As lawmakers nitpick their way through the finances of programs for poor, disabled and senior Utahns they are seeing several big issues emerge for the entire state health care system.
During the past two weeks, dozens of medical providers, recipients, lobbyists and health care administrators have, in so many words, told lawmakers in charge of health and human services budgets that the gilded, spare-no-expense era of medical care is at an end.
Members of the Health and Human Services Appropriations Subcommittee have been getting deeper into the bang-for-the buck minutia than any previous oversight panel. In committee and in the Capitol hallways, talk sways toward the financial well-being of the entire system and big picture questions:
Why does 33 cents of every medical care dollar go for end-of-life interventions that usually just prolong imminent death?
Should Utah adopt the Oregon health care system model and prioritize procedures the state will and won't pay for and stick to it?
Should there be an age limit for open heart surgery candidates?
Should people really be able to just show up at an emergency room and expect free care?
Should those who cost the system millions by eating themselves sick be singled out for an excise tax like the one proposed this year for people who smoke themselves sick?
"With crisis comes opportunity, and this economic one offers a really valuable chance to talk about these very tough issues," said Sen. Dan Liljenquist, R-Centerville. "This discussion is focused right now on Medicaid, but it really is about all of us."
Liljenquist is a new member of the Legislature but has experience with a health care decision that is both personally tragic and an appropriate illustration for a courageous public discussion that may help people get educated and "internalize the real costs of their choices."
His first child died just a few minutes after being born and a few hours after he and his wife and their doctor chose not to fight to keep the infant alive. Doing so would have required costs upwards of $1 million and still probably would not have saved her life.
Care providers have told committee members that doctors are borderline miraculous at extending existence, but that doing so is often tantamount to holding a soap bubble on a grappling hook. "My brother tells of elderly folks during his residency of being kept on life support for months and months because their children felt it was their moral duty to keep them alive," he said, noting that there is compelling duty as well to at least consider the expense of that kind of care.
Sen. Allen Christensen, R-North Ogden and a dentist, said such issues remain well outside the arena of public debate. "I just don't see the motivation out there to address it."
Dave Gessel, government relations vice president for the Utah Hospitals and Health Systems Association, believes if not now, when?
If the cutbacks go through as proposed, Utah hospitals would be losing around $100 million because "for good or ill, over half the revenue to hospitals is coming from government programs" such as Medicaid, Medicare and military medical programs."
Gessel, who has been speaking for Utah hospitals at the Legislature for 15 years, said he believes the state's economic woes have only begun and that a new round of budget cuts will be awaiting lawmakers a year from now.
"Things could revert back in a few months, but I don't think so," he said. "The economy is helter-skelter and at the levels of cuts we're talking, this is uncharted territory. There are seismic changes under way, and we need talk about them."
Over the past 40 years of remarkable medical technological advances, people have tried to forget that death is part of life, Dr. Chris Cowley said. And in the process they've disconnected from the fact that most people, most of the time, have the greatest impact on their own well-being.
"Educating them to that fact and then getting them to act on it is very difficult," Cowley said. "I advise many of my patients on blood pressure medication that if they really wanted to lower their blood pressure, they should start to exercise and lose some weight," he said. "They say they know, but it's apparently a lot easier to just keep going to the pharmacy and taking a pill."