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 31^st 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.).