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Utah lawmakers get creative with Medicaid expansion

Despite years of discussing the issue, Medicaid expansion and various plans to implement it in Utah are again on the docket for this legislative session.
Despite years of discussing the issue, Medicaid expansion and various plans to implement it in Utah are again on the docket for this legislative session.
Matt Gade, Deseret News Archives

SALT LAKE CITY — Despite years of discussing the issue without resolution, Utah lawmakers will again take on Medicaid expansion and various plans to implement it for the thousands of Utahns who remain uncovered by health insurance.

And, while some lawmakers are taking approaches that have been tried before, others are trying new things — an indication of a potential desire to bring health care benefits closer to Utahns who can't afford them.

"We're moving slowly in the direction of getting it. It's frustrating how long it takes, but I believe we're moving in that direction," said Rep. Ray Ward, R-Bountiful, who is backing a bill (HB18) with an underlying concept similar to that of UtahAccess+, which failed to gain favor of the house majority and never made it before the whole body for consideration last summer.

There are nearly 70,000 Utahns in the coverage gap — earning too much to qualify for existing Medicaid coverage, but not enough to qualify for subsidized health insurance through the Affordable Care Act's federal marketplace. The majority of them have no option for health care and usually end up looking for help in the emergency room, with insured Utahns making up for those costs.

Ward wants health coverage options for every Utahn in the coverage gap, up to 138 percent of the federal poverty level, seeking waivers to get there and then pay for it with a hospital assessment and a new tax on e-cigarettes.

"My bill is what I want and what I feel would be best for this state," Ward said.

The same hopefulness is had by Senate Minority Leader Gene Davis, D-Salt Lake City, who has twice steered the discussion toward full expansion "the way the Affordable Care Act intended it" in the past two years. His substitute bills have been shut down, and this year, he's bringing back the same idea in its own bill, SB77.

"I want access for all Utahns to health care, not a selected few," Davis said, adding that he doesn't like bills that discriminate based on income or ability or other factors. He said he won't vote for anything that singles anyone out or isn't fair.

In his bill, Rep. Robert Spendlove, R-Sandy, is looking to bypass the current federal administration and start working with "the next one" on a plan for Medicaid expansion in Utah. He's hoping for more flexibility for the state — though nothing could happen until after the election.

His bill would extend coverage for those up to 100 percent of the poverty level, but it would seek the full reimbursement available from the federal government, requiring a waiver. The full match has been offered only to states that expand to 138 percent, per the Affordable Care Act rules. Spendlove is also eyeing a work requirement and other ideas that federal officials have already balked at.

"It's a difficult issue," he said, adding that the three main issues surrounding potential options are the cost, quality and access. "It's easier to just go after one and really hard to get all three."

But Spendlove, who ran a similar bill last year, said he's "committed to doing something."

Utahns hanging in the balance are also hoping for some movement, though it remains unclear where the most support will be, as the various proposals for partial expansion stand to help only specific populations of people in need.

One thing for sure, said RyLee Curtis, senior health policy analyst with the Utah Health Policy Project, "it's become clear over the years that the need is there."

But the proposals introduced and some not yet numbered (with likely more to come from other lawmakers), Curtis added, may not meet the real need.

"There's not a lot of promise in actually closing the coverage gap and providing adequate health benefits for everyone who needs them," Curtis said.

Davis said the state's current Medicaid system incentivizes disability and facilitates a "revolving door" at the prison, as released convicts don't ever get the care and treatment they need to curtail certain behaviors that are driven by mental illness or addiction.

He believes health care is a right for all.

It's a prospect that is projected to cost the state about $50 million, which has many Republican lawmakers balking at moving forward, saying the federal government won't hold up its end of the bargain, potentially costing the state even more.

Sen. Allen Christensen, R-North Ogden, has said that with local lawmakers rejecting plans being brought up time and time again, it is time to start anew.

"I have opposed it from the beginning as another financially unsustainable give-away program," he said. "We already offer Medicaid to the disabled, to pregnant women, to the elderly and to children. The only ones left are basically the able-bodied, childless adults."

Christensen is backing a plan that would extend traditional Medicaid benefits to Utahns below the poverty level, "who have signficant medical or mental need," he said. Individuals would have to qualify financially and medically.

He worries about the cost of any program crippling the state budget and said any additional burden would come from taxpayers.

"Those who want expansion forget that someone has to pay the bill," Christensen said, adding that he will oppose any bill that expands benefits to more people that he has proposed to cover, as, he said, they are "financially unsustainable."

Rep. Jim Dunnigan, R-Taylorsville, is also proposing to insure a limited number of Utahns, based, however, on what the state can afford.

His bill, which has support from various advocates for the homeless, would offer the current Medicaid program to uninsured Utahns, based on income levels. It would include mostly homeless individuals, but some single parents and others might also qualify for benefits, he said, adding that it was for "the poorest of the poor."

The plan, extending an existing benefit system and a cost structure that is already in place, would not require signoff from the federal government.

Dunnigan said it is a way to "start down the path of taking care of people in the coverage gap."

After implementation, he said, state officials could glean real numbers and have something to build on in future years, if that's what they wanted to do.

He said many lawmakers aren't interested in pursuing Medicaid expansion at all but are instead awaiting election of a new president later this year. But, Dunnigan affirmed, his fellow legislators likely "see value in going forward, in starting something."

The attitude might not be shared across party lines, however.

"Nibbling on the edges just to say we did something is not doing anything. It is still not attacking the problem," Davis said. "Full Medicaid expansion is what the constituents of the state of Utah are looking for. They want this problem resolved, and they know that full expansion will get us where we need to be."

He said the issue is just as much an economic issue as it is about health care.

Rep. Rebecca Chavez-Houck, D-Salt Lake City, said she's "disappointed in our collective lack of action," citing the Legislature's inability to agree on something she also believes the people of Utah want. She said political agendas and a leaning toward anti-government organizations are the reasons Utah still has such a large number of uninsured people and families.

"… most of my Republican colleagues in the House are more determined to prove the program and myriad analyses wrong than they are to bring back Utahns' federal tax money to our state," she said. "Instead of helping our own working families who can't quite pay for their insurance, and need just a bit of help to get themselves moving forward, we watch our money go to help the uninsured in 32 other states."

Proposals on the table are perplexing, Chavez-Houck said, as they are "aimed at only helping those who are the sickest and most costly patients."

She is pushing for voters to decide on the issue and is backing a ballot resolution to let Utahns speak for themselves.

"Many of my colleagues cringe at the constitutionally afforded right of the people to petition their government this way," Chavez-Houck said. "As such, it is certainly a long shot."

Dunnigan said any approach will be difficult, as the state budget is "basically flat after all of the have-tos."

"But it's doable," he said.

The ultimate decision is up to Utah Gov. Gary Herbert, who proposed his "Healthy Utah" plan last year, which didn't get enough votes to pass. He still believes that it was better than anything since and would still be the best option for Utahns, but Herbert said Thursday that he understands the concerns and questions of sustainability.

"The issue is not going to go away," he said. "We need to find a solution. It may be an imperfect solution. It may not be what I want. But something is better than nothing."

Herbert said he is optimistic a solution will be found. He believes the issue is "still top of mind" for many Utahns, lawmakers and others who are waiting for the state to make its move.

And while it remains to be seen how the session will play out, Ward said he remains hopeful that lawmakers will help close the coverage gap in some way, big or small. He said that given the choice to cover only a few Utahns as opposed to doing nothing, he would opt for progress.

"I'm still going to run my bill because that's what I think should be done," Ward said. "I'll run it every year. I won't stop."

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