This is an archived article that was published on sltrib.com in 2015, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.
Now that the Utah Legislature has rightly rejected (again) a flawed proposal to expand Medicaid under Obamacare, the question is: What do we do now? Some diehard supporters of expansion will continue to brainstorm ways to conform to the misguided and harmful restrictions imposed by the Affordable Care Act for the sake of federal money. But due to those restrictions, these proposals will suffer from the same moral and policy flaws that undermined Healthy Utah and Utah Access Plus.
Because Medicaid expansion is only for the expansion population — mostly able-bodied adults — it excludes Utah's poorest children and the disabled Utahns who are already in the Medicaid program. As a basic financial reality, that program pays health care providers less than the commercial insurance favored by Utah's Medicaid expansion supporters. In a world where economic incentives matter, this means the able-bodied adults given financially superior health coverage by Medicaid expansion will be prioritized ahead of low-income children and the disabled, who will be forced to wait (and suffer) longer for doctors' appointments and needed surgeries.
The reality of these access problems is recognized both by national health care experts who support Medicaid expansion, such as the RAND Corporation, as well as local opponents of Medicaid expansion, like Sutherland Institute. And it is already playing out in Oregon — where expansion is "locking out" some Medicaid patients from the health care system, according to news reports — as well as Arkansas, where a commercial insurance model of Medicaid expansion has reportedly led to expansion enrollees "moving to the front of the line and gaining access to medical care traditional Medicaid enrollees have been denied."
But if Medicaid expansion under Obamacare is the wrong way to address the uninsured problem, then what is a better alternative? The answer is to address the moral issue behind the uninsured problem: poverty.
The reason Utahns in the coverage gap do not have health coverage is that they cannot afford it — they are in poverty. Instead of addressing this moral issue, Medicaid expansion largely ignores it and simply tries to relieve one of poverty's symptoms. But as common sense and life experience should tell us, treating symptoms of a problem while ignoring the root of it just causes the problem to get worse.
What should this anti-poverty alternative to Medicaid expansion look like? First, it should offer these Utahns the dignity of helping lift themselves out of poverty and the life satisfaction that comes from being responsible and accountable for one's own success. Second, it should address the fundamental reasons Utahns are in serious poverty.
For a portion of the Medicaid expansion population — commonly referred to as the "medically frail" — this reason is their health status. Giving this targeted group access to Medicaid makes sense, whether that be the current Medicaid program or a targeted, Healthy Utah-style pilot program.
For most in serious poverty, however, state poverty data suggest that the reasons behind poverty are insufficient employment; a lack of formal education; or family structure problems, such as divorce or having children before marriage. The anti-poverty alternative to Medicaid expansion, then, should offer Utahns in serious poverty the temporary benefits they need to get the job training or education that will lead them to better employment. In many cases, this improved employment will solve the lack of insurance.
These benefits should be time-limited and include progress benchmarks, while offering second chances to those who fail to make adequate progress once they have prepared themselves to try again. Those who succeed in achieving better employment should be encouraged to pay back a portion of the cost of their benefit over time, giving them the satisfaction of being responsible for their own success and perpetually defraying the cost of benefits to future enrollees. A portion of the payback could also be forgiven if an individual marries and stays married long enough that research suggests divorce is unlikely. This would help ensure that a temporary rise out of poverty becomes permanent by encouraging the family structure that is the best anti-poverty program available.
Are these ideas the comprehensive, "silver bullet" alternative to the Medicaid expansion? Of course not. But is the anti-poverty approach better policy than expanding Medicaid at the expense of Utah's poorest children and the disabled community? If solving problems rather than treating symptoms is the goal, then the answer is yes.
Derek Monson is policy director at Sutherland Institute, a conservative think tank based in Salt Lake City.