Commissioner of the Minnesota Department of Human Services, describes
the challenges facing the agency due to potential budget cuts. Health
care comprises the majority of DHS spending, and half of that spending
is funded by federal sources. The state needs to rework its payment
schemes so that people may assume more self-direction of their care
without the state foregoing its responsibility to protect and provide
services to those who need them. Commissioner Jesson calls for more
effort at prevention in controlling health care costs. She believes
paying providers based on outcomes should be considered and contends
that families should assume some of the risks of care for vulnerable
individuals. She suggests that the state should explore whether
counties should be given more flexibility--while being held
accountable for results--in the delivery of human services.
For the complete
interview summary see:
Readers have been asked to rate, on a scale of (0) most disagreement,
to (5) neutral, to (10) most agreement, the following points discussed
by Commissioner Jesson.
ratings shown below are simply the mean of all readersí zero-to-ten
responses to the ideas proposed and should not be considered an
accurate reflection of a scientifically structured poll.
(8.9 average response) It is
essential in controlling health care costs that major efforts be
directed at prevention, particularly in the high cost areas of heart
disease and diabetes.
(6.9 average response) Payment to
health care providers should relate to whether or not treatment is
successful (outputs) and not relate only to the amount of service
(7.3 average response) Instead of
assuming exclusive responsibility for protection of some vulnerable
populations, the state should allow some risk-sharing with individuals
(6.9 average response) Instead of the
state making all decisions, county governments should be given more
flexibility to decide how human services are delivered, while being
held accountable for results.
Ayotte (10) (10) (10) (10)
Hennessey (2.5) (0) (7.5) (7.5)
This is an example of "sounds good in theory." But how do you propose
to implement it? I can just see the food police and the exercise
police knocking on your door every day (heck, three times a day). A
doctor can only tell you how to change your habits, and give you
medicines to treat your symptoms and consequences of your conditions.
He can't make you change. And we all die of something in the end. What
do you propose to do about the ravages of old age, such as immune
deficiency, heart and kidney failure? Parts simply wear out.
2. Outputs. I
wonder what the reaction would be if the same idea were applied to
government. We've had a "war on poverty" since LBJ in 1965, a "war of
organized crime" since the 1950's, a "war on drugs" since the 1980's,
a "war on terror" since 2001 -- have any of them been won yet? What if
we paid government for successful outcomes? Seriously, how do you
propose to pay doctors and hospitals for the care of patients who are
not going to get well, no matter what? Will government pay their
office staff, malpractice insurance, tuition loans, leases and
mortgages, etc.? Of course not. Doctors are among the filthy rich who
have to be taxed higher and pressed harder in the name of social
Case history. When my mother reached retirement age, and was separated
from my father, she was pressed by a social worker to apply for SSI. I
went with her to apply. The clerk at that time demanded to know about
my finances, insisting that it is first and foremost my responsibility
as her son to help her. This was in 1974. Just seven years later
another social worker was absolutely furious with her for her refusal
to apply for the whole package of SSI, food stamps, MediCAL, etc. By
that time she was back with my father and did not need the extra
assistance. I don't know why we changed the old-fashioned rules about
family having the responsibility to help.
4. Counties. I am
all for pushing all decision-making as far down to the local level as
possible; but again, there is that phrase, "accountable for results."
What does that mean? Success in getting people back on their own feet?
Getting rid of federal mandates? Weaning our local governments off the
federal funds for all these programs? Or convincing the old and the
sick that it is their responsibility to die before they run up their
bills too high? Let's get serious. Social programs are expensive
and a bottomless pit. The more we try to help, the more we feed only
the neediness, not the self reliance, in the people we try to help. We
only foster dependency and gamesmanship, not decency. Politicians
respond to reforms by demagoguing them to death. It is only the
politicians who don't understand that no matter what you call it,
local taxes or federal taxes, it is the same people whose pockets are
being picked. Most people don't even understand "family values"
anymore, or only see then as intrusion on their "privacy" or as
"cramping their style." Everything we tried so far has only made the
problem worse, and in fact destroyed entire classes and generations of
people. Just look at how statistics have exploded since the 1960's in
the categories of promiscuity, divorce, illegitimate birth, addiction,
single parenthood and other social ills, even as, or more correctly,
because of all the money and programs we've thrown up against them.
Only a return to the understanding and appreciation of traditional
values will lead us out of the mess we are in now. But government is
exclusively about the use of power. So the only way government can use
its power to help -- that is, reduce the cost of social programs - is
by revising its rules for providing assistance, by means testing it
against the applicant's extended family. However, this only raises the
level of intrusion into everybody's lives to draconian levels. The
other extreme is no government assistance at all; let every family
fend for itself. I don't know where the reasonable middle ground is,
except official and cultural insistence on self-reliance and
A. Lundeen (7.5) (5) (2.5) (2.5)
4. Counties. I am
skeptical local governments can be fair without oversight.
(Bill) Hamm (7.5) (5) (7.5) (7.5)
This is a thinly veiled statement in support of Governmental attacks
on smokers and the obese and will do little to go after the industries
pushing this garbage at us. Instead this effort is about legislatively
attacking these individuals, which is much easier. This is the
clearest reason why we need to get government out of the healthcare
2. Outputs. By
whose determinations? Instead of promoting a patient based healthcare
system this proposal will bring about the same kind of institutional
failure as "Outcome Based education" which moved us from child
centered education to state mandated top down education. Same
mechanism of control with no guaranteed outcomes for the patient, only
outcomes for the system.
Helping organizations like LSS is much more cost effective than any
state run program.
4. Counties. While
I tentatively support this direction, the proof along with my support
is in the final details.
Dennis L. Johnson (10) (7.5) (10) (10)
4. Counties. The
general approach outlined by the speaker is commendable; the question
is how it is to be accomplished. The record in prevention is not
strong when administered through the state, or even through public
education programs. Much of the need for health care is brought about
through poor life-style choices, with a smaller percentage through
inherited genes and just plain luck. My guess is about 75% the former
and 25% the latter. Alcoholism, smoking, lack of moderate exercise,
high stress occupations, overweight and related factors (are) the most
obvious life-style factors. Regrettably, persuasion rarely leads to
improved life-styles; another method must be found. One likely
approach would be through rating health insurance costs according to
lifestyles, just as auto insurance now is. Safe drivers with no
violations get the best rates; others pay more. Health insurance
could be rated the same way, at least in the private market. The state
or federal government could never do this, politically. The hard part
is how to get health care to the indigent or those who refuse to
purchase health insurance. If the state picks up their costs, the
numbers will increase greatly as people learn "why pay when you can
get it free". Some formula of limited or only partial payment must be
devised to create the incentive for all to purchase some form of
insurance, regardless. States and Counties must be free to experiment
with their use of funds to create a formula that works effectively and
reasonably fairly for all.
Barnum (2.5) (0) (7.5) (7.5)
1. Prevention. You
can't legislate behavior to protect oneself, no matter how hard you
try. Not to mention that it is not the role of government to try.
Doctors and patients are the only ones that are in a position to judge
the proper treatment and successful results. I simply cannot imagine
having a government bureaucrat deciding what outputs are successful -
we already have enough interference with insurance companies trying to
make health care decisions.
There really is not enough information in the recap about what "some"
we are talking about, both in populations and risk, to adequately
answer this question. In general individuals should be responsible for
their own decisions and expenses. Government should provide for a
safety net for those truly incapable of providing for themselves. But
more often than not, it works against the disabled by requiring
totally dependency on the government when perhaps only partial
assistance is needed (i.e., take a look at the rules regarding Social
Anderson (10) (5) (7.5) (2.5)
Prevention also touches on the topic of fat and fast foods. How can we
work with the food industry when their profits depend on fat and fast
Sometimes the treatment isn't successful, not because of the health
care providerís treatment, but because of the patientís own condition.
Persons, a lot of times, become patients because of their own
4. Counties. Are
we a State or a collection of Counties with their own ideas?
Schmitz (10) (7.5) (5) (2.5)
Curse the devil, etc. How does the system really work on prevention?
Most of what I have seen involves a discussion and filling out a form,
but there are not services of follow up
If the individual/family is capable of doing this why is the person
listed as vulnerable.
4. Counties. This
assumes the will and ability of 87 counties to do so. My experience
suggests that this is not true. Why not centralize or regionalize the
Broden (10) (10) (10) (10)
1. Prevention. The
key is to get people to take ownership of their own health issues
particularly related to these two problems. In the case of heart and
diabetes much of the problem is cultural and the related life style
and diet. So just dwelling on health is not the answer that makes this
issue as tough as it is (but the)need to make a life style change is
some meaningful way without changing the culture impact.
2. Outputs. We
must move to outcome-based measurements but without the complex system
that may be needed to implement. This will drive both better health
and better health care delivery.
3. Risk-sharing. A
risk sharing approach must be core to the solution. Challenges are how
should risk be defined, who is not part of the risk pool (i.e.,
chronic diseases, mental health, disabled?) and who defines? Most
medical organizations agree that far too many people believe that the
state will care for all, for all causes, and personal responsibility
is not a factor--this is a cultural change without establishing a
Moving from state to county or even city level should provide both
flexibility and better direct attention to the specific need. The one
concern that needs to be addressed is that all areas of the state or
cities do not have the same services and some links and sharing must
be established to ensure uniformity.
Triplett (10) (7.5) (7.5) (2.5)
Anonymous (10) (7.5) (7.5) (7.5)
Patients, however, do not always follow their doctor's advice. How
would the state put responsibility on patients who don't pay for their
own care to follow through on treatment...by denying future care? If
so, how would that be done? I envision a bunch of appeals if care is
Good idea, but how to actually implement...Choice is great, but
hindsight is better than foresight when it comes to things like elder
Shapira (10) (0) (0) (0)
2. Outputs. I urge
you to give serious consideration to a single payer system, similar to
what is being proposed in Vermont. I want insurance companies out of
the equation. Government can and should be responsible for wise
spending of out health care dollars.
3. Risk-sharing. I
am a socialist who favors good, big government. People cannot afford
this wrongheaded idea.
4. Counties. Why
should county governments be involved? One layer of government
properly managed should be enough.
F. Durenberger (10) (10) (10) (10)
This is my 40th
year on this subject, and suggestions for policy change remain the
same. Execution requires a kind of leadership that apparently doesn't
exist in our community. Unfortunately. I wish her and Mark well.
Richard McGuire (10) (10) (8) (8)
debate, program restructuring that deals with medical care that fails
to deal with the underlying costs of medical care [not merely how it
gets paid for, i.e., insurance vouchers v. Medicare] is doomed to
failure because it does not address the real issue.
Milton (10) (10) (0) (5)
Miller (9) (5) (8) (3)
Until we finally
adopt some form of single payer, we will continue to remain as a third
world provider when it comes to health care. While corporations and
their executives reap in the profits, 47 million Americans go without
health care. Absurd.
Fraser (9) (9) (6) (8)
Quie (10) (0) (10) (5)
Assuming there are
inputs, activities, outputs and outcomes. Outcomes ought to be the
determinant. Second, third party payers will always be a fiscal
problem. If there were none, the decisions would be solely between the
physicians and the patients. Any way that the patient has more
responsibility and the physician has less worries about lawsuits, the
less costly healthcare will be.
Harrigan (10) (10) (9) (8)
Robert J. Brown (10) (10) (10) (10)
Lutz (10) (9) (8) (9)
and Ruth Hauge (9) (8) (8) (8)
Adams (10) (8) (8) (10)
Press (10) (0) (0) (0)
Shirley Heaton (10) (10) (10) (10)
Christine Brazelton (10) (7) (7) (8)
2. We must make
sure that we don't punish providers that care for people with chronic,
3. To the degree
that those families are able to take responsibility. Many families
are not physically, mentally or emotionally able to care for
vulnerable members of the family.
Jennings (10) (8) (8) (9)
comes up again as it should. I would like to see more active projects
and less talk. The compliance orientation of the state agencies,
important as that is, puts a real dampener on innovation. Plus
creating and implementing new designs has to be done on the fly, like
changing tires while the car is moving. Nonetheless, it must be done
and encouraged by state agencies.
and Nancy Halstead (10) (10) (5) (5)
How do you get
individuals that have very little income and assets to be more
responsible for their health and reducing the cost of health care? We
have sin taxes, but we don't connect the income brought by the sin tax
in with the services provided.
Arvonne Fraser (10) (8) (7) (5)
prevention and, frankly, overuse of health care facilities; too much
spent on last six months of peoples' lives (and I'm an old woman!).
More use of health care directives--maybe even sanctions against
health care workers who disobey them. More and better public
education about hospice services. Doctors can't fix everything;
shouldn't have that mentality and neither should the public. And more
use of technology in health care so that tests aren't duplicated and
health care costs cut with efficiency in record keeping and billing.
Cut administration and give teachers the same status as doctors. They
are equally important.
Detert (4) (4) (10) (8)
Prevention is a
good idea but it will be decades before it results in cost reduction
and we need cost reduction now. A big improvement would be to make
people much more accountable for their own health as question three
starts to suggest. Most of what passes as health care reform now is
way to late or the potential benefits are too far in the future to be
of any practical good. Health care reform as we are doing now is what
we do to keep busy while we wait for the health care system to go
bankrupt and take the rest of the economy with it.
Schwarzkopf (8) (6) (8) (8)
Clarence Shallbetter (4) (8) (8) (7)
Bright Dornblaser (10) (10) (8) (8)
Stone (8) (6) (8) (8)
Carolyn Ring (10) (4) (8) (8)
2. Outputs. Who
is going to make the decisions as to what the outputs should be?
Spitznagle (9) (9) (9) (9)
Leanne Kunze (8) (10) (5) (7)
Swain (10) (10) (7) (8)