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Op-ed: Medicaid isn't charity; it's community investment

Published December 28, 2013 1:01 am
This is an archived article that was published on sltrib.com in 2013, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.

Sen. Allen Christensen, chair of the Senate Social Services Appropriations Committee, argued in a recent Tribune op-ed ("Medicaid expansion is just forced charity," Opinion, Dec. 22) that taxpayer-supported health services for the poor should be considered forced charity.

Alternatives to this philosophy should be considered by Gov. Gary Herbert as he decides about expanded Medicaid coverage for Utah.

First, a few facts should be clarified. Sen. Christensen states that a "huge proportion [of Medicaid funding] will have gone for administration." Actually, Medicaid overhead is 4 to 6 percent of claims paid, which is less than half the overhead of private health insurance providers.

The reasons for this relative efficiency are straightforward — the program need not make a profit, advertise or employ a workforce to collect premiums. We also can compare this efficiency to the overhead of charitable organizations.

An investigative report by the Tampa Bay Times found that "The very best charities spend no more than 35 cents of every dollar raised on funding costs." Further, "America's worst charities spend more than 80 cents of every dollar on fundraising."

Considering the return on a dollar, it is far more efficient to support the health care of the poor through government programs than through charitable organizations or private insurers.

Relying on charity also would be challenging because individual health care needs vary widely. According to the federal Agency for Healthcare Research and Quality, 5 percent of patients with chronic, complex conditions account for almost half of total health care expenses.

In the Medicaid population, the elderly and disabled are 25 percent of the recipients but account for 70 percent of the expenses. This pattern of large but critical expenses for a small proportion of patients is true for children as well.

Can we rely on charity to cover the enormous expenses, year after year, for each and every child and adult with a complex, chronic disease or multiple conditions? Who would be responsible for consistently collecting and administering charitable funds in such large amounts for individual recipients?

How would charities decide who would receive their gifts and what health care services were covered? Would charities based in other states address the needs of Utah citizens?

The broader implication of viewing health care for the poor as a charity is that we would have no formal obligation as a society to support these services. When charitable funds fall short, the resulting deaths and disabilities would be unfortunate but not a matter of state concern.

Sen. Christensen should clarify whether it would be acceptable to allow a newborn infant with, say, a congenital heart malformation to die because her parents could not find a charity to cover her expenses.

An alternative philosophy argues that successful communities entail a mutual commitment to the welfare of others.

Basic services such as health care, education, defense, transportation and clean water are essential to the pursuit of life, liberty and happiness for us all.

For those who do not agree that such an obligation exists, there are more self-interested arguments to consider. We live, work, and play together. Our economy needs healthy, educated workers to compete in global markets. We all benefit when a commitment to basic health services for all strengthens the very fabric of our community.

If we were to design a system through which we, as a community, contribute to the health care of the less fortunate in a fair and efficient manner, that system would look a lot like Medicaid.

Medicaid should not be considered a forced gift but as an essential investment in our community in a way that is both ethically justified and likely to yield tangible benefits for us all.

Jeffrey Botkin is a professor of pediatrics at the University of Utah and chief of the Division of Medical Ethics and Humanities.




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