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If Medicaid isn’t providing good coverage to those in need, why would we think expanding it would make things any better?

Mary Mayhew wants Utahns to hear the other side of the Medicaid expansion debate.

Chances are you’ve heard one side — the one about how expanding Medicaid in Utah would extend health coverage to people who fall in the unfortunate category of being not quite poor enough, not married, not pregnant or not old enough to qualify. Obamacare allowed states to expand coverage to people earning up to 138 percent of the poverty level, with the federal government paying most of the cost (phasing down to 90 percent by 2020).

If expansion efforts have a face, it would be that of a mythical young male recently released from prison, who needs medication to keep mental health problems under control but who can’t get it because he doesn’t qualify for Medicaid.

If you haven’t heard this, you probably will soon. A petition is circulating in an attempt to get Medicaid expansion on ballots this November. A recent poll commissioned by Utahpolicy.com found about 60 percent of Utahns in favor of it.

Mayhew counters these arguments with a simple reminder. “It’s a government program.”

And that, she said, means it is inefficient and the incentives are all mixed up.

“There’s nothing forcing them to keep pace with efficient and effective delivery. They’re not looking at best practices,” she said of Medicaid in general. “No one’s evaluating whether or not primary care physicians supporting Medicaid patients with diabetes are adhering to the best practice to support good, chronic disease management, to keep them out of the emergency room, to keep them out of readmissions or preventable admissions to the hospital.

“It’s government, and that’s the bottom line. It is still government. It needs to be kept limited and focused on that truly most vulnerable population, that limited safety net.”

In other words, she said, if Medicaid isn’t providing good coverage to those in need, why would we think expanding it would make things any better?

Mayhew is the former commissioner of the Maine Department of Health and Human Services. Today, in addition to being a Republican candidate for governor in Maine, she is traveling the nation as a senior fellow with the Opportunity Solutions Project, a group that focuses on what she calls “state-level best practices in welfare reform.”

She spoke to the Utah Legislature’s Social Service Appropriations Subcommittee on Tuesday, warning them that, among other things, expanding Medicaid would cost more and include more people than any current estimates.

She cited statistics from several states to prove her point, including Ohio, where the Legislature last year voted to put a freeze on expansion, which subsequently was vetoed by Republican Gov. John Kasich.

But she uses her own state, and her experiences as health and human services director, as the prime example. Maine had expanded Medicaid before Obamacare. When she came along, Mayhew told Utah lawmakers, 30 percent of the state was enrolled.

The state no longer could afford to pay hospitals for Medicaid patients. Nursing facilities closed. Doctors refused to accept new patients.

She learned a cruel irony. The people covered by the Obamacare Medicaid expansion, mostly healthy people between 19 and 64, were protected with a “golden circle” because Washington covered their costs at nearly 100 percent. But states in financial trouble tend to cut coverage for the truly needy, whose needs Washington covers at only 50 to 60 percent.

Maine ended up scaling back its Medicaid program, but only temporarily. Last fall, voters there backed an initiative to re-expand it.

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And that illustrates an underlying, complicating factor to this issue. People tend to be compassionate. They want to extend coverage to people in need. They sympathize with those who are caught in health care’s “no man’s land.”

Mayhew believes more could be done through a program that is flexible. Giving states block grants and letting them tailor programs for specific needs would be more effective than the current system.

“But even with that, it’s still a government program,” she said. “The notion that we can create the kind of accountability and efficiency that exists in the private sector — we need to let that go.”

That may be easier said than done.