Thursday marks the halfway point between the end of the
legislative session in March and the self-imposed deadline of July 31st for the
“Committee
of Six” to find a sustainable solution to Utah’s coverage gap. Ten
weeks remain for Gov. Herbert to work out a deal with Speaker Greg Hughes and
the remaining committee of six.
The good news is that lawmakers thrive on deadlines, often
debating and passing dozens of bills during the final hours of a legislative
session.
The bad news is that July 31st isn’t the first self-imposed
deadline to solve Utah’s coverage gap. Missed opportunities fill the 130 weeks that
have elapsed since the Utah legislature first addressed Medicaid expansion in
the fall of 2012.
Still, Utah’s consideration of this crucial issue has matured
since the days when people still doubted the existence of the coverage gap. For
example, here are five common-ground statements that just about everyone engaged
in this debate can agree on:
1) The coverage gap exists in Utah and affects 53,000 adults
and their families
2) The coverage gap prevents people from seeing providers and
receiving necessary medical care
3) Utah adults caught in the coverage have died because of their lack of access to care
4) Utah’s decision should be guided by the most accurate
enrollment and cost projections available
5) Any solution to Utah’s coverage gap must be fiscally sustainable
Finding common ground is a good starting point. But the
previous statements only define the scope of the problem and a general framework
for addressing it. None of these statements suggest realistic guidelines for
solving Utah’s coverage gap.
Fortunately, the previous 2.5 years of reports, studies, and
debates have generated a wealth of data and insights. Gov. Herbert’s team believes Utah’s
prior work should inform the current negotiation, claiming, “When we say we're
starting over, it's not that every good idea we had goes away.” That
makes sense. As a result, here is a list
of Four Principles—based
on Utah’s own research and findings—that should guide a solution to Utah’s
Coverage Gap:
1) Respect Utah Taxpayers
Much of Utah’s reputation as among the nation’s best-managed states
rests on prudent fiscal policies. But
being fiscally smart doesn’t mean that you hide the state treasury in a
mattress and never spend a penny. Instead, it means that lawmakers should spend
Utah’s limited tax dollars as wisely as possible.
Right now Utah sends over
$680 million in taxes, fees, and penalties to the federal government to pay for
implementation of the Affordable Care Act (ACA). Currently only a percentage of
these funds are returned to the state in the form of tax credits through
healthcare.gov. Increasing access to healthcare by closing the coverage gap
will return hundreds of millions of dollars a year to our state to improve
access to quality healthcare for Utah families. Any solution should seek to
return the maximum amount of taxpayer dollars to help low-income Utah families
purchase health insurance. As a result, Utah should respect Utah taxpayers by
designing a plan that triggers the enhanced match rate of 90% federal funding
and 10% state funding.
2) Close 100% of Utah’s Coverage Gap
Right now
there are 53,000 Utahns who live in the Medicaid coverage gap. They earn too
little to qualify for subsidies on the personal exchange marketplace, but earn
too much to qualify for Medicaid. Closing the coverage gap means helping these
Utahns access health insurance that 1) they can afford, 2) is real insurance.
We believe any solution to Utah’s coverage gap must involve
health insurance that you can actually use at doctors’ offices and hospitals.
Although that principle might sound
self-evident, it’s an important distinction because Utah’s Primary Care Network (PCN) is not comprehensive health
insurance. PCN doesn’t cover specialty care, mental health or substance use
disorder services, MRIs and CT scans, and many emergency room visits (see PDF for
more details).
During the most recent legislative session, one of the plans proposed in the Utah House attempted to close the coverage gap by putting 20,000 people
on Medicaid, but also put over 24,000 Utahns on PCN’s inadequate benefit
package. In contrast, we believe Utah
should close the coverage gap with health insurance that can better meet your
needs when you have an accident or get sick.
3) Promote a Private Market Solution
A “Made in
Utah” solution to the coverage gap isn’t just political window-dressing. Designing
our own plan also allows state agencies, insurers, and providers to develop tools
to collect data and insights on how Utahns are using their new coverage. This
data can lead to more efficient care and taxpayer savings, just like it has for
Medicare and Medicaid accountable care organizations in our state. One example
of this is the $50 co-pay to discourage inappropriate use of the emergency room
(see PDF,
page 15) that Gov. Herbert negotiated as a part of the Healthy Utah plan. These
reforms acknowledge that simply giving Utah families access to affordable
health insurance doesn’t solve all of our healthcare challenges—especially if
the newly insured continue to rely on emergency rooms for basic care instead of
primary care providers. To reduce costs and improve quality, we need new tools
and data to make this expanded coverage work more effectively.
As a result,
we encourage the “Committee of Six” to create a coverage plan that includes
access to subsidized employer-sponsored and private market insurance, as well
as a robust definition of “Medically Frail” for adults who need the full array
of services offered through traditional Medicaid. This combination of care not only gives Utah
families more choices, but also strengthens our state’s healthcare system and
reputation for innovative and efficient care.
4) Promote Personal Responsibility
Fact: Working
families comprise the majority of Utah’s coverage gap. Studies show that over
60% of the individuals who would benefit from an expansion are currently
employed. Plus, 86% of Utah families who would benefit have at least one adult
working in the household. Many adults who aren’t working are either in school
or caring for children or family members.
Are many of these
uninsured Utahns able-bodied? Yes. But ask yourself two questions. 1) Are you
and your family members able-bodied? 2) If you answered “yes,” does that mean
you and your family don’t need health insurance? Of course not. You should have
access to affordable health insurance, and so should the 53,000 Utahns in the
coverage gap. This is because health insurance is important to have not just
when you get sick or injured, but also to keep you healthy, productive, and
able to secure your family’s well-being. As
a result, any plan approved by “Committee of Six” should strive to:
- Ensure
individuals are given the option to seek assistance through Department of
Workforce Services to find employment or develop the skills to improve their current
employment situation.
- Empower
beneficiaries to use their new healthcare coverage to create better health
outcomes (Examples: smoking cessation, finding and using a primary care doctor,
etc.).
So that’s why everyone is asking “10% of what?”
The state of Utah, including the legislature, has
ordered and commissioned more studies, reports, and surveys than anyone can
keep track of. You can find and read
many of them here
at UHPP’s 
Could Utah benefit from newer and more accurate studies on projected enrollment
and state cost? 
