Todays Press Register carried an excerpt of an article from Governing Magazine which contrasted the differences in attitude towards health care reform between Alabama and New Mexico. The article made some interesting points which require some context to fully appreciate.

New Mexico has about half as many people as Alabama (2 million to 4.6 million) and is twice as big (120,000 square miles to 54,000 square miles) so is much more rural. Rurality poses a problem for care delivery for both states but Alabama health care is dominated by several largish cities (Birmingham, Mobile, Montgomery, Huntsville, and Tuscaloosa) that each have a medical school or a medical branch campus. Albuquerque is the only city of significant size in New Mexico. The medical education enterprise in Alabama is dominated by the University of Alabama, Birmingham has as its stated mission “The School of Medicine is dedicated to the education of physicians and scientists in all of the disciplines of medicine and biomedical investigation for careers in practice, teaching, and research. Necessary to this educational mission are the provision of outstanding medical care and services and the enhancement of new knowledge through clinical and basic biomedical research.” The medical school in New Mexico ” Our goal is to provide top-notch clinical services to the residents of New Mexico while being recognized as a respected School of Medicine training doctors for New Mexico.”

Both states are in the bottom quartile of state rankings. The difference is in how the state health officers see the role of health insurance refom in their path to becoming a high performing state. In  Alabama,  Commissioner Stekel sees impending doom. Alabama chooses to insure almost all of its children (97%) but relies on the medical schools to care for the poor adults as a by-product of the education process. As a result there are 100,000 diabetics in Alabama who do not get needed preventive services and either die prematurely or suffer significant disability. 250,000 of its citizens use the emergency rooms as their usual source of care. Although most children have insurance under the current system, 150,000 do not have access to primary care because of a shortage of providers to deliver that care. Commissioner Steckel wishes “more modest approach of incentives for small businesses and pooling had been tried instead.”

The Medicaid commissioner of New Mexico sees opportunity. The per capita numbers may look the same (or even a little worse) but New Mexico Medicaid Director Ingram sees ” it as a tremendous boost to the state economy. Those providers, in turn, will have more money to spend in ways that benefit New Mexico’s economy. Ingram points to a study conducted by the advocacy group New Mexico Voices for Children that found that each dollar spent by New Mexico on Medicaid generated $2.90 in federal Medicaid funds, which in turn generated an additional $2 in extra economic activity as the spending rippled through the economy, ultimately creating a combined “multiplier” effect of $4.90.”

Part of why Commissioner Stekel see impending doom where Director Ingraham sees opportunity may be how Academic Medicine fits into the care delivery system. At the University of New Mexico College of Medicine, many programs exist to enhance care delivery and integrate the clinical offerings into the communities. I saw a very impressive presentation of some of their telehealth activities  at the National Rural Health Association meeting in Miami. I hope that we in academic medicine in Alabama will be offered the opportunity to work with Commissioner Steckel to do the same.