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Medicaid: A disconnect between debate and reality

By   /   February 5, 2015  /   No Comments

Image from the homepage of the healthcare.gov website

By Derek Monson | Watchdog Opinion

I want to discuss a topic of significant political news reporting this week: how should Utah deal with Medicaid expansion, as allowed and encouraged by Obamacare.

The proposals for expanding Utah’s Medicaid program being considered by the Utah Legislature are varied, including a plan for full Medicaid expansion using the traditional Medicaid program; Governor Herbert’s alternative plan for full Medicaid expansion under Obamacare using private health insurance; and the Health Reform Task Force recommendation to avoid Obamacare altogether and opt for a targeted expansion to the “medically frail.”

The defining feature of the debate can be summed up in one word: “complexity.” Health care generally is an extremely complex policy issue – whether morally, fiscally, economically or politically. Add to that the fact that we’re talking about health care for low-income Utahns, and the fact that the debate stems from an unpopular law named after a liberal sitting president, and the complexity and difficulty increases exponentially.

It should come as no surprise then that finding the right way forward has been hard to come by. Simply put, there is no easy answer to the question of Medicaid expansion. For our part at Sutherland, we think the federal involvement and restrictions on Medicaid policy make this herculean task nearly impossible, because the feds shoot down the ideas that hold the most potential to generate support.


But an even bigger problem with Medicaid policy and debate is the misguided focus on all sides about what Medicaid is and should be. First and foremost, Medicaid is and should be a response to poverty in society – an anti-poverty program, not a health care program. Another way of putting it is that we created Medicaid in the first place because poverty made health care unaffordable for some, not as a response to issues of public health.

But Medicaid policy and debate ignores this fundamental issue. Instead of trying to address the poverty of the poor, the debate focuses on improving health care for the poor. As a result, Medicaid policy obsessively focuses on the symptoms of the problem, such as access to doctors, payment rates for providers and costs to taxpayers, rather than on the problem itself, which is that poverty makes needed health care inaccessible and unaffordable for low-income Utahns. This disconnect between political debate and human reality drives much of the complexity of Medicaid policy debates, as liberals intuitively understand and focus on the symptoms of poverty and conservatives intuitively understand and focus on the problems created by programs like Medicaid.

A big part of the solution is to recognize and accept that Medicaid should be an anti-poverty program, not a health care program. The latter approach means that Medicaid will be a failure as policy if all it does is provide health care coverage to low-income Utahns, while doing little or nothing to help them get out of poverty. What’s more important, this new approach is likely to be better for society and the common good on all levels.


It is better morally because Medicaid will actually improve the lives of poor Utahns, by helping them get the education, life skills and networks they need to rise out of poverty, rather than naively assuming we’ve solved their problems by cutting a check for their medical bills. It is better fiscally because it provides a financial commitment from taxpayers that lasts only until an individual or family rises out of poverty, rather than an unending entitlement that adds to federal deficits and eats up ever-larger portions of state budgets. It is better economically because it means helping low-income Utahns become more prosperous and economically productive, while limiting the economic resources required to get and keep them in that position. And it is better politically because both liberals and conservatives are voicing understanding of the need to address poverty.

So what does this approach mean for dealing with Medicaid expansion today? It means Utah should focus on a minimal expansion of the current flawed approach to Medicaid, such as the targeted proposal for the medically frail, and then get back to the drawing board to reform Medicaid into a program that uses health care to combat poverty. Only then will we get a Medicaid program that is actually solving real problems, rather than just chasing after the next symptom.

This piece was first published by the Sutherland Institute.