SALT LAKE CITY — The Utah Legislature passed it. The governor signed it.
But HB437, which proposes to extend Medicaid to 16,000 of the state's neediest, is still nothing more than a piece of paper until the federal government approves it.
"From the very outset we have said, 'We've got to come up with something that will pass the state policymakers as well as our federal partners,'" said the bill's sponsor, House Majority Leader Jim Dunnigan, R-Taylorsville.
The measure now enters months of negotiations between state officials, federal officials and local advocates.
The health department hopes to start enrolling people by January 2017, according to Utah Department of Health Medicaid spokeswoman Kolbi Young. That means officials need to have a rough draft to show the public by April or May.
The deadline to submit the state's proposal to the federal government is July 1.
The timeline will be a “really quick and tight turnaround,” Young said.
"It's a pretty detailed and intensive process of writing the waiver, receiving public comment and providing opportunity for public hearings," she added.
The discussions on Capitol Hill can seem distant to the patients who are treated at the Fourth Street Clinic, where the waiting room was bustling on a recent afternoon.
Clayton Chandler, a former ceramic tile worker who has been homeless for more than a year, said he hasn’t heard of the Medicaid expansion debate but would support it.
Chandler has a broken ankle, high blood pressure and sleeping problems. He used to install tile in Park City, often in multistory homes on steep mountain slopes. That's now impossible.
"Once or twice up with a load of tiles and I'm done," he said.
Chandler was on Medicaid at one point but was later removed. That’s not uncommon among the homeless due to fluctuating incomes and difficulty with follow-up.
"I need my medication, I need clothes, I haven't got nothing," Chandler says to a medical assistant who is taking his blood pressure.
He gestures at the cast on his ankle, the overalls he's wearing and the borrowed copy of the Dan Brown thriller "Digital Fortress" in his right pocket.
"This,” he says, “is it.”
Roberto Garza, a 53-year-old laborer who struggles with arthritis and alcoholism, is also unsure if he’s insured. He only knows that the Fourth Street Clinic takes care of him when he gets sick. In addition to arthritis, Garza also deals with hernias and bladder infections.
“I can't walk, I can't stand,” said Garza, who often used to work pouring concrete. “When I go to Wal-Mart, I have to get me one of those little carts."
He's heard that lawmakers have been debating Medicaid expansion. He said he — like many other undocumented immigrants — would like to have better medical attention so he can go back to work.
Homeless advocates say they don't know how many of their patients might benefit from the partial expansion until they find out the specifics of the plan.
Lawmakers estimate the measure will cover an estimated 12,500 adults without children and 3,800 parents, but it’s up to the state Medicaid program to set eligibility requirements.
"The problem with the bill is that it gave the (Utah) Department of Health both a blessing and a curse," said Rylee Curtis, an analyst with the Utah Health Policy Project. "A blessing in that it's very flexible in who it can cover, but the curse is that now everybody who has constituents that are either homeless or criminally involved, they want to get the maximum amount of people covered."
For childless adults to qualify, they have to prove that they are chronically homeless and make less than 5 percent of the federal poverty level, or $594 a year — a figure that officials can adjust upward.
Nevertheless, the income limit is "pretty much the strictest you could go,” said Curtis.
Dunnigan said he’s not sure if the income ceilings include benefits like unemployment.
He said slots will be left for people who are involved in the criminal justice system or have behavioral health issues.
Those who get on Medicaid will also be guaranteed coverage for a year, giving them more stability and time to find a job.
Dunnigan said he doesn't anticipate any objections from federal officials. He said lawmakers have been in touch with officials from the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services since the start of the session.
“Overall, when we had our conversation with them, it was, ‘Let’s see what you can get passed,’” Dunnigan said. “So now that we’ve done that, the health department starts to work.”
But Utah is charting its own course on Medicaid expansion, meaning that state officials have little to compare it to.
Young declined to speculate on whether the Centers for Medicare and Medicaid Services would approve the Utah plan.
“We will put forth our best effort and through their guidance and consultation, through the process, we'll receive their feedback and we'll implement that in their waiver application, but it will really come down to their feedback in the end,” Young said.
Dunnigan said the partial expansion should provide "some very helpful data" to policymakers, including enrollment rates and cost. He said that information can be used in future debates on full Medicaid expansion.
Many advocates, fearful that legislators are no longer interested in full Medicaid expansion, are still pushing lawmakers to discuss the issue during next year's session.
Dunnigan said he’s more focused on getting the partial expansion implemented first.
"There'll be a new president, there'll be a new administration. … And as the governor said, hopefully the next administration will give states more flexibility," he said. "There's an awful lot of variables between now and then."