The Poisoned Bill

State budget cuts are undermining national health reform.
August 2009
Donald F. Kettl
By Donald F. Kettl  |  Columnist
Sid Richardson Professor at the LBJ School of Public Affairs at the University of Texas at Austin

Even if you haven't heard of Wendy Brown, you know her work. In 1971, she designed "Mr. Yuk," who stars on poison-control stickers. Children have learned to not sip on bottles with Mr. Yuk on the outside, and parents have relied on the toll-free number the sticker advertises if their children ingest what's inside.

Mr. Yuk lives on, but the poison-control system that stands behind him is in trouble. The Michigan and Washington State poison-control centers have been scaled back, and cuts are on the agenda in Arizona, Oregon, and Tennessee. In California, Governor Arnold Schwarzenegger has proposed zeroing out the state's $6 million contribution to its four poison-control centers. That would make California the only state without a poison-control center.

National experts worry that shutting down California's centers would set off a chain reaction. "Many poison centers are poorly funded and on the brink," explains Stuart E. Heard, executive director of the California Poison Control System. California's shutdown could swamp centers in other states and give budgeters there fresh fuel to support their own cuts.

Parents say the centers are lifesavers, and the American Association of Poison Control Centers claims they save money. Almost three-fourths of inquiries are handled over the phone, which cuts down on unnecessary visits to doctors' offices and emergency rooms--a savings of $1 billion per year in health costs, the association says. Other studies suggest a $7 savings for every $1 spent on poison control.

So these centers seem a cost-efficient way of providing better care. Governor Schwarzenegger certainly doesn't want to handcuff Mr. Yuk, but facing a $24 billion budget hole, he's searching for every bit of savings he can find. As his press secretary told the New York Times, "We simply cannot continue to provide that service with a 27 percent drop in revenue."

Most of health care reform is premised on the idea that we can reengineer the system to save enough money to expand coverage. We know we don't have enough money to give everyone everything they want. It's a lot cheaper to make people healthy by keeping them out of doctors' offices and hospitals to begin with than to pay for their care once they get there.

But the states are facing big pressures to move in the opposite direction, cutting programs in order to save money right now. Health policy experts recognize that paying for health reform is going to require more preventive care, better technology and more assessments of what medical interventions work best. Faced with mega-deficits, states are struggling to pay for the very programs they're going to need to make health reform work.

We're heading for a big collision here. It's going to be hard to pay for health reform if the short-term pressures distort the long-term strategy. And it's going to be increasingly difficult for states to step up to the expanded role that inevitably will be theirs if extended budget crises make these kinds of cuts inevitable.

That might make the "single-payer" (as in: federal payer) plan look more attractive. But President Obama has calculated that Congress doesn't have the political stomach for national health insurance or a federal medical system. So he's cobbling together whatever plan he can get that will expand coverage without exploding the costs.

We might well get a health reform plan, but the odds are that it will be tremendously complex. If you like the nooks and crannies of Medicare and Medicaid, you'll love what we're about to get. This strategy can help get a bill passed, and it can help get more people covered. If the wheels fall off health reform--or if compromises leave it a shadow of its original promise--the problems will be magnified.

How are we going to focus the system, in all its complexity, toward better prevention, sharper technology and stronger assessment of what drugs and procedures work best? Most of the political and budgetary pressures we face are pulling policy makers away from these questions and focusing them on strategies that, like the California poison-control battle, might save a few dollars now but drive up health costs in the long run.

One way or another, we're going to face a more complex health care system, with greater expectations for more care and bitter dilemmas over how to pay for it. That will put federal managers and their state partners in the middle of a huge dilemma. The famous scowl on Mr. Yuk's face might prove a good match for what results.