By Dr. John Livingston | Medical Policy Advisor

Over the 41 years of my medical career, my first patient is still one of the most memorable. I saw him my first night of surgery duty at St. Al’s in 1988, a 65-year-old man who had been diagnosed with Down syndrome at birth. He came to the emergency room with his mother and father, both almost 90-years old and his legal guardians. In talking to the family, I found that all had lived their entire lives in Emmett, Idaho. As their son could not take care of himself, he required the full-time attention of the couple—for his entire lifetime.

But the parents were not alone in their endeavor. I observed that my patient was attended to by many friends and neighbors in the Emmett community, including members of the family’s church, the women’s club, and many other organizations that banded together to help the family. For example, on Tuesdays and Thursdays, ladies would come to the home for four to six hours at a time, so that the patient’s mother could get out of the house, shop, run errands, and enjoy some alone time. These sweet saints attended to the family’s needs for more than 65 years.

This case stuck with me. Several years ago I worked with discharge planners at the hospital to estimate the cost to society had that patient been institutionalized as a child. The answer? More than $1.5 million.

Similarly, last year, my wife’s mother passed away. She lost her husband 13 years ago, and within a year she suffered a stroke herself. My mother-in-law was unable to walk and had severe left-sided hemiplegia, but thanks to the dedicated kindness and support of her neighbors, friends, and family in Blackfoot, she was able to live in her own home until her death.

These are the kinds of situations a recent Wall Street Journal article addresses. “The U.S. is running out of health caregivers,” the article’s author reveals. The article notes, soon there will be more than 55 million people in need of in-home health care. Because of changing demographics, there will be a 13 percent increase in available caregivers—family and friends—but a more than 185 percent increase in the number of patients who require home health services.

This number seems shocking, until you consider the health services Americans already provide. The Wall Street Journal article also pointed out that there are 35 million people, mostly friends and family members, who provide in-home health services to 55 million patients (mostly family members) for free. Such is truly charitable care, unfunded by private or public sector dollars. The price tag for this care: more than $500 billion a year. And this sum doesn't factor in lost opportunities for the caregivers, who could otherwise have been working more hours or holding a second job. The $500 billion is almost equal to annual state and federal government Medicaid spending.

Last week, I met with several prominent business leaders and politicians, and we discussed the issues that surround Medicaid expansion. A refrain I heard more than once, "As a society, we have an obligation to take care of those in need.” I couldn't agree more, except for the fact that I believe we as individuals—and not society—can, and already do, carry that obligation. We are indeed called upon to be “our brother's keeper,” but nowhere in the New Testament can I find that it is the province of government to be the conduit for charity.

I find quite the opposite: Jesus says to render unto Caesar that which is Caesar's and unto God that which is God’s. Charity is between the giver, the receiver, and God. My Catholic Catechism describes a charitable act as a covenant between the giver and the receiver, to which God is a party—"what you do unto the least of my brethren you do unto me.” Charity is personal.

Thus, I have two main concerns with expanding Medicaid. My first and biggest concern: Medicaid expansion will allow many people to believe that when government steps in, they are discharged of their personal obligation to take care of their own family, friends, and neighbors.

Let's remember a few things about private charity. It is never coerced, and therefore the outcome of a gift has more relevance to the giver and to the receiver than a forced tax that is collected and distributed without accountability. And, let’s look at how Americans already give hundreds of billions of dollars worth of care to their friends and relatives, without compensation and without force. These are meaningful and charitable relationships that once shifted to the public dole will lose both a sense of personal connection and responsibility, and cost taxpayers and families millions.

My second concern is, because of changing demographics—smaller, more mobile families, and the loss of community that results from a reliance on government programs—the final cost for government medical care will make it impossible to support the other services that are truly the province of government.

Consider this. The interest payment on the federal debt is between six and eight percent. Medicaid spending runs about 13 percent of the combined federal and state budgets, which is a sum very close to the $500 billion in uncompensated home care given today. What will happen when growing debt-interest payments draw money away from the Medicaid budget? Without active charitable systems in place, the Medicaid system will implode. First and foremost, such a breakdown would hurt those in the system for whom Medicaid was first designed: women, children, and adults with disabilities.

Let's strengthen Medicaid by first taking care of those for whom the program was designed: people with chronic diseases who, through no fault of their own, cannot afford to take care of themselves. Putting money into the pockets of large insurance and provider monopolies which already receive millions of dollars of subsidies, and make billions of dollars of profit, does absolutely nothing to aid those on the margins.

As medical markets evolve, demographics change, and governments at all levels assume the costs that traditionally have been the responsibility of friends, family, and communities, we as individuals will no longer be responsible for ourselves. This not only results in dangerously increased costs and lower quality care, it endangers the charitable spirit by which Americans already care for their friends and families.

Medicaid expansion is simply not the Idaho way.