President Obama announced and defended his budget yesterday. Having studied the federal budgeting process in graduate school I know that the proposed budget by the executive branch is hardly ever what ends up on the President’s desk so I tend not to pay a lot of attention to it. The budget did get some press in Alabama, however. It seems that a program to train pediatric generalists and specialists has been listed for extinction in the President’s budget and that would cost the state of Alabama approximately $7,000,000 annually. Turns out the President wants to use the money differently

The money for training pediatricians is one of about 200 federal programs targeted by Obama to trim $33 billion starting in 2012. The White House wants to cut the program in favor of competitive grants “that create incentives for improved performance,” according to the president’s budget.

Who isn’t in favor of improving performance?  Maybe the feds see their role as a more global, pointing out to the states how they can deliver care better. Unfortunately, the $7,000,000 of federal money  coming into Alabama every year is not only used for training residents but it pays for a lot of care that gets delivered as a by-product of this training. The current thinking in Washington is that the health of Alabamians shouldn’t be  a federal problem as is the current thinking in Alabama. Maybe we need to find another source for the federal money we now use for care delivery.

Perhaps the state is responsible? Unfortunately, former Governor Riley spent his time avoiding increases in taxes and hence did not leave Alabama much wiggle room to pay for health care this year. In his recent testimony to the Alabama House, the new Medicaid Director points out that there is a projected $700,000,000 shortfall and I guess he’ll have to add the $7 million to that. Dr Mullins was fairly straightforward with the legislators

Mullins said he is reviewing the program looking for places to cut. “I have to be honest with you, even those trim backs are not going to make a difference in $700 million,” Mullins said.

Mullins urged lawmakers to remember that Medicaid is critical to the state’s health care systems. Medicaid pays for about half of all Alabama births and provides medical care to 40 percent of Alabama’s children,

“Without Medicaid, the rural hospital system would probably collapse,” Mullins said.

Seems like a problem that has a potential solution. Unfortunately, that solution (more money into the system in the short term and ultimately transforming the system to be more efficient)  is not politically viable at this time.

Rep. John Rogers, D-Birmingham, said the $700 million request will be difficult to meet.

“We’re in real trouble,” Rogers said.

Perhaps the answer is local. Maybe the health care providers in a local area should all get together and provide the services to those most in need, especially those that are vulnerable and can’t care for themselves. In 2001, the local newspaper looked at our community (Mobile Alabama) and here is what they found

[From 1995 – 2000], the levels of charity care at all three private hospitals have dropped significantly, according to hospital reports filed with the state. Providence, a 349-bed, tax-exempt, Roman Catholic-affiliated hospital in west Mobile, proclaims a mission to pay special attention to the poor. In the last five years, though, 10 percent of its patients were uninsured or on Medicaid, records show. The hospital showed a positive net income of almost $14 million in fiscal 2000 — an 8.5 percent profit margin — although a sister company lost $4 million. At Springhill, about 7 percent of the patients in the last five years did not pay their bills or were covered by Medicaid. Springhill’s profit level topped $2 million last year, financial records show. But 252-bed Springhill, some community leaders say, may have less of an obligation to provide charity care than other private hospitals: It is a private, for-profit company that pays taxes.

My employer, the University of South Alabama is the other care provider in Mobile and it has 40% of its adult beds taken up by medically indigent people at any given time. How do we do this?

The medical college’s faculty salaries are among the lowest in the country and it has fewer teachers per student than any public medical school in the Southeast.

In addition, we rely heavily on Medicaid money which, I’m afraid, is likely to go away.

My experience tells me that it is important to pool our money to provide access to health care for our neighbors. On what scale that happens, whether national state, local, or family, is currently up for debate. I know that here in Mobile it is me, my colleagues, and the USAMC who are not being paid like our peers in order to allow poor Mobilians to receive what care we can provide. I’m not sure that it should be our problem, but it is…

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