Editor’s Desk

Medicaid Wellness Programs Face Challenges

Frank Diamond
Managing Editor

One of the paradoxes of human nature is that people who have little money are often the most generous. My old Uncle Joe (dead for over 30 years) had half his stomach blown away in the Battle of the Bulge and suffered the rest of his life from what we today would call post-traumatic stress syndrome and what they referred to then as battle fatigue.

That Uncle Joe carried this burden only occurred to me years after his death because those among the Greatest Generation who most experienced the horrors of war tended not to talk about it.

Uncle Joe gave a portion of what little he had to charity. And the charities would ask for more. To one, he wrote: “I would love to help, but I only have enough money for the staples: beer, whiskey, and cigarettes.”

I thought of Uncle Joe yesterday when I read this excellent story by Phil Galewitz on the Kaiser Health News wire. We here at Managed Care have long covered the expansion of Medicaid under the ACA and the historically unique challenges that will bring. We’ve covered wellness from when many considered it the possible savior of health care, to these days, when it faces withering criticism. Not only does wellness not save money, some argue, it doesn’t really improve outcomes.

As Galewitz reports, one place policymakers think wellness will work is Medicaid, where a little bit of prevention could really impact millions of people who interact with the health care system sporadically, often by going to the emergency department.

These well-intentioned programs flounder for the same reason that caring for Medicaid patients is always a struggle: providers deal with a population in which lack of transportation, illiteracy, substance abuse, sedentariness, and poor eating habits come with the territory.

Then there’s this: Most of us—rich, middling, or poor—want to make our own choices. Uncle Joe knew cigarettes would kill him, a fact of which my aunts never tired of reminding him. Didn’t matter. He chain-smoked unfiltered Camels right to the end, each one to the nub.

Wellness that educates does some good although, again, the effectiveness is anyone’s guess. It’s when government, or employers, or insurance companies (with employers’ blessings and encouragement) reach into our lives and tell us that you will eat more healthily, and you will stop smoking, and you will exercise. Or you will be penalized.

So, as the firestorm of debate kindled by New York City’s decision to ban supersized sodas illustrates, wellness doesn’t just camp out in a little corner of the health care industry. It cuts to what kind of society we want to live in. If I am hungry and someone places two plates on opposite sides of the table, one with French fries and the other with carrots, I know which direction I’ll head in. And if they outlaw beer, I am moving Ireland. I don’t smoke so, of course, jail all the smokers. (Sarcasm.)  

Which is not to dismiss wellness outright. I understand, and half agree with, the argument that others shouldn’t have to pay for my poor decisions. But there needs to be balance. Unless I’ve missed a major medical development, the mortality rate for all of us remains 100%. And the desire among us to live a long and healthy life probably approaches that number. But at what cost?

Congress could save over 30,000 lives each year with a single piece of legislation that would set the national speed limit at five miles per hour. That’s the definition of a society going nowhere slow.