THE BLOG
03/11/2011 05:24 pm ET Updated May 25, 2011

Medicaid Reform? Try Harder

Whoops. Uh, oh. The new state Medicaid Redesign Panel, composed of 27 health industry leaders appointed by Governor Cuomo, completed its first task -- recommending $2.85 billion in immediate cuts to spending, or 2% of New York's annual Medicaid budget --- in such record speed that it presented the governor with a package of 79 recommendations in less than two months. The Commission has received widespread, and deserved, praise for such an unusual and generally commendable performance, especially a performance by a government-appointed panel of industry leaders.

This success in its immediate mission, however, makes it more striking and depressing that, as the Commission moves to its next task -- long-term recommendations for reform to be given to the Governor by November -- it is already clear that true long-term reform is not on the table.

The immediate cuts which can be reaped from Medicaid have to do with how the health industry functions for itself -- i.e. the distribution, through rates, consolidation, allowable services and administrative efficiency of however many billions are available. Many of the short-term proposals do, in fact, through administrative improvement actually provide what state Health Commissioner Dr. Nirav Shah calls "real reforms" -- which is to say, rearrangements that benefit patients even as they save money.

Long-term reform is another matter; it has to do with how the health industry functions for the public overall, beginning with its only acceptable first mission -- keeping people well in the first place. However, the some 140 remaining recommendations, which the panel will now review and rank to form its long-term plan, provide no basis for substantial, effective disease prevention becoming the first order of reform.

We live, as everyone knows, in an age of chronic disease. This means, among other things, that keeping people well means keeping them utterly out of the medical system to the greatest degree possible. Treating or preventing infectious disease almost by definition involves some type of medical encounter even for basic tasks like the administration of vaccinations or antibiotics. By contrast, teaching and empowering people to take care of their own health is conclusively the most powerful approach both to preventing. chronic disease -- and to minimizing the costs and the burden of illness when people do have chronic conditions; this means that a prime cost-slashing strategy for the long-term is to curb over-dependence on the medical system by putting people in command of their own well-being -- a strategy ignored in the New York State "long-term" proposals.

Take just one example: If any chronic disease has been shown to be preventable, it is diabetes. In the well-known National Diabetes Prevention study which included 3,000 people across the country with high blood sugar, coaching these high risk men and women to lose modest amounts of weight and start modest amounts of exercise was twice as effective -- and much cheaper -- as trying to halt their progression to diabetes by prescribing standard medication. These outstanding results in halting diabetes with modest "lifestyle changes" were the same for men, women and all ethnic groups -- and even more significant by age since trying to stop the development of diabetes with medication didn't work at all for those over 60, but "lifestyle changes" still did.

In a state where diabetes is by far the most costly disease, and rising relentlessly -- a state where some 4 million or so people with very high blood sugar are now on the cusp of diabetes -- the single most obvious priority to suppress long-term Medicaid costs would be to make proven diabetes prevention education easily available, yet the panel does not even mention that New York State regulations, themselves, now make all diabetes-related education very expensive -- and inaccessible -- by requiring that educators have graduate degrees to be reimbursed by Medicaid. The panel's vague proposal for "coverage (for) diabetes prevention services" is meaningless so long as almost deranged and unnecessary state "qualifications" assure almost no educators are available, and especially not available in the poor communities where they are desperately needed.

Self-care education for people who already have chronic disease also produces major results in health improvements and cost savings. For just one example, the well-known Stanford University Chronic Disease Self-Care Course which consists of five two-hour sessions that help people set step-by-step goals to better care for their heart disease, diabetes, high blood pressure and other chronic conditions, pays for itself twice over in lessened doctor and emergency room visits in just the first year. But, in the current list of some 140 "long-term" savings proposals the Medicaid Redesign Panel is slated to consider for its final recommendations, the words "self-care education" do not appear at all.

How is it possible that a panel which did such a credible job of producing recommendations to re-arrange its industry for short-term savings is simply unable to direct its attention to the proven benefits of self-empowering health education -- the only proven and possible strategy which can at once rapidly produce better health for millions of people while producing literal billions of long-term Medicaid savings? Certainly one reason is that the Medicaid panel is entirely an industry panel; it consists of leaders and administrators from what is now widely referred to as "the medical industrial complex." No industry or power group likes to focus on ways to decrease its constituency; but the hard truth of preventive and self-care education is that it works best when removed from the medical industry and placed and conducted in communities where it is accessible to the people who most need it. Who wants to trudge to hospitals and clinics -- and their depressing atmosphere -- for education to feel well?

And, just as good self-care education is best taught in communities -- and away from hospitals and clinics -- it doesn't need medical personnel as teachers. The Stanford Course, in fact, is designed to be effectively delivered by peer educators who have not a master's degree but a week of training! Integral to the effectiveness of this course is that it is taught by people who actually come from the low-income and minority communities most overwhelmed by chronic disease.

In sum, a real fight against chronic disease demands that communities really be involved -- a complete shift in approach. Helping the communities most affected by chronic disease to start delivering this kind of education, themselves, is as important to improved health as alternate approaches to education, such as charter schools, are to reforming education.

The Medicaid panel is now supposed to form work groups that will expand its vision. There will be no real vision until at least one work group is formed to concentrate on plans to implement preventive and self-care education as a priority -- and under rules that change reimbursement to assure that communities can take the lead role in education and empowerment for their own health. Never has real prevention been more necessary -- or possible. The federal government, with its own urgency to cut costs, is now unusually amendable to waivers that allow states to use Medicaid reimbursement in effective new ways.

Otherwise, 2% Medicaid reductions are meaningless in a state which, on the one hand, has the worst diabetes disaster in the nation, and, on the other, by regulation, blocks the basic possibilities of preventive education. As it stands now, most of those 4 million or so New Yorkers with high blood sugar will develop outright diabetes within 10 years. What will Medicaid costs be if that is allowed to happen because of berserk regulations and studied industry blindness?