Remarks as prepared by Derek Monson, vice president of policy at Sutherland Institute, for a panel on “Charting the Future of Utah Medicaid” at the 2019 Utah State of Reform Health Policy Conference in Salt Lake City on April 24.

What is the future of Utah’s Medicaid program? That’s the question we are here to discuss today. The more I’ve thought about this question, the more intriguing it is, because you can go any number of directions with it. But the more I thought about it, the more difficult it has been to answer, because it is an exercise in predicting the future – which means it is more likely to produce wrong answers than right ones. 

But perhaps, by summing together the collective wrongs of this panel today, we can offer you a few useful and correct insights, which is what I will endeavor to do.

For my part, I see the future of Utah’s Medicaid program playing out within a broader context of a debate about the future of our health care system generally. And that debate seems to be focusing on one question: Do we want a health care system that functions more like the customer-centric, market-oriented systems which provide most of our food, our jobs, our entertainment and other things in life – or do we want a health care system that functions more like a government-centric, central-authority oriented model, in the mold of most government programs?

The customer or patient-centric approach would mean innovations and reforms designed to empower patients. One thing this might mean is giving patients price information for health care before they get it, so they can be empowered to shop around and decide where they get the best blend of quality and cost. For basic health care, that might mean a menu of prices for doctor visits and common tests, based on the patient’s health insurer and coverage plan. For more specialized, non-emergency surgical care or long-term treatments, that might mean something more akin to a price-quote system, again based on insurer and the type coverage, that would be reasonably binding to the hospital or clinic, with exceptions for significant complications that dramatically increase costs.

For Medicaid, the patient-centric approach would mean things like putting non-disabled Medicaid enrollees at all income levels into the kind of commercial health coverage that we all want for ourselves. They would then be free to use the prices they can see to find the best care they can for them and their families, based on cost and quality. The state would likely have greater latitude to manage and change its Medicaid program without asking permission from Washington, D.C.

 An alternative future could be the government-centric approach, which is represented by the various flavors of the Medicare-for-All concept. In this future, the government would decide – either by law or by regulatory action of a federal agency – most or all payment levels for care, and patients would get care largely without concern for its cost. States would have little flexibility to innovate or make state-specific changes to health care policy.

For Medicaid, this might mean it is simply replaced by Medicare. Or, if Medicaid continued, it would look and feel more like a version of Medicare.

A third alternative is continuing in a blended patient-centric, government-centric system similar to what we have today. This could be possible simply because political gridlock and partisan division prevents any significant change in direction from happening, and so we end up with the status quo. With a few exceptions of reform at the margins, the future of Medicaid in Utah in this scenario means something akin to what we have today. Today’s problems would continue, and we may be able to solve symptoms of problems, but not likely the problems themselves.

Different versions of these three alternative futures that I have sketched out are possible, of course. But based on the policy proposals on offer today from the two political parties at both the state and national level, this is what to me seems the most likely set of future possibilities for Medicaid in Utah. I look forward to engaging with you in the Q&A session later. 

Thank you.