departments within the government as well, especially education.
“Medicaid is the way we pay for the poorest. The federal government pays for a lot of Medicaid, but it’s also the case that the states have to kick up a lot of the money,” Leider said. “In many states, Medicaid is one of the biggest if not the biggest money spending, usually behind schooling.”
One example cited by Leider showing the complexity of Medicaid and how it can drastically affect individuals was a case in Ariz. where transplants ceased to be covered by Medicaid.
As a result, potential recipients were left without any potential transplants in their medical treatment plan because they could no longer afford it.
Through this change, the state of Ariz. will save $1.4 million; however, 98 people who were waiting for transplants will not get them unless they can pay for the transplant themselves out of pocket.
Another example included cuts in Texas that would affect home visits of the elderly or disabled. This case brought in more complicated and sensitive issues, such as human dignity and the scope of healthcare.
These examples proved to show the complexity of the U.S. healthcare system and how difficult it can be to appease all sides of the argument; in this case, how could the government allocate funds while best satisfying the demands of each sector of society?
As a potential solution, Leider suggests that rationing may be the best way to address the issue of U.S. healthcare; however, he is well aware of the reaction that rationing can elicit from the American public.
“It’s just the case that healthcare is getting more expensive — faster than a rate that we can keep up with. We will have to make choices in scarcity — which are rationing choices. People don’t want to talk about it in this country, but we already do it,” Leider said.
However, even this solution brings with it its own set of challenges. One of the classic challenges that is universal to public health issues in this country is whether to offer small benefits to many or large benefits to few.
Medicaid is a prime example of such a dilemma — should we spend $1.5 million to fund Traumatic Brain Injury (TBI) rehabilitation or use those funds to build a wellness clinic for hundreds of children? Should we dedicate $120 million for 50,000 substance abuse admissions and their treatment or commit $400-500 million for all net LHD funding?
Furthermore, what happens when policy makers disagree? In every situation, there are winners and losers, but can policy makers get to a just outcome through a fair process alone? This too is contested amongst officials at all government levels.
