The Chronicle-Herald
Opinion, Wednesday, February 11, 2004

Accountability matters, even in health care

Brian Lee Crowley

FEW THINGS are guaranteed to produce more squawks of outrage faster, from the complacent defenders of the status quo in health care in Canada, than the suggestion that people are competent to make their own choices about what sort of care they receive and under what conditions.

“People cannot be trusted” is their battle cry. We must have legions of officials to safeguard members of the public, who are too ignorant and gullible to know their own best interests. And of course, the ill are least likely of all to know what is good for them.

Fortunately, there is new evidence that shows the ill are perfectly capable of deciding where their own interests lie, and of making wise decisions about the care that makes sense for them. They’re even able to do so in a way that maximizes the services they receive, while not increasing costs to the state.

Where does this evidence come from? An innovative experiment called Cash and Counselling (C&C)A bit of background: Medicaid is the joint federal-state program to finance medical care for certain low-income individuals. Like Canadian medicare, Medicaid is in financial trouble. Medicaid spending in 2003 was about $283 billion and the Congressional Budget Office estimates the cost will be $611 billion by 2014.

About one-half of Medicaid spending goes for long-term care for the aged. As the population ages, this piece of Medicaid is expected to quadruple by 2020. State lawmakers, like their provincial counterparts, are scared by what this means for state budgets and other spending priorities.

Part of the answer to the Medicaid cost juggernaut, it appears, is to stop offering institution-based programs for the poor, and to give them the cash instead, along with some good guidance and information about how to spend it.

The states I mentioned were the first to be granted permission to do just that under a “demonstration project” to give certain Medicaid beneficiaries a cash allowance with which to purchase needed services. The program is an unqualified success; people are lined up to join where it exists, and programs like it are being extended to other states to meet demand there.

C&CThe consumer makes his or her own decisions. They can hire traditional providers, family members, neighbours or friends for various tasks and pay them a mutually agreed upon wage every two weeks.

No one is forced into this program. Not everyone wants these responsibilities and they may not even be appropriate for some. But for those who do want it (the great majority of those eligible), the program is wildly popular, with approval ratings well over 90 per cent. The Florida legislature recently unanimously agreed to renew Cash and Counselling.

Did I mention that costs are controlled and service levels improved? Just this past November, the C&CAccording to the Health and Human Services Department in Washington, while this better access led to higher overall costs for personal care under C&C,In March of last year, a separate review of the Arkansas program in Health Affairs found that it greatly improved quality of life, reduced unmet needs for care and did not compromise participants’ health or safety.

Let’s see: That’s more and better services for vulnerable people by giving them more control over their lives and rewarding them for spending wisely, while keeping the cost to taxpayers under control. I guess personal responsibility, accountability and incentives really do matter after all – even in health care.