Utah Medicaid approach gets mixed reviews

Anyone looking for clues as to how the Bush administration might overhaul the nation's Medicaid system should come to Utah and read the fine print of Tony Martinez's health insurance plan.

Martinez, 56, was homeless and without any health coverage a year ago. Now, under an experimental plan of partial insurance that was devised under Mike Leavitt when he was governor of Utah, Martinez can see a doctor or go to the emergency room for only a small fee.

But he and his wife, Lisa, are not covered at all for the potentially catastrophic costs of extended hospitalization or specialty medical treatment, from dermatology to oncology. For those services, they must rely, as they did when they were homeless, on charity.

And that brings the story back to Leavitt, who as Bush's new secretary of health and human services is now leading a drive to change how Medicaid works and often points to Utah as an illuminating example that other states might consider — although it is an innovation that policy experts, doctors and advocates for the poor are deeply ambivalent about.

In Utah, Leavitt's plan departed from the traditional Medicaid program on two main fronts. First, it spreads out a lower, more basic level of care to more people and reduces coverage for some traditional beneficiaries by imposing co-payments for services. And second, it relies on the generosity of doctors and hospitals to provide specialty services free of charge.

In doing so, the state has in many ways reframed and reshaped the national debate over Medicaid and health care for the indigent, experts say, broadening the focus from the question of who does and does not have health insurance, to what constitutes basic health coverage.

Many academics and health-care analysts say they also worry that substantial state-by-state Medicaid experiments could fracture and fragment a system that, while never without its critics, has evolved into an anchor of health coverage for the poor since its introduction in the 1960s. Medicaid could create a landscape of winners and losers determined largely by whether they are lucky enough not to get seriously ill.

Martinez, for one, considers himself a winner. From no insurance, he now has some, and he considers that a victory.

"We can go to sleep at night and not worry," Martinez said. "For me it's been great because I'm healthy and not on a lot of meds."