What’s happening with Medicaid expansion?

On Friday the Utah House of Representatives amended and passed SB 96, a bill that makes adjustments to Medicaid expansion. This bill, sponsored by Sen. Christensen and Rep. Dunnigan, has been the subject of debate, tension, political maneuvering and protest throughout the first two weeks of the legislative session.

On the one side was a majority of voters who passed Prop 3 for full Medicaid expansion; on the other a majority of legislators tasked by the Utah constitution with the responsibility of balancing the budget – both with equal power to create laws in Utah. In between was a myriad of emotions, conflicting information and even distrust. But, in the end, the bill that passed on Friday turned out to be a prime example of compromise. Here’s why.

The premise of SB 96 was to expand Medicaid in a more limited way than Prop 3 in order to reduce costs. Although the bill had the strong support of leadership and sailed through the Senate, SB 96 had some troubling issues for advocates, such as a delayed implementation date, lack of transparency about cost calculations, concerns about the fiscal note and the problem that it relied on the uncertainty of a waiver from the federal government to get a 90/10 cost sharing split. If the government failed to approve the waiver (as has happened with similar waiver applications filed in Utah), the limited expansion would have cost Utah far more than Prop 3 for less coverage or would get rolled back all together, leaving Utah with no Medicaid expansion.

The Fourth Substitute that passed in the House will ensure that Utahns get Medicaid expansion one way or another in 2019 and beyond. A “bridge plan” will start on April 1st to cover people with incomes up to 100% of the FPL with the federal government paying a 70/30 share of the costs. Two stopgap measures will protect Medicaid expansion should the federal government fail to grant Utah the necessary waivers.

Stopgap 1: A waiver application will be submitted requesting the federal government pay a 90/10 share to cover the limited expansion (up to 100% FPL) with work requirements, enrollment caps and lifetime caps. Unlike the previous version of the bill, if the waiver fails to be approved by January 1, 2020, Medicaid will be expanded to cover people earning up to 138% of the FPL, and a new waiver will be submitted, asking for a 90/10 match with a work requirement for enrollees and other cost containment functions, such as enrollment caps and per capita caps.

Stopgap 2: If this waiver is not approved by July 1, 2020, then Utah will revert to full Medicaid expansion as outlined in Rep. Ray Ward’s bill, HB 210. That means Medicaid eligibility would remain at 138% FPL with the full 90/10 cost sharing split for federal matching funds and no caps or work requirements, just like voters wanted. The only differences between Prop 3 and HB 210 are some cost containment strategies, including a hospital assessment and a reduced provider reimbursement rate.

The nature of compromise is that both sides get something, and neither side gets everything they want. A majority of voters did not get exactly what they wanted in SB 96 — yet there is a chance they could get full expansion as early as July 1, 2020 if the waivers don’t come through. Many legislators don’t want Medicaid expansion at all, but they came to the table to pass enough Medicaid expansion to ensure that every Utahn can receive health care coverage one way or another and that no Utahn will fall in the “coverage gap” by making too much money to qualify for Medicaid but too little to qualify for a subsidized plan under the ACA.

Time will tell if one side was right or wrong about the costs and cost benefits of Medicaid expansion. But for now, Utah will get Medicaid expansion the Utah way by forging our own plan and compromising.

Action Utah would have preferred full expansion per Prop 3, but we also understand that there were some flaws in the funding and reimbursement portions of the initiative that needed to be addressed. While HB 210 alone would correct those flaws, SB 96 provides more buy in from legislators and includes HB 210 as a stopgap, making it a compromise between competing fixes. We are proud of Utahns who spoke up about their health care needs and desire to protect Medicaid expansion. Although you may not have gotten everything you wanted, your voices were heard and proved critical in making SB 96 a better bill. We are also glad to see legislators take on a challenge and compromise.

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