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In the world of predictions, it’s too easy to be wrong. People don’t particularly care to offer up a vision of five to 10 years down the road for nearly any subject, especially publicly funded health care. Who needs the public humiliation? Is the reward of being right in the coming years worth the risk of being visibly wrong?
It doesn’t take much craning of the neck to see the future is too unstable to predict. Just take a look at the short, unhappy life of the ergonomics rules breathed into life by the Clinton administration only to be quickly brushed aside by the Bush administration. Though politicians, Hill staffers, and tens of thousands of aides and bureaucrats across the 50 states make health care policy their life’s work, most would agree what seems likely today may well be in the rearview mirror of policies-that-might-have-been tomorrow.
The jobs of government and the health care industry also include extrapolating into the future. It involves a fair amount of educated guessing, but ideally there are hard numbers to back up these educated guesses. And that’s how many of State Health Watch’s futurists came up with their visions of the future that highlight this month’s issue. The National Academy for State Health Policy (NASHP) in Portland, ME, for instance, has taken the Institute of Medicine’s (IOM) estimation that medical errors are the eighth-leading cause of death in America. (See related story, p. 9.)
The IOM says medical errors lead to between 44,000 and 98,000 patient deaths annually. Those figures are hard and high enough for the academy to be concerned about. Its vision of the future: Reduce the errors and save lives. NASHP officials predict the loss of life, and also of dollars, will drop when the errors are reduced. But first, it needs to get a handle on what constitutes a medical error.
"There’s a big knowledge gap," Jill Rosenthal, NASHP policy analyst, tells SHW. "Research will lead to more best practices, leading to fewer errors. We just don’t have a good baseline right now. There is no national reporting system for medical errors and most states don’t have a system. Without a baseline, it’s not good to judge. I think the baseline will change, but a lot of work has to be done to clarify what we mean by medical errors."
In less than five years, Ms. Rosenthal predicts, a baseline that is credible will be formed, leading to fewer errors and fewer deaths. "States feel strongly that they need flexibility to adapt their system to meet current needs. I think states would be amenable to a core set of requirements, then go above that to meet other issues. States do not want the federal government to impose reporting requirements without their input."
Medicaid expenditures from the recent past help frame a vision of the future for the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute, both in Washington, DC. Armed with Medicaid enrollment figures from 1997 and 1998, the two groups predict Medicaid spending will grow in the coming years, as much as 10% in the near future due to rising health care costs, most particularly prescription drug costs.
"The Congressional Budget Office projects federal Medicaid spending to grow by an average annual rate of 8.6% from 2001 to 2011," according to the groups’ recent publication — Medicaid Spending Growth Remained Modest in 1998, But Likely Headed Upward. "The reasons behind both actual and projected cost increases include enrollment growth, escalating prescription drug costs, demands for higher provider payments, health care price inflation, and states’ increasing use of [Disproportionate Share]-like funding mechanisms."
The future is unlikely to ever shake the doubts thrown in its path by the economy. At times, the economy is stable and predictions are easier. But the country, and perhaps the world, is entering a period of increasing economic doubt. Will these Medicaid figures hold up in the coming years?
"You can’t forecast that with real precision," John Holahan, one of the paper’s authors, tells State Health Watch. "Now hitting the Medicaid program is what is coming out at the end of a boom. . . . If it slows, more people will be eligible and we’ll get more enrollment and states will be under budget pressures. What will they do? They may not have revenues to keep up. We may see states constraining enrollment; eligibility thresholds could be constrained."
In this scenario, Mr. Holahan adds, "Health care inflation is going up, enrollment is going up, with a big hit from prescription drug costs. It could hit the Medicaid program pretty hard."
States will continue to use upper payment limit arrangements to draw down more federal funds, according to the Kaiser Commission. "As states seek new revenues from all sources, the Medicaid program has been identified as a way to obtain additional federal funds to replace state matching funds. While Congress has curbed the practice, states are allowed some continued use of this financing tool. The current economic slowdown is likely to encourage states to use these and similar mechanisms for more revenue."
Turning Point, a project by the National Association of County and City Health Officials in Washington, DC, has set its sights higher than the next two or three years as it seeks to make fundamental changes in a health care and policy-making system that it sees as having gone off course. The future to Turning Point participants is one in which integrates as much input into the public’s health as possible. Because the public and many policy-makers do not understand the current health care system, Turning Point contends the current system has fallen into what its officials call "a state of chronic financial neglect" and cannot protect Americans from major causes of death and disease. To change this pattern of neglect and illness, state and federal health policy need to include more and more input from all corners of society, Turning Point officials say.
"We need to know more across communities, not just states," Vincent Lafronza, Turning Point National Program office director, tells SHW. "How do people go about assessing and monitoring and reporting collaboratively, and move away from just tracking diseases?"
The public health care system’s future for Turning Point (for more information about the project, go to www.naccho.org/project30.cfm) is a place in which more voices affect policy than are currently allowed.
"The most important theme of this kind of work, and other national movements, is seeing the return of civic engagement as opposed to looking at disease-based models of institutional work," Mr. Lafronza says.