This is an archived article that was published on sltrib.com in 2015, and information in the article may be outdated.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.

Derek Monson (with the Sutherland Institute) made the excellent point that we need to work on eliminating poverty rather than expand Medicaid to help people afford medical care (Oct. 18). However, his opinion piece contained several logical fallacies that should not be ignored.

Monson's first logical fallacy is that providing Utahns training/education for new and better jobs will result in everyone getting the job they need in order to afford health care. Even if 50,000 Utahns have trained to become construction workers or conservative think tank policy directors, there is no guarantee that the economy will require these newly trained individuals. Even if we could stimulate the economy enough that we needed all of these workers, there is no guarantee that hiring companies will pay a sufficient wage to pay for health insurance. Even if we were to insist on a minimum wage of $15 per hour (like Seattle — $31,000 per year), many people still could not afford health care for their families.

As a pediatrician, I have met countless families in which parents have turned down promotions or new jobs because their children would lose Medicaid but they still could not afford commercial insurance. One might argue that these people just need to work harder. However, most of these people cannot afford the time it will take to rise through the ranks and finally earn a sufficient wage to provide for housing, food and health care. If people cannot provide for their children, it only increases the odds that their children will have the same issues.

The second logical fallacy is that expanded Medicaid enrollees will receive priority for resources over existing enrollees because the new enrollees will have better-paying commercial insurance. This ignores two vital points. No. 1, there is no requirement that the Medicaid expansion utilize "commercial insurance favored by Utah's Medicaid expansion supporters." Notably, only conservatives, who prefer the private sector over anything government, desire commercial insurance and its higher overhead costs. If all new enrollees were in the same program as existing enrollees, there would be no cost differential creating disparate priority levels.

No. 2, a huge proportion of existing Medicaid enrollees are children. Children generally see pediatricians, while "able-bodied" adults do not. Providing resources to "able-bodied" adults will do nothing to reduce the availability of care to children for the vast majority of the state (Pediatricians generally already accept Medicaid).

It is true that disabled adults may see an increase in competition for limited medical resources. However, when "able-bodied" adults need resources (especially without prior preventive care), they tend to be emergencies (more expensive) and when not paid for, definitely take resources away from everyone else. Instead, we could have increased patient demand (with ability to pay) serve as an impetus to increase supply by medical providers (free market economics).

The reality is that we need a multi-pronged approach. We do need to do better at providing resources to improve peoples' chances of getting good-paying jobs (as Monson wisely points out). However, we also need to maintain a safety net for working people who do not earn enough to pay for insurance. We especially need our safety net to remain even if someone is going to earn $11 an hour instead of the $8 an hour she has been earning. By setting the cutoff level so low, we are actually creating a disincentive to people increasing their gross income (and potential to add to the economy and tax base).

We simultaneously need understanding that health care is similar to fire/police protection. No one wants to visit an oncologist due to colon cancer or get facial reconstruction after encountering a flesh-eating bacterium (just as no one wants to have their house catch on fire and get a visit from the fire department). We currently try managing via a combination of commercial and limited government health insurance. Unfortunately, our current system also carries high overhead costs and leaves many without any official coverage (other than "free" lifesaving ER care). There is good reason to consider having more people (even most) covered by government health insurance. There is also good reason for maintaining commercial insurance — much as one might hire private security as an adjunct to police service. The trick is striking the right balance.

The truth is that none of these options are a "silver bullet" or easy to do. However, ignoring all of them so we can pretend to "attack" poverty and then blame the poor when it doesn't work. That's just a waste.

Benjamin Kalm, MD, FAAP, is a pediatric hospitalist and assistant professor of pediatrics at the University of Utah.