Louisiana has some serious health care challenges, with the fourth highest uninsurance rate in the country, among the highest cost and lowest quality outcomes for patients with Medicare, and among the highest rates of tobacco use, obesity, poverty, and infant mortality, to name a few. For health status and outcomes, Louisiana is among the worst in the country.

Like in other states, the health care system in Louisiana is an amalgam of private and public providers and programs loosely woven with some attempt to care for the entire population. The solutions are not simple, but in Louisiana we have perhaps the most qualified governor to address them: McKinsey consultant, Secretary of Health for Louisiana, executive director of the Bipartisan Commission on the Future of Medicare, and assistant secretary of the U.S. Department of Health and Human Services. However, instead of providing desperately needed leadership and clarity for his constituents, Bobby Jindal continues to confuse us.

Two recent reports in the New England Journal of Medicine indicate that Medicaid coverage results in better preventive care and is associated with lower mortality. Implementation of the Affordable Care Act's Medicaid expansion would provide Medicaid insurance to 456,000 Louisianans and reduce the uninsured in the state by 60 percent. Gaps in Medicaid coverage and care for the uninsured (350,000 of whom would remain after the expansion) are addressed by safety net systems which, according to the journal Health Affairs, can provide care at half the cost of providing insurance, an assessment consistent with an Urban Institute study done in Louisiana in 2007. The Louisiana State University Health Sciences Centers operate the statewide safety net system, serving over half a million people annually through which the uninsured and underinsured receive care from immunizations to neurosurgery, with outcomes on par with national norms for people with insurance.

The amount of state dollars spent on Medicaid in Louisiana is less than 9 percent of total state funds compared to the national average of over 15 percent. The average state spends twice as much on Medicaid as it does on prisons; Louisiana spends roughly the same amount. Since Jindal took office, Medicaid and Disproportionate Share Hospital spending (funding for uninsured care) in the public safety net system has decreased by nearly $200 million on an annual basis. In September he cut funding for the safety net by another $329 million, over half of the total funding for uninsured care.

Escalating health care spending in Louisiana and the U.S. is driven by the insured, not the uninsured. Jindal's spokespersons, however, have characterized care for the uninsured in the safety net system -- which has had flat spending in the last 10 years -- as "unsustainable" while proposing an ambiguous plan to shift that care to a private sector that has demonstrated cost increases that actually are unsustainable.