If Not Now, When?

The U.S. has a large and complex healthcare system and the Affordable Care Act has increased its size. There is a small and perhaps significant effort to expand prevention but much of that is secondary prevention, which remains within the mind-set of medical care. Meanwhile, the greatest health challenge remains primary prevention. Perhaps medical care and attention to secondary prevention leads to better health but the path continues to pass through or near sickness and disease. Sickness and disease are never as good as avoiding them and the question arises as to whether avoiding them can be achieved in the medical care mind-set. Keep in mind that not all improper and over-use of medical services is the result of patient choices. Medical care is an industry and industries tend to expand their business.

I cannot put myself in the position of defending South Carolina, my home state, in refusing the Medicaid provision of the Affordable Care Act. However, they do have a point about the improper and over-use of medical care. The Rand Study of the Oregon Medicaid lottery does not create confidence that medical care results in better health. I will grant that a sense of security is beneficial but it might be better if that sense of security was associated more with a healthy and productive life than sustaining a state of sickness.

My wish is that the states had plans to address the problem. Simply saying no will not work and increasing medical care as we know it has not worked. Somewhere, sometime there needs to be consideration of a health system that includes medical care but is not dominated by medical care. Economic well-being, education, public and community health and primary medical care are important elements the states should be addressing. If that is what the states have in mind by advocating block grants for Medicaid, I am all for them. But they need to have specific plans with improved health status as the goal and commitment to measuring progress.