Medicaid, America’s government-run health insurance program for the poor, should be a lifeline that provides needed health care to Americans with no other options. Surprisingly, however, it doesn’t. The medical literature reveals a $450 billion-a-year scandal: that people on Medicaid have far worse health outcomes than those with private insurance, and no better outcomes than those with no insurance at all.

Why is this so? In How Medicaid Fails the Poor, Avik Roy explains how Medicaid’s clumsy design and perverse incentives make it hard for people on Medicaid to get the medical care they need. Medicaid doesn’t reimburse doctors or hospitals for the cost of caring for Medicaid enrollees, forcing many doctors to opt out of the program.

The Affordable Care Act, otherwise known as Obamacare, doubles down on this broken system. Roy shows us that there are better ways, using private insurance, to provide needed care to our poorest citizens.