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Tuesday, May 19, 2015

10% of What?

"10% of what?"
That simple question has been chasing Utah’s coverage gap debate for the last few weeks.
And it makes sense to ask it.
If lawmakers pass the Healthy Utah plan, the federal government will pay for 100% of the expansion cost only for the first year. After that, the federal share drops incrementally from 100% to 90% until the year 2020 when the 90/10 match rate will remain in place. From then on the federal government will pay 90% of Utah’s costs for the program, while the state will contribute 10%.

So that’s why everyone is asking “10% of what?”
If the state is going to pay 10% of the total cost for closing Utah’s coverage gap, lawmakers need to know 1) How many people might enroll, and 2) How much it will cost the state.

But some people asking the 10% question make it seem like the state hasn’t crunched the numbers yet. They seem to suggest that "10% of something" is all we know. In other words, they make it seem like Utah is gambling with the state budget.

The fact is that Utah has already crunched the numbers on closing the state’s coverage gap.
We have solid projections not only on how many people are expected to enroll at each income level, but also what the state cost will be from 2016 to 2021. 
What is the state cost in 2021? $77.8 million
How many people are expected to enroll in new coverage by 2021? 146,000

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 vast archives website.

The sheer number of these Utah-focused studies might be one reason some people never mention them or their findings. Or it could be that all of these studies, reports, and surveys—which rely on real numbers and accurate mathematical models—show that closing Utah's coverage gap with the Healthy Utah Plan is best strategy to create savings, encourage higher-quality care, and protect Utah taxpayers.

To help we’ve boiled down the key facts and numbers into this simple report, “What Do We Know about Utah’s Coverage Options?”(pdf)

Could Utah benefit from newer and more accurate studies on projected enrollment and state cost?
Yes. And those new studies are being developed right now.  
Should Utah’s enrollment estimates account for higher-than-expected uptake rates that occurred in Ohio and Michigan?
Absolutely. Plus, our projections should recognize that every state’s Medicaid program and eligibility requirements are different—resulting in different uptake rates, efficiencies, and state costs.

But to understand how closing the coverage gap actually works, we need to read and understand many important studies and reports that already exist … and not just claim that “10% of what” is too much and move on.

Because it turns out that we know a great deal about “…the what?” when it comes to closing Utah’s Coverage Gap.

What Do We Know about Utah’s Coverage Options? (pdf)

What We Believe

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 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 Utahs 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 doctorsoffices and hospitals.
Although that principle might sound self-evident, it’s an important distinction because Utahs 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.).

Monday, May 18, 2015

Mental Health is Healthcare, Too

Some Utahns have rates of mental illness and substance use disorders that are double the rest of the population. They are also the Utahns living in the coverage gap.

By Stacy Stanford

May is National Mental Health Awareness Month, an issue that is of particular importance to Utah given that we have the nation’s highest rate of mental illness, with more than one-fifth of the population experiencing at least one mental health disorder in 2014.

With Medicaid expansion still up in the air, there are increasing numbers of uninsured and impoverished Utahns with mental illness and substance use disorder that are unable to obtain the treatment they need. A new report from the American Mental Health Counselors Association, entitled, “Access Denied: Non-Medicaid Expansion States Blocked Uninsured People with Serious Mental Illness from receiving Affordable, Needed Treatments,” outlines the consequences of this inaction.

In Utah, the rates of mental illness and substance use disorder among the Medicaid expansion population—uninsured Utahns who are both ineligible for Medicaid and subsidized private insurance on Utah’s marketplace—are more than double the numbers in the rest of the population: 22.4%, versus 47%. There is no denying the relationship between poverty and mental illness, and without access to treatment options, the cycle continues.

It is estimated that more than 15,000 adults in Utah would have sought mental health care last year if the state had provided coverage to the expansion population. When uninsured persons with mental health and substance use disorder are forced to forgo treatments due to unaffordable out-of-pocket costs, there are real consequences for individuals, families, and our community, including: 

Thus, failure to act on Medicaid expansion has public health, public safety, social, and economic repercussions when it comes to addressing substance use disorder and mental health needs.

Are you concerned about Utah’s dangerous gap in mental an behavioral health coverage for the uninured?

Here’s how you can get involved: