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Gov. Gary Herbert unveils his plan for covering Utahns in the health care “gap”

First Published      Last Updated Dec 18 2014 06:35 pm

Herbert’s Healthy Utah plan would help 95,000 working poor statewide buy health insurance.

Kylie Toponce is just the kind of person that Gov. Gary Herbert's Healthy Utah plan is designed to help: sick but working, too poor to qualify for federal health insurance subsidies, but unable to qualify for Utah's Medicaid program.

But after years of living with undiagnosed stomach troubles and mounting medical bills that forced her into bankruptcy this fall, Toponce, 23, is dubious whether Healthy Utah — unveiled in detail Thursday — or any solution the Utah Legislature devises will help her.

"I don't think there's much hope it will change," says Toponce, who lives in Kaysville and works as a waitress in Roy. "There will always be people like me falling into a bracket who will be screwed."

Herbert, who surrounded himself by a phalanx of medical, insurance, business, religious and charitable leaders at a news conference Thursday, said Utah should provide concrete help in the face of such discouragement.

"These are our neighbors, our friends and our family members," said the governor. "Turning a blind eye and doing nothing is really not the Utah way."

The governor faces a skeptical Legislature, though, especially after he and lawmakers learned this week that any alternative to expanding traditional Medicaid will cost millions more than previously thought.

That's because of a 40 percent increase in the state's estimate of the number of people in the coverage gap who would seek coverage, up to 63,000 from the 45,000 predicted in a 2013 state-commissioned study. A study led by University of Utah economist Norm Waitzman several months ago pegged the number at 77,000.

These are people in the so-called coverage gap, who don't qualify for Medicaid because they don't have children, are not pregnant, disabled or seniors or who have children but earn from 49 percent to 100 percent of the federal poverty level. Those in the gap don't qualify for health insurance subsidies in the federal marketplace.

The Affordable Care Act had envisioned every state would expand Medicaid to cover those people, but the Supreme Court let states opt out of expanding Medicaid, and that created the gap in states like Utah, that did opt out of traditional Medicaid expansion.

Herbert's Healthy Utah plan, negotiated over several months with the U.S. Department of Health and Human Services, would help adults in the gap and those earning up to 138 percent of federal poverty levels buy private health insurance plans.

Those whose employers offer health insurance they can't afford would get wrap-around plans that would help them pay the premiums, co-pays and deductibles of employers' plans.

Herbert's plan goes further than the coverage gap because that brings a much higher match from the feds, starting at 100 percent in 2016 and falling to 90 percent in 2020.

Healthy Utah would be a three-year pilot program. The state's share would rise from $4.6 million for half a budget year in 2016 to $80 million to $90 million per year by early in the 2020s. That's steeply higher than the previous estimates, which had the state saving money for the first few years.

If Utah extends coverage only to those in the gap, HHS will chip in only 70 percent, which is the share they now provide for Utah's Medicaid program.

The Legislature signaled Thursday that the governor's plan won't be the only thing on the agenda when it convenes for the 2015 session on Jan. 26.

"The question of Medicaid expansion isn't just going to be a yes or no to Healthy Utah," said Speaker of the House Greg Hughes, R-Sandy.

Rep. Jim Dunnigan, R-Taylorsville, sketched out four other options to the Legislature's Health Reform Task Force on Thursday. An insurance company owner and House majority leader, he is the co-chairman of the task force.

None of the four would be as generous with low-income people as Healthy Utah, and all would cost millions, he noted. Like Healthy Utah, all the legislative plans would give poor people help paying for private health insurance plans and they'd see similar co-pays, Dunnigan said later.

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Healthy Utah, Explained

What it is » Gov. Gary Herbert’s plan to get health care coverage for tens of thousands of low-income Utahns who fall in the health care coverage gap created when Utah opted out of expanding traditional Medicaid. They don’t qualify for the existing Medicaid system, but also don’t qualify for subsidized health insurance under the Affordable Care Act (Obamacare).

Who is affected:

Group 1 » Adults without children who aren’t pregnant, disabled or seniors and who make less than poverty income ($11,670), and adults (with children) whose income is more than half of the federal poverty level (roughly $9,800 for family of three) but less than poverty level, $19,790. The Utah Department of Health says there are 63,000 such Utahns; the Legislature estimates 67,000.

Group 2 » People who make from 101 percent to 138 percent of federal poverty levels, or $16,105 for an individual or $27,310 for a family of three. The health department estimates 32,000 of these.

How it would work:

People would apply through HealthCare.gov and would be transferred to the Utah Department of Workforce Services if they qualify for Healthy Utah. Or they could start there, at jobs.utah.gov. All would automatically be enrolled in a “work effort” to get jobs, better jobs or job training.

If someone who qualifies for Healthy Utah has an offer of health care insurance through his job, Healthy Utah would help pay for the premiums and co-pays with wrap-around coverage.

Those who don’t have insurance through work would get premiums to help pay for private insurance through Utah’s health insurance marketplace, Avenue H. Their children, if on Medicaid, could join them on their plans.

Source: Health Utah summary, Utah Department of Health, December 2014.