Went to see Brad Byrne speak at the MGMA meeting here in Mobile. He is one of the announced candidates for governor and a very impressive speaker. I was troubled by his take on our health care crisis. Our state has an educational budget and a general fund budget, each funded separately. The general fund budget takes care of roads, prisons, and most importantly, Medicaid. Mr Byrne identified Medicaid as the area of the budget where $300,000,000 could be found. His belief seemed to be that we have too much fraud and too many folks who could be in the work force and are not because of personal choice and that is where the savings will be.

I would ask that Mr Byrne and his advisors spend a little time understanding Medicaid  prior to making these types of decisions. The Kaiser Family Foundation is a good place to start. The total amount spent on Medicaid in Alabama was $4,117,497,718, of which 67% is paid by the feds and we pay 31%  but only $491 million comes from the general fund. We actually put together a “provider tax” to pay the rest which is then remitted back to the facilities, which allows us to draw down the federal “match”. In other words, the hospital providers are willing to tax themselves in order to draw down the federal money (as only 4 others states do) because the state cannot or will not raise the money through the general fund. Why do this? The speculation is that without this mechanism, the state would withdraw from Medicaid. If Mr Byrne is only going to look at Medicaid to eliminate the budget shortfall, we will have to eliminate almost all payments from the general fund to meet his target and the providers can not tax themselves for that amount as well.

It may be that elimination of Medicaid is one of the goals of the Byrne administration. If instead it is to “rethink” Medicaid, we need to truly understand the spending. Following are some selected facts. 21% of the population in Alabama is covered by Medicaid. Of the $4 billion over $1.3 billion goes into longterm care. 45% of all births are Medicaid births in Alabama with 17% of our births being preterm births. 11% of our citizens have diabetes with our deaths from diabetes (preventable with primary care access) at 25% higher than the national average. Our death rate from stroke (a marker for hypertension, another disease preventable with access to primary care) is also 25% higher than the national average.

I agree with Mr Byrne that we need to rethink healthcare in the state of Alabama. I also agree that we are paying enough money to get better results than we are getting. As North Carolina has done, let’s focus on improving healthcare in total. To do so will mean a major expansion of the primary care infrastructure. But it will also force us to work on related, important questions, such as how to improve the handoffs between the community, primary care, and specialty settings. I have had a number of conversations with primary care doctors about “UAB” or “USA” that should have ended differently. But most of all, we need to  focus on healthy communities. North Carolina found that this has brought community groups (including public health), primary care groups, other disciplines, and specialists together towards a common goal. Ultimately, I think we all agree that we’re going to need large shifts in emphasis and funding. I hope we’re going to be able to work through this problem…

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