As a transplanted New Yorker, I was bemused to read U.S. Rep. Bill Cassidy’s depiction of my home state’s Medicaid expenditures for disabled people as “gaming the system,” and his comparison of Medicaid to “heroin addiction.” (“Cassidy pushes heath plan,” Dec. 9) But if Rep. Cassidy’s ideas can help poor people in Louisiana get Medicaid coverage, then I welcome his remarks.

New York spends a lot on Medicaid, but as a high-income state, the federal share of these expenditures is lower than for other states. Louisiana is a middle-income state and has a higher federal share. But Louisiana is very reluctant to extend Medicaid to poor people and has refused federal money for Medicaid expansion.

The standard by which we can measure the health-care system, including Medicaid, is whether people get the care they need as efficiently as possible. By that standard, U.S. health care does very poorly in comparison with other wealthy countries. Louisiana’s high rate of uninsured residents indicates that many people fail to get the care they need. Also, as Rep. Cassidy reminds us, if doctors refuse to care for indigent patients because they are not paid enough to provide care, this too is a problem.

Rep. Cassidy’s proposal might help states to provide care. But the proposal is puzzling, although perhaps it has not been clearly described. A per capita cap on Medicaid expenditure for disabled people is a bad idea if the cap is too low for disabled people to get the care they need.

Efficiency in health care requires thinking about how people can get the care they need. For example, if Medicare eligibility age is raised from 65 to 67, as has been proposed, more people would die prematurely as a result, and only a small amount of money would be saved, if any. So raising the Medicare eligibility age would be inefficient.

There are basically two ways of cutting health-care costs:

The first is by denying care to people. The second is by changing the system to ensure people get the care they need, and money is not spent for other things, such as unneeded care or insurance company overhead. Various parts of the Affordable Care Act (also known as Obamacare), including accountable-care organizations and the independent payment advisory board, are intended to do the second of these.

But if health-care reform is going to work, this will require the cooperation of both doctors and patients, and that is not done just by making a law.

Aaron Lercher


Baton Rouge