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The States Are Reeling. Will Health Reform Help?

Harold Pollack, is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.

I don’t have much to add to Jonathan’s reporting and numerical run-down of the HELP bill. For somewhere between $1 trillion and $1.3 trillion in additional federal outlays over the next decade, we can cover 97 percent of the legal population. Within our fallen world of politically feasible legislation, this would be a good outcome. The HELP bill would assist millions of people and would improve our health care system without breaking the federal budget.

Still, one piece of the puzzle needs to be carefully placed: the impact of health reform in 50 state houses around the country.

July 1 marked the beginning of the new fiscal year. Many states are reeling. My own state of Illinois still lacks a budget. Lawmakers seem overwhelmed by the worst fiscal crisis in decades. Governor Quinn and the legislature face the unenviable task of choosing some combination of steep tax increases and deep budget cuts to stem a $9 billion budget gap. They have been debating a “Doomsday Budget,” that includes astonishing proposed cuts of one-third or more in appropriations for the Departments of Human Services, Public Health, Child and Family Services, Aging, and more. The alternative to those deep human service cuts is a big tax increase that enjoys only shaky public support. At least we are not issuing IOUs as they are doing in California.

Here is another irony. Provisions in the federal stimulus package effectively forbid states from cutting Medicaid. Other provisions effectively protect big educational programs. Political realities make it hard to cut other areas, such as state universities or corrections, that touch cranky and powerful constituencies. The cumulative effect is to place severe pressure on the human service components of state budgets.

Jonathan reports that the HELP bill would expand Medicaid by up to 20 million people. I haven’t seen much about the resulting impact on states. I don’t know that there is a problem lurking here--the HELP bill includes important provisions that assist state and local governments that now groan under the load of having to provide much uncompensated care. Still, with all the attention paid to CBO scoring of the federal budget impact, it is striking that few people are asking how health reform affect the intricate state-federal fiscal partnership that is no longer working well.

We write about health policy at The Treatment. You might think I’m straying to get into the narcolepsy-inducing mechanics of fiscal federalism. I’m not. Too many citizens and policymakers conflate health policy with health services, and then conflate health services with traditional medical care. That’s a big mistake.

Services now being cut in Illinois and elsewhere--substance abuse treatment, home visiting services for overwhelmed pregnant and parenting teens, youth violence prevention services, education, and child care, foster care, and more--rank among the most effective and evidence-based strategies available to improve population health. When social policies to provide these services break down, so does public health.

Ironically, the high and growing costs of healthcare and the specific burdens of Medicaid greatly aggravate these problems. Attention must be paid.

--Harold Pollack