Book Misses its Opportunity to Suggest Real Medicaid Reforms

Published December 1, 2007

Making Medicaid Work: A Practical Guide for Transforming Medicaid
Atlanta: SHPS and Center for Health Transformation, 2007
84 pages
Available for free download at

Making Medicaid Work is a colloquium by the staffs of the health care company SHPS and the Center for Health Transformation, proposing Medicaid reforms with essays, tables, and graphs, punctuated by written commentary by many public officials responsible for the federal program’s administration.

Newt Gingrich, founder of the Center for Health Transformation and former Speaker of the U.S. House, contributes an introduction, followed by another from current Health and Human Services Secretary Mike Leavitt, who notes Medicaid must be reformed if it is to survive as the “go-to” health safety net program.

The first four chapters detail many of Medicaid’s problems and suggest ways to improve the quality of Medicaid services–as well as ways to create economic efficiency and contain costs.

Too Wonky

Of the 12 policy experts whose commentaries are included in the book, several contribute essays on what has worked, or will work, to make Medicaid viable and improve the quality of its services.

In Chapter 4, for example, the authors discuss seven strategy steps for Medicaid reform, including assessing health risks and their costs, aligning Medicaid programs with strategies, creating individually focused strategies for patients’ care and wellness, better record-keeping, more coordination of care, incentives for patients and providers, and flexible and intelligent regulations.

The book is valuable for the detail devoted to the difficulties with the current Medicaid system … and also for what it reveals about the minds of policymakers and theorists at the center of the discussion. In the midst of a Medicaid financial crisis, they seem obsessed with making the program bigger and better.

There is a certain maddening wonkish content to much of the commentary.

Missed Opportunity

For example, consider this passage–literally picked at random, with my eyes shut. The matrix on page 74 has seven rows of “Action Step” boxes for four columns of “Core Principles.” My finger landed on the fifth action step (coordinate care) in the second core principle (promote social advancement), which states:

“Ensure multiple diverse touch points: field offices, enrollment, create multilingual and culturally specific programs, link care coordination with social programs to create personal relevance, provide training and education to support back-to-work initiatives.”

One supposes these are all good ideas, but why don’t the administrators of the current Medicaid program already do these things? Why do we think they would or even could do these things well?

Excessive Complexity

The matrix gives us a glimpse of the millions of moving parts that even a reformed Medicaid program would have, and the futility of believing some small group of central planners in Washington, even if extremely wise and benevolent, would be able to keep such an enormous and complex bureaucratic machine running smoothly year after year.

The bureaucratic approach causes the book’s authors to miss opportunities to discuss how to control runaway Medicaid costs caused by gaming the system and the inclination of politicians and administrators to expand programs and loosen eligibility. Medicaid is not financially viable in its current form, and this book makes no attempt at real transformation.

Instead, it offers better color schemes for the staterooms and new deck chairs. Watch out for the icebergs ahead.

John Dale Dunn, M.D., J.D. ([email protected]) is a member of the American Council on Science and Health’s advisory board and a faculty member at a hospital in Fort Hood, Texas.