Medicaid Finally Has a Place at the Table

Health care for low-income people has finally taken its place among other health programs; no longer Medicare’s little sibling, Medicaid has earned the public’s support and trust, and people are voting to broaden its reach.

Over 30 years ago, I embarked on a career and a business with a social mission: to help low-income people gain access to health care. It must have had something to do with the fact that I graduated college with a business degree but was the son of a social worker. 

I quickly learned that while Medicaid was a very costly public program — even called a “budget buster” in Massachusetts in the 1980s — it was really the stepchild of all health care programs.

Medicaid was viewed as essentially a welfare benefit, even though its largest cost drivers were not the typical welfare population but rather seniors in nursing homes who had impoverished themselves to pay for that care and people with disabilities who required costly, complex care.

Medicare, as a program that covered mainly the elderly, at all income levels, did not suffer the same stigma.  

Most of the working population had coverage through a private health plan.  

Medicaid was largely out of sight and out of mind. And so were the people who depended on the care it provided.

First, let’s take a look at last month’s election results. Ruby red states such as Idaho, Nebraska and Utah, the last of which has voted for the Republican ticket nationally in every election since 1968 and just elected Republican Mitt Romney to the Senate with 62 percent of the vote, voted to expand Medicaid to cover more individuals. Utah’s expansion is funded in part through an increase in the state sales tax.

In Kansas, also a red state, voters elected a governor who supports a Medicaid expansion there, as did the voters in Wisconsin.

Why are voters supporting the expansion of Medicaid? Because they see firsthand the value that the program delivers to those who depend on it. They see the level of security it provides to a family with a child who has a disability or a family where the parents work two or three jobs and struggle to pay rent and provide groceries.

And they don’t need to look very far. In Massachusetts, a state that led the trend in Medicaid expansions and continues to innovate through a bold and timely modernization of its program, more than one in four individuals have Medicaid coverage, and the percentage is similar coast to coast. Everybody knows someone on Medicaid.

In addition to the public supporting broader eligibility for Medicaid in many states, another major series of developments is occurring that will not only improve the health of low-income individuals but will potentially lower the cost of care.

U.S. Health and Human Services Secretary Alex Azar has expressed his department’s willingness to address and, ultimately, fund social determinants of health.

Poor people suffer from many challenges, and these include a lack of housing, poor options for quality food in their neighborhood, and limited access to transportation. It has been well documented for many years that these so-called social determinants of health lead to poorer health generally and a higher rate of certain chronic diseases, such as asthma and diabetes.

Medicaid and other public health insurance programs have never been able to comprehensively cover things such as healthy meals, safe housing or air conditioners for people with asthma, because they were not viewed as health care services. That is now changing.

Azar’s bureaucratic aim is not entirely altruistic — and as taxpayers who fund these costly programs, that should not concern us. The data clearly demonstrate that paying upfront for things such as food, housing and transportation saves cost over the longer run, with fewer ambulance runs, hospital emergency department visits and inpatient admissions.

The Medicaid of decades ago that I remember, whose state agency headquarters were hidden away in the tough section of downtown, whose provider claims it was said — probably apocryphally — were kept in shoe boxes, and that lagged private health plan counterparts in innovation, has graduated to be something that is cherished by those holding the purse strings: the voters and their elected representatives.

Low income health care is a vital part of our health care continuum, and it has finally achieved the status it so rightfully deserves among both policymakers and the public.


Gerard A. Vitti is the president and CEO of Healthcare Financial Inc. of Quincy, Mass., a firm that specializes in enrolling the uninsured into health programs.

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