Barbour on Medicaid

"Some politicians act like they love our constituents more than we do."

So says Mississippi Gov. Haley Barbour. But it's hard to imagine "love for his constituents" being the first phrase that comes to mind when people think of Barbour, whose arguments in support of charging Medicaid recipients pharmaceutical co-payments included the nugget: "We have people pulling up at the pharmacy window in a BMW and say that they can't afford their co-payment." For anyone old enough to remember Ronald Reagan, Barbour's folksy account of Medicaid queens speaks for itself.

Barbour made both comments at a governors' conference at which he argued states should have greater flexibility to trim Medicaid benefits and eligibility. To put it mildly, Mississippi is not the ideal state for Republicans to argue the supposed merits of local control in public assistance and health policy. This is a state that sets its maximum monthly welfare benefit for a family of three at $170. This is also a state that has in the past required federal intervention to ensure it maintains decent policies. To provide one especially pertinent factoid, Medicare and Medicaid were key to Mississippi's startling infant mortality declines in the 1960s: Fewer African American children died of diarrhea and other simple diseases once federal programs pried open the doors of that state's segregated hospital system. 

On a more personal note, Barbour's comments brought back my experience on a National Academy of Sciences panel concerned with HIV prevention and AIDS treatment funds provided under the Ryan White CARE Act. Our charge was to examine the merits and implications of different formulas that might be used to allocate the money across states and localities.

Most of our work was dry and mathematical. Yet the human faces behind our numbers sometimes shined through. At one point, a Mississippi clinician testified, in surprisingly emotional terms, about how hard it was to care for AIDS patients in that state. He spoke right after counterparts in Washington and New York, whose well-resourced facilities were beyond the scope he could possibly provide. He described the lack of locally accessible pulmonologists who were willing or able to treat his patients: lung infections are a frightening problem for AIDS patients. He described the very meager resources Mississippi provided to meet the medical, housing, and social service needs of his low-income patients.

I and other public health professionals struggled with a basic fairness question. Mississippi and some other states were doing as little as they could to serve this stigmatized, politically marginal population. At the time, I thought that the attitude of state legislators was pretty clear: This is what we are willing to do. If you believe that these AIDS patients deserve more, you can pay for it yourself.

If one wanted to ensure that every AIDS patient received decent services, one needed to channel federal Ryan White CARE dollars to patients in these states who would not otherwise receive help. Of course this implicitly penalized other states, who were doing so much more for similar populations. It's frustrating, but AIDS patients don't sit in the state legislature. We can't abandon them because their state doesn't provide the proper help.

Similar stories might be told regarding Medicaid, health reform, and other matters. Blue states are footing the bill to provide poor Mississippians basic services and basic access to health care. That's right and proper.

The state's political and economic establishment benefits greatly from this outside help. That's ok, too. Mississippi is a poor state that needs the help. Still, it's hard to stomach the spectacle of Barbour and others denigrating these federal programs and disparaging their fellow citizens.

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