published Thursday, July 28th, 2011

America needs a medical safety net

Lost in Washington’s toxic debate over the deficit is the question of what kind of society we aspire to be. Proponents of radically shrinking governmental expenditures demonize services including many crucial to the nation’s health. These are lumped under the heading of entitlements.

I write in defense of medical entitlements.

Medicare. My training straddled the passage of Medicare. Before the July 1965 enactment of Medicare, many elderly and disabled Americans had no health insurance. Even in an era of less costly medical care, seniors often had to choose between heath care and financial solvency. I have vivid memories of a patient who chose to forego dialysis rather than sell the farm upon which his family depended for its livelihood.

Medicare offers a standardized national format of benefits administered through private insurers. Challenges face the program. Wide regional variations in the cost of care must be solved. Alternatives to expensive in-patient care must be developed. Care of chronic conditions must be coordinated. To date, Medicare has saved millions of lives while sustaining the dignity and financial security of older and disabled Americans.

Medicaid. Enacted in 1966, Medicaid promised health care for the nation’s poor. I grew up with classmates too poor to have dental care or corrective surgery for birth defects. In my internship and residency years, I worked with colleagues to patch together care for impoverished sick people who had neither money nor health insurance. Unlike Medicare with its uniform program, Medcaid leaves broad discretionary powers to individual states. Federal support is pegged to funding and eligibility standards adopted by each state. Some states, including Tennessee, provide decent care to most poor residents. Other states provide only meager services to a fraction of poor people. Provisions of the Affordable Care Act of 2010 standardize eligibility across state boundaries, removing the “right” of some states to ignore health needs of their poorer citizens.

The future of Medicare and Medicaid, and health care in general, depends upon controlling costs. New models encompassed in the ACA are vital to reducing costs while improving outcomes. Waste, fraud, and abuse in both programs must be eliminated. Faced with an aging population, both programs will need more money either through increased taxation or shifts from areas such as defense spending.

Mental health services. Feeling like a modern day Rip Van Winkle, I recall years in which asylums constituted the only publicly financed options for people suffering from mental illness and substance abuse. Engraved in memory is Grace, an older retarded girl in my sixth grade class. One day two officials took her from our classroom. We were told that she was transferred to the state asylum since she was sixteen and too old to remain in school. I remember two girls who cared for her dissolving into tears. People with mental illness were sequestered rather than treated.

From research to clinical activities such as community clinics, children’s mental health services, rehabilitation for homeless and incarcerated people with mental illness, Federal funding has reshaped how our country addresses mental health and substance abuse. Tax dollars have provided humane alternatives to neglect and brutality.

Protective agencies. The Food and Drug Administration (FDA), despite efforts of lobbyists to limit its authority, has set standards for food safety and for research and safety of prescription drugs. FDA needs more authority and funding to apply similar standards to countless over-the-counter products of unknown composition and potential toxicity.

The Environmental Protection Agency (EPA), another target of lobbyists and legislators, provides national standards for identifying and regulating toxic substances in air, water and soil. States cannot deal with toxins that do not respect boundaries. Environmental poisons are a major public health menace. I dealt with one, a pesticide, blamed for cancers in a neighboring area in Alabama. EPA was crucial to its resolution.

“Statistics are people with the tears wiped away.” The quote from Richard Doll reminds us that each of the above programs deals with the health and lives of individuals. These are people with fundamental rights to “life, liberty, and the pursuit of happiness.” They cannot be dismissed or depersonalized with anti-government rhetoric. Do we honor them, give them a helping hand, protect their air, water, and food? Do we toss them overboard?

We do not have to sacrifice Americans to balance budgets.

Contact Clif Cleaveland at cleaveland1000@comcast.net.

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