Tuesday, September 29, 2009

Plans for swingeing hospital cuts as British system on brink of 'Armageddon'

Health service managers warned of an "Armageddon scenario" facing NHS finances as they draw up secret plans for swingeing hospital cuts. Senior officials have set "aggressive" targets to reduce the number of patients referred to specialists, or treated in Accident and Emergency departments, while GPs will be asked to cut down on the amount of time spent in consultations.

The plans are being issued as senior managers warned that the NHS is about to face the greatest financial pressures since its inception. They fear that when the current spending round ends in 2011, the impact of an anticipated real terms freeze or cuts – coming as the demands on the NHS of an ageing population increases – will be devastating.

The NHS Confederation, which represents NHS managers, will tell this week's Labour Party conference that the impending challenge is so great that hospital closures and job cuts must be enforced across the country. It comes as two leading think tanks predict a future funding gap of between £20bn and £40bn within six years of 2011. Regional health authorities have ordered hospitals and primary care trusts to draw up plans for cuts worth billions.

In London, NHS trusts have been told to divert more than half of A&E patients, and those seeing specialists, to cheaper "polyclinics" run by groups of GPs. Meanwhile, family doctors will be asked to speed up their consultations, reducing the average time per patient from 12 minutes to eight.

The instructions drawn up by NHS London, and seen by The Sunday Telegraph, order trusts to demonstrate that they can deliver an "aggressive scenario" in response to funding pressures. Under its "affordability assumptions," already controversial plans to reduce the number of patients treated in hospital are given more demanding targets in an attempt to cut costs.

Sixty per cent of activity which now takes place in A&E departments should happen in community clinics within five years, the document says, along with 55 per cent of outpatient treatment. Thirty per cent of outpatient appointments will be stopped altogether. Managers say not all appointments are necessary, though many doctors argue it is impossible to know in advance which patients do not need to be seen. The number of diagnostic tests carried out will be cut by 15 per cent, while the amount of surgery will be reduced by seven per cent.

Although the "polyclinic" model, to reduce demand on hospitals, is supposed to shift more treatment into the community, GPs will be told to reduce their average appointment time by one third, from 12 minutes to eight.

Senior managers in other regions, who will draw up their own plans later this year, said rural communities faced particular pressures, with small maternity and district general hospitals likely to struggle in the funding crisis.

In a speech tonight to the Labour Party conference in Brighton, the NHS Confederation will warn that the service across the country faces unprecedented difficulties, which require "bold and decisive measures". Its policy director Nigel Edwards told The Sunday Telegraph: "The NHS has never experienced a financial challenge of this magnitude or duration in its history". He said improving the operation of the NHS, and treating more patients earlier in primary care, would not be enough to balance the books. Delegates will be told: "Savings only start to become available when we can shut entire buildings, sites and reduce staffing numbers."

The organisation, which represents NHS managers, will also call for "uncomfortable decisions" to be made to limit staff pay. Under a three year deal already agreed, nurses will receive a rise of 2.25 per cent in April. Sir Robert Naylor, chief executive of University College Hospital in London, said pay should be frozen for NHS staff after that point. If it was not, every one per cent pay rise could cost 10,000 job cuts, he said.

The chief executive said that while he supported plans to treat more patients in the community, he was concerned that PCTs were planning to cut back on hospital services before alternatives were put in place. "The investment in those services has to come first or where do the patients go?" he said, criticising "over simplified" analyses which failed to take into account of increasing public demand.

Dr Laurence Buckman, chairman of the British Medical Association's GP committee, described the plans as "desperate and inadequately thought through". Dr Buckman, who works as a GP in London, said targets to reduce outpatient appointments by 30 per cent would put patients at particular risk. He said: "All this means is that those people who are refused a referral to a specialist will be forced to go privately, or go nowhere. This will be difficult for doctors, but patients will be the real victims." While some specialist referrals turn out to be unnecessary, GPs only asked for a specialist opinion when they needed it, Dr Buckman said.

A study by the King's Fund and the Institute for Fiscal Studies forecasts a funding gap of between £20bn and £40bn by 2017, if funding for the NHS receives no increase, or gets a real terms freeze which only keeps pace with inflation. Sue Slipman, director of the Foundation Trust Network, which represents the best hospitals, warned of an "Armageddon scenario" which could unfold without decisive action on pay, and terms and conditions. She said: "There is a trade-off between saving jobs, and pay increases, and in the current climate, protecting jobs needs to be a priority."

Katherine Murphy, from the Patients Association, accused NHS managers of wasting billions on management and repeated organisational restructuring during the boom years of record investment. She said there was no evidence that plans to shift patients into the community would provide safe care. "Elderly patients often require intensive support which often means lots of staff, in hospitals. The need is only going to get greater – these plans look like madness," she said.

A spokesman for NHS London said its documents provided planning scenarios, rather than forecasts, to cope with a changing economic environment. He said the NHS was investing heavily to ensure care was provided in the most appropriate setting. [Blah, blah, blah!]


NHS dental crisis: Can the rot be stopped?

As new figures reveal over 40 per cent of the population has no NHS dentist can a new review finally fix the system once and for all?

Not that long ago we were queuing in the streets for an NHS dentist, with scenes of hundreds of patients camping overnight likened to the January sales. Now, new figures suggest that many of us have given up, and are paying for private treatment or simply going without care if we cannot afford it. Data from the NHS Information Centre released last month shows that only 58.3 per cent of the population saw an NHS dentist in the two years ending March 2009, with the number of complex treatments, such as root canals and crowns, falling dramatically, by 40 and 50 per cent respectively, since 2004.

Ironically, the parlous state of NHS dentistry seems to have been exacerbated by the very attempt to overhaul it – the 2006 dental contract. The new contract was intended to end the old "drill-and-fill" practice whereby dentists were paid for each treatment they carried out, so the more procedures they undertook the higher their earnings. The idea behind the new contract was to encourage dentists to spend more time on preventative work, teaching patients how to care for their own teeth, thereby reducing future treatment.

Dentists are now paid a fixed contract value for the amount of work they do each year. Work is measured in UDAs (units of dental activity). Dentists now essentially have "UDA targets" to meet each year. Under the new contract, their salaries have not been cut as they had been in the early Nineties, which led to an exodus to the private sector. Dentists are free to choose whether to provide NHS or private treatment, or a combination of the two. While many NHS dentists' basic pay is around £90,000 in large practices, but in areas where NHS practitioners are few and far between, they can make a lot more.

Around 400 practices earn up to £300,000 a year, shared among several dentists. Private dentists earn little more – one survey in 2005 by the Health and Social Care Information Centre estimated the gap at no more that £800 a year. Most claimed to have left the NHS due to the pressure of working harder for less money, with less time to spend on each patient.

Local Primary Care Trusts (PCTs) were given responsibility for providing dental care in their areas. It is they who employ dentists, and it means that managers can offer incentives to dentists to work in their area, and thus increase patient access, eradicating once and for all the problem of how to get on an NHS dentist's list.

But, despite these good intentions, the situation appears to have deteriorated further. According to figures from the NHS Information Centre, last year nearly 50 per cent of NHS dentists did not take on any new patients. In addition, 2,000 dentists have left the NHS since 2006. So what has gone so badly wrong?

The flaws are fundamental, says Liberal Democrat health spokesman Norman Lamb. "Many good dentists have become fed up with NHS bureaucracy, voted with their feet, and left the profession. So there is a danger that while not all the NHS dentists left are second rate by any means, we could end up with a two-tier profession."

Lamb believes that the financial disincentive to carry out complex work is so serious it threatens to "de-skill" the profession and that far from encouraging the public to look after their teeth, "there is no incentive for the dentist to do preventative work at all."

The public are not happy, says Dr Anthony Halperin of the Patient's Association."Simple procedures can end up costing the patient more than before, while there is no incentive for dentists to perform complex and time-consuming treatment. Most of all, the overwhelming public complaint is access."

The majority of dentists are unhappy, too. One complained: "If you take on a new patient who has not been to the dentist for a few years, they might need a lot of work, and you are effectively penalised for doing it. Under the new contract, whether a patient needs one filling or 10 fillings, the dentist gets paid the same."

Another said: 'Dentists are unwilling to take on new patients whose teeth are in a poor state. They know they will be paid the same as if they treated a patient who needs very little work. This is very sad for patients. It means that those who are most desperate for treatment are finding it most difficult to get a dentist."

Dr John Milne, chair of the British Dental Association, the professional association and trade union for dentists, adds that many complain that "the target-driven nature of the existing contract has made life difficult". If a PCT has set targets for the number of procedures it expects to be completed, many dentists are left with no time to teach their patients about hygiene.

So what is the answer? Professor Jimmy Steele, Head of the School of Dental Sciences at Newcastle University led the recent independent review of NHS dentistry, which has just published a set of recommendations aimed at redressing the problems of access and receiving appropriate treatment (for patients) and bureaucracy and pay (for dentists). It has been Prof Steele's unenviable task to pick apart the 2006 contract and put it back together, making it work at no extra cost to the taxpayer.

"The 2006 contract was intended to make fundamental changes in thinking. Dentistry had been pretty much unaltered since the birth of the NHS in 1948," he says. "The idea was that the PCT would be able to buy what they wanted on behalf of their patient, making better use of resources. Previously dentists had been able to move around to where they wanted there was no ability to fit services to local needs."

In effect, dentists could set up an NHS practice where they wanted to live, not necessarily where one was needed. "The idea of local commissioning is sensible," he adds. "Access problems should have been addressed in time."

The new contract also aimed to simplify payments. Previously, dentists billed the NHS centrally for any one of 400 different procedures. The more work they did, the more they got paid. "The new system, where contracts are paid on UDAs in three bands is probably too simple," says Prof Steele. "The payment bands are wide and differ depending on where the dentist is located, on their history, sometimes on their negotiating skills."

Dentists earn one UDA (worth between approximately £17 and £40) for a simple procedure such as a check-up, three UDAs (worth about £75 on average) for any number of fillings (in one appointment), or 12 UDAs (worth about £300) for crowns or dentures, in addition to any other treatment.

"The system is open to misuse," says Prof Steele. "It is possible to take one tooth out and make an impression for a denture and then charge 12 UDAs which is clearly not as complex or difficult as root canal work which pays only a quarter of the fee."

Incentives to take on new patients are not having the desired effect. Far from encouraging dentists to see more patients, it has become easier to make a living seeing existing patients more often. One of the biggest problems is taking time to put a mechanism in place for centrally collecting data, so it is difficult to know where and how the system isn't working.

So do we need to start again from scratch? Prof Steele thinks not: "When we carried out the review it became clear that access is improving, but there is a communication problem. The public didn't know how to find an NHS dentist. Meanwhile the PCT claimed that they were running plenty, and that all the public needed to do was ask. The public would then be saying, 'what's a PCT?' Better communication could sort that problem out easily."

Prof Steele is also recommending improvements in payment methods. "We need a blended contract, where a dentist is paid for every person on his list, and also for every treatment he carries out. We don't want people under-treated any more than over-treated. There also needs to be a reward for quality so we need to get data back into the system."

While Prof Steele approves of the scheme of local commissioning, Norman Lamb warns that PCT managers may not be ready. "We need to train them better, a lot of them are far too passive. You do get pockets of excellence but many don't have the skills they need."

Shake-ups, however worthy, cost money, and increased investment is unlikely. Dentistry is threatened by the spectre of financial cuts, as part of cuts in public services, regardless of who wins the next election.

So while the Patients Association has welcomed Prof Steele's review, Dr Halperin, a dental surgeon who does both NHS and private work in central London, says: "We are concerned that because of funding problems, once again there will be no real improvement in the dental contract and subsequently no improvement to the services for our patients."

The biggest challenge says Dr Milne, is to get all political parties to recognise the value of Prof Steele's report. "We need to embrace it; it is our best chance of providing a dental service of which we can all be proud."

Dr Milne is also optimistic: "The number of dentists in training is increasing, but we need to make the NHS an attractive place to work. And dentists who have left will only return if the NHS offers them the chance to treat their patients properly. Some might even be quite excited at the chance."


Australia: Penny-pinching government healthcare system refuses to save seriously ill young woman

Forcing her into expensive but successful private treatment. In their "kind" socialist hearts, they condemned her to death. Now they are in coverup mode and refusing to admit error -- even though she is living proof of their wrong call

THE Department of Human Services has been accused of abandoning a Victorian woman with a brain lesion who survived only because of life-saving surgery interstate. Victorian medicos ruled her condition was inoperable and the DHS has refused to pay $300,000 for the surgery in a private NSW hospital.

Alicia Withington was sent home to die, but the 30-year-old is living proof the Victorian system failed her.

In another twist, the state Opposition has accused the department of hiding documents relating to Health Minister Daniel Andrews' decision not to fund her operation. Details of the case come after a string of controversies involving the DHS, including:

REVELATIONS vulnerable women in state-monitored care homes were trading sex for cigarettes, or being raped.

CLAIMS the DHS was aware of violence in the home of a toddler six months before she died after an assault by her father.

SHOCK details of a man fathering four children with his daughter who he used as a sex slave for 30 years.

Mrs Withington said Victoria's top neurosurgeons refused to operate on her arteriovenous malformations (AVM) - a tangled mass of abnormal blood vessels 12.5cm long in the right side of her brain. "I had a ticking time bomb in my head about to explode and I was told it was too risky to operate," she said. "I feel I was sent home to die at the age of 27."

But Mrs Withington, now 30, who runs a cafe in Ocean Grove with husband Daniel, sought a second opinion. Sydney specialist Prof Michael Morgan agreed it was risky, but operated in March 2008. "No one should have ever said my AVM was inoperable, because here I am today walking, talking and very much alive," Mrs Withington said.

Mrs Withington and other family members have taken out second mortgages on their homes to pay the bill. "The Health Minister, Daniel Andrews, refused to pay it because he said I had gone through the private system in NSW," she said. "It's not like I went to another country." She says the Victorian Government should have funded the operation because it should have recognised it could be successful.

Opposition community services spokeswoman Mary Wooldridge has taken up Mrs Withington's cause, applying under Freedom of Information for documents held by Daniel Andrews and DHS. Officials told her there were no documents held by Mr Andrews' office on Mrs Withington, in correspondence seen by the Sunday Herald Sun. But in a letter obtained by the paper, Mr Andrews discusses with a Labor MP why the Government would not fund Mrs Withington's treatment. A tribunal has ordered the department to answer requests for information.

A spokesman for Mr Andrews said: "It would not be appropriate for the Government to selectively fund private treatments." He said the minister's letter discussing Mrs Withington's plight was not in Mr Andrews' office, but held by the DHS.


Canada's healthcare limitations good for brokers

Richard Baker is known as a critic of the Canadian health care system, but he's the first to acknowledge that it represents a real bargain for those with routine afflictions.

"In Canada, if your wife is pregnant, you have great prenatal care, great postnatal care, and the delivery is free. If you have the flu, your exam is free. If you break a leg, you can go to the emergency ward, and they'll set it immediately," Mr. Baker said. The trouble starts when patients need treatment that isn't so routine. That's where Mr. Baker comes in. A British Columbia medical broker, he takes patients who find themselves on long waiting lists for procedures such as MRIs and surgeries, and connects them with specialists who can handle their cases immediately. Most of the time, his clients wind up in the United States - and business is booming.

"That's what Americans need to know about the Canadian system," Mr. Baker said. "It's not that we have poor-quality health care - the quality is perfectly good. It's that we have poor access to health care."

Mr. Baker, founder of Timely Medical Alternatives, is among the featured speakers at a conference Monday in Vancouver, British Columbia, aimed at exposing weaknesses in the Canadian single-payer system. The event, billed as a one-day fact-finding trip, is sponsored by the Independence Institute, a Colorado-based free-market think tank that has opposed the Obama administration's push for a public option in U.S. health care. "The idea is to look at real human stories about how the public option treats people with serious medical conditions," said Independence Institute President Jon Caldara. "If we're moving toward the public option, we ought to know what it looks like."

Scheduled participants include Cheryl Baxter of Edmonton, Alberta, who wound up traveling to an Oklahoma City hospital for a hip replacement, and Christina Woodkey of Calgary, Alberta, who had her spinal surgery performed by a Montana doctor. Both paid for their procedures out of pocket, at costs of $30,000 and $50,000, rather than wait a year or longer to undergo the same surgeries free of charge in Canada.

In Canada, the public and private sectors have moved to address the long surgical waiting list. In July, Alberta Premier Ed Stelmach acknowledged the increase in wait times for hip and joint surgeries after deep cuts in the province's medical budget, saying the government would soon address the issue, according to CTV News.

Private health care clinics have begun cropping up despite a Canadian law that makes it a criminal offense for a private provider to charge patients for medically necessary procedures. Doctors avoid breaking the law by going through a third party, such as Mr. Baker's company, to collect their fees. "The other way they get around the law is they say, 'This patient has been on a waiting list for three years for hernia or bunion surgery, so it must not be medically necessary,' " Mr. Baker said. "On the other hand, if you have a life-threatening condition such as cancer, you can't be treated in these private centers." Such clinics are increasing in number but still account for less than 1 percent of all surgeries, he said.

Supporters of the Canadian health care system remind naysayers that the majority of Canadians receive prompt, high-quality care at virtually no cost. Their neighbors to the south may opt to avoid treatment if they don't have adequate insurance. Canadian Sen. Grant Mitchell, a Liberal Party member who represents Alberta, spoke in Washington earlier this month to remind U.S. lawmakers of the Canadian system's virtues. "The reality is that our health care system costs less and delivers more, and each and every Canadian has health care coverage, regardless of their wealth or status," Mr. Mitchell said in a statement. "Further, and importantly, it acts as a competitive advantage in international competition for international investment and markets."

For Mr. Caldara of the Independence Institute, the issue goes beyond policy. His 5-year-old son, Chance, has Down syndrome and has undergone eight operations, including open-heart surgery to repair a hole in his heart. Under a Canadian-style system, Mr. Caldara said, Chance likely would have wound up on a waiting list and could still be waiting for life-changing or even life-saving procedures. "This is not about some wonky public-policy issue; this is personal," he said. "This is about saving my son's life."


Congressional liberals seek health-care access for illegals

Fearful that they're losing ground on immigration and health care, a group of House Democrats is pushing back and arguing that any health care bill should extend to all legal immigrants and allow illegal immigrants some access. The Democrats, trying to stiffen their party's spines on the contentious issue, say it's unfair to bar illegal immigrants from paying their own way in a government-sponsored exchange. Legal immigrants, they say, regardless of how long they've been in the United States, should be able to get government-subsidized health care if they meet the other eligibility requirements.

"Legal permanent residents should be able to purchase their plans, and they should also be eligible for subsidies if they need it. Undocumented, if they can afford it, should be able to buy their own private plans. It keeps them out of the emergency room," said Rep. Michael M. Honda, California Democrat and chairman of the Congressional Asian Pacific American Caucus. Mr. Honda was joined by more than 20 of his colleagues in two letters laying out the demands.

Coverage for immigrants is one of the thorniest issues in the health care debate, and one many Democratic leaders would like to avoid. But immigrant rights groups and the Democrats who sent the letters say they have to take a stand now. President Obama has said he does not want health care proposals to cover illegal immigrants. The bill drawn up by Sen. Max Baucus, Montana Democrat and chairman of the Senate Finance Committee, excludes illegal immigrants from his proposed health care exchange.

Mr. Honda and his allies, though, say illegal immigrants should be allowed to pay for insurance if they can afford it, even if it comes through a government-established exchange. As a generally young, healthy part of the population, illegal immigrants could help reduce overall costs for those who buy into health exchange plans, the lawmakers said. The Democrats' letters, however, do not issue ultimatums or threaten to withhold support for the bills if their requests aren't met.

The National Council of La Raza launched its own "flood their voice mail" campaign last week to put pressure on Mr. Baucus to expand coverage in his proposal to include all legal immigrants and to drop verification language in the legislation that would prevent illegal immigrants from obtaining coverage.

Mr. Honda told The Washington Times that he's not pushing for illegal immigrants to gain access to taxpayer-subsidized benefits. "That's an argument that's been done already," he said.

Rep. Steve King, Iowa Republican, said proposals that include government coverage for illegal immigrants leave him incredulous. "If anybody can, with a straight face, advocate that we should provide health insurance for people who broke into our country, broke our law and for the most part are criminals, I don't know where they ever would draw the line," he said. Mr. King, who opposes Democrats' health care plans in general, said illegal immigrant access in legislation "would be a poison pill that would cause health care to go down" to defeat.

Twenty-nine Democrats signed on to the letter on legal immigrants, while 21 signed the letter on covering illegal immigrants. Although the leadership of the Congressional Black Caucus signed the legal-immigrant letter in their capacity as CBC officials, they signed the other letter as individual members of Congress.

Under the 1996 welfare law overhaul, Congress restricted most federal benefits to longtime holders of green cards - those who have been in the country at least five years. But Democrats chipped away at that rule when they reauthorized the State Children's Health Insurance Program earlier this year and allowed states to cover all immigrant children and pregnant women, regardless of how long they've been in the country.

In their letter, the Democrats said health care costs are much lower for legal immigrants than for native citizens. "Immigrants are part of our families, our communities, our economy, and contribute to the fabric of America," they wrote. "It is simply wrong that their taxes would pay for public health insurance programs to which they are not allowed access." [How many pay taxes? Very few]


Max's Mad Mandate

The Baucus health bill will break 50 state budgets via Medicaid

The more we inspect Max Baucus's health-care bill, the worse it looks. Today's howler: One reason it allegedly "pays for itself" over 10 years is because it would break all 50 state budgets by permanently expanding Medicaid, the joint state-federal program for the poor.

Democrats want to use Medicaid to cover everyone up to at least 133% of the federal poverty level, or about $30,000 for a family of four. Starting in 2014, Mr. Baucus plans to spend $287 billion through 2019—or about one-third of ObamaCare's total spending—to add some 11 million new people to the Medicaid rolls.

About 59 million people are on Medicaid today—which means that a decade from now about a quarter of the total population would be on a program originally sold as help for low-income women, children and the disabled. State budgets would explode—by $37 billion, according to the Congressional Budget Office—because they would no longer be allowed to set eligibility in line with their own decisions about taxes and spending. This is the mother—and father and crazy uncle—of unfunded mandates.

This burden would arrive on the heels of an unprecedented state fiscal crisis. As of this month, some 48 states had shortfalls in their 2010 budgets totaling $168 billion—or 24% of total state budgets. The left-wing Center for Budget and Policy Priorities expects total state deficits in 2011 to rise to $180 billion. And this is counting the $87 billion Medicaid bailout in this year's stimulus bill.

While falling revenues are in part to blame, Medicaid is a main culprit, even before caseloads began to surge as joblessness rose. The National Association of State Budget Officers notes that Medicaid spending is on average the second largest component in state budgets at 20.7%—exceeded only slightly by K-12 education (20.9%) and blowing out state universities (10.3%), transportation (8.1%) and prisons (3.4%).

In some states it is far higher—39% in Ohio, 27% in Massachusetts, 25% in Michigan, Rhode Island and Pennsylvania. Forcing states to spend more will crowd out other priorities or result in a wave of tax increases, or both, even as Congress also makes major tax hikes inevitable at the national level.

The National Governors Association is furious about Mr. Baucus's Medicaid expansion, and rightly so, given that governors and their legislatures will get stuck with the bill while losing the leeway to manage or reform their budget-busters. NGA President Jim Douglas of Vermont recently said at the National Press Club that the Baucus plan poses a "tremendous financial liability" and doesn't "respect that no one size fits all at the state level." He added: "Unlike the federal government, states can't print money."

Mr. Baucus hopes to use his printing press to bribe the governors, at least for a time. Currently, the federal government pays about 57 cents out of every dollar the states spend on Medicaid, though the "matching rate" ranges as high as 76% in some states. That would rise to 95%—but only for five years. After that, who knows? It all depends on which budget Congress ends up ruining. Either the states will be slammed, or Washington will extend these extra payments into perpetuity—despite the fact that CBO expects purely federal spending on Medicaid to consume 5% of GDP by 2035 under current law.

As for the poor uninsured, they'll be shunted off into what Democratic backbencher Ron Wyden calls a "caste system." While some people will be eligible for subsidized private health insurance, everyone in the lowest income bracket will be forced into Medicaid, the country's worst insurance program by a long shot. States try to control spending by restricting access to prescription drugs and specialists. About 40% of U.S. physicians won't accept Medicaid at all.

Why? One reason is that Medicaid's price controls are even tighter than Medicare's, which in turn are substantially below private payers. In 2009 or 2010, 29 states will have either reduced or frozen their reimbursement rates to providers. Democrats love Medicaid because is it much cheaper than subsidizing private insurance, but that is true only because of this antimarket brute force. Of course, such coercion will be extended to the rest of the health market under ObamaCare.

The states aren't entirely victims here. Both Republican and Democratic state houses regularly game the Medicaid funding formula —which itself is designed to reward higher spending— to steal more money from national taxpayers. Then when tax collections fall during downturns, budget gaskets blow all over the place. This dynamic helps explain the spectacular budget catastrophes in New York and California. We'd prefer a policy of block grants, which would extricate Washington from state accounting and encourage Governors to spend more responsibly.

That's not going to happen any time soon, but the least Mr. Baucus can do is not make things worse. Instead, his Medicaid expansion is a disaster on every level—like the rest of ObamaCare.


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