A Population Health Perspective on the Wisconsin Budget

By David A. Kindig, MD, PhD

Regular readers know that I often gravitate to political and fiscal issues of population health importance, such as my suggestion that Sam Brownback might be a population health governor or my commentary on the Arizona Medicaid rationing proposal. For several weeks now, several people have asked me to blog about what’s been happening here in Wisconsin. With the release of the proposed budget last week, it is time to share some initial reactions.

Governor Scott Walker has proposed eliminating most of Wisconsin’s $3.6 billion dollar structural deficit in two years. I’ve been a manager in both the public and private sector, and such situations require tough and imperfect decisions. In last fall’s Wisconsin campaign, I recall Walker’s Democratic opponent Tom Barrett saying he sometimes wasn’t sure why he wanted the job because he knew he would have to make hard and painful decisions.

A population health perspective would argue that cuts should be made in proportion to their impact on producing health, just as when there are new resources to invest. My current sense of Governor Walker’s proposed budget is that it’s hard to sort out which proposals are primarily ideologic and political and which are pragmatic “least bad” choices. There is even bipartisan agreement for some proposals, such as the need for public employees to contribute more to health and pension benefits. The rationale for the most controversial element (e.g., the proposal eliminating the right for public employees to organize and bargain) is not compelling and may not itself have a substantial health impact.

However, some proposed cuts have serious health implications for Wisconsin. We know that health care access is a critical determinant of health, but that social factors like jobs and education are probably even more important. Everyone should have access to basic preventive services and have catastrophic health insurance for hospital and other health care expenses which can bankrupt families. Reducing Medicaid eligibility is not a pro-population health policy, but if cuts are necessary, perhaps they should come from reducing less cost effective benefits…and not only for Medicaid recipients but for all covered employees (including politicians).

Jobs and income are critical determinants of health and I favor economic development investments -- but it is not clear to me that the tax cuts proposed for business will actually create jobs and increase income. The proposal to make substantial cuts to the Earned Income Tax Credit seems unfairly aimed at our state’s most vulnerable population groups. I think it’s also clear that cutting education and early childhood investments in the short run will reduce both health and economic productivity in the long run. A robust body of research links eliminating child poverty, lowering smoking rates, and increasing college graduation rates with improved population health.

But Medicaid, education, and social services are such large parts of state and local budgets that they can’t be off the table, as Medicare and Social Security can’t be for the nation. But that table should also be set with tax increases for those who can afford them, to protect programs which have put Wisconsin in the "pretty healthy" category and to keep disparities from further increasing. There is no free lunch, and we have to pay for the government we want.

I’m happy to have my state tax rate go up to help keep us from falling back. But I’d also like to see more discussion and transparency as these decisions are made. I’d like to see a state deficit calculator like the New York Times developed for the federal deficit (you-fix-the-deficit puzzle) which invited solutions from citizens to legislators to balance the nation’s budget through a combination of cost cutting and revenue generating options.

Perhaps we should recruit the Watson supercomputer to go beyond Jeopardy and be put to good use on these issues.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Comments

[Robert Stone Newsom, PhD]

As usual a very measured and reasonable response. It is not however clear that the budget represents the thinking of reasonable people. Therefore the question inevitably is what do we do when measured reasonableness fails?

[Pamela Russo]

You might be interested in the Health impact assessment of the NH state budget:
•The New Hampshire Center for Public Policy Studies, a nonpartisan, independent organization that pursues data-based research on public policy issues, will develop an HIA that will inform state lawmakers on the budget process beginning January 2011 and ending in June of the same year. The HIA will evaluate proposed state budget changes and show how funding changes in these areas might affect the health of residents. A synthesis of HIA findings and recommendations will be presented at a policy forum in mid-2011 and will be made available to legislators for their consideration during the budget process. The HIA will be guided by an interdisciplinary advisory group with participants from the legislature, state agencies and several advocacy groups to maximize the effect the information has on the budgeting process.

[Sarah Gollust]

Thanks for your thoughts, Dave! Was hoping you would discuss the WI budget issues through the lens of population health.

[Paul Creswell]

Great to get your perspective on this. I think you've hit most things right on. However, I would argue that taking away people's rights to collective bargaining has the potential to have a major impact on population health. The reasons are many, but the underlying mechanisms are likely similar. This law will likely hurt strong communities within the state. Unions are examples of organizations that work for collective good of their members and can increase people's sense of job security and enfranchisement. By increasing a sense of insecurity and disenfranchisement, this law may to lead increased stress and anxiety -- known predictors of ill health. After the passage of this bill, members of these groups may feel that their voice in the democratic process has been lost. I would anticipate higher levels of depression for these folks in the coming years and would not be surprised by other negative stress-related health outcomes. In fact, one could even invision for 'spill-over' effects in which all citizens in the state may feel more anxious and insecure because of the 'example' they see in the way the unions were treated. In sum, I think this move may actually be an important contributer to the health of Wisconsin in the coming years.