Once-reluctant supporters of Utah’s partial approach to expanding Medicaid, many advocates for the state’s low-income, homeless and disabled residents now fear a new set of limits on the expansion will harm rather than help.

State officials recently modified their original August 2016 proposal under the Affordable Care Act, also known as Obamacare, to extend health care coverage to many Utahns who are chronically homeless or in need of mental health or drug addiction services.

Their additions — which, like the original, still await federal approval — include new co-payments, a five-year lifetime cap on benefits and mandatory 30-hour work week for able-bodied adults. Advocates say the requirements will reduce even further the number of Utah’s most vulnerable who could receive care.

A leading proponent of the new rules on Utah’s Republican-dominated Capitol Hill described them as “reasonable safeguards” that will give the state added flexibility with how a widened Medicaid program would be implemented.

(Chris Detrick | Tribune file photo) Rep. James A. Dunnigan, R-Taylorsville, at the Utah State Capitol in 2015.

The entire debate, of course, hinges on whether Obamacare survives congressional bids to repeal it. But if it survives, and Utah’s proposals are approved by the feds, the resulting expansion could provide more treatment and care for Utahns who need it most, said state Rep. Jim Dunnigan, R-Taylorsville.

“These are the people we should be helping,” Dunnigan said. “This could make a measurable difference in a lot of lives.”

But advocates say the latest proposed Medicaid limits instead make the so-called “micro-expansion” plan untenable — and could actually stunt efforts to help those struggling with drug addiction or other mental health issues.

“I’ve been playing this game for so long with these folks that I didn’t trust that it would manifest to help the population we were aiming to help,” said state Rep. Rebecca Chavez-Houck, D-Salt Lake City, who likened Utah’s stabs at expanding Medicaid to Peanuts character Charlie Brown’s never-ending struggle to kick a football before Lucy snatched it away.

Chavez-Houck and other homeless and health care advocates are urging residents to voice opposition to the latest Medicaid requirements, in what remains in the official federal public comment period ending Sept. 30.

(Trent Nelson | Tribune file photo) State Rep. Rebecca Chavez-Houck, D-Salt Lake City, in 2016.

According to Dunnigan, the state is pursuing two tracks for its Medicaid expansion plans to avoid any delay from entangling them. Utah seeks federal approval of its first, broader expansion proposal by Nov. 1, followed by acceptance of its new work requirements, lifetime coverage caps and other limits by Jan. 1.

The Medicaid amendments, which target some of the state’s neediest adults, also apply to those covered under Utah’s Primary Care Network (PCN), a related program administered by the state Department of Health to provide health coverage for those who don't qualify for Medicaid.

The limits Utah is now seeking, considered nonstarters under the Obama administration, include:

  • An overall cap on new enrollees at 25,000 people, including Medicaid and the PCN.
  • A 60-month lifetime limit on coverage for those new enrollees.
  • A requirement that PCN beneficiaries either work 30 or more hours per week; seek employment; or participate in training unless they qualify for one of a half-dozen exemptions.  
  • A $25 copayment for nonemergency visits by individuals currently on Medicaid to an emergency room, with some exemptions.

Estimates on the original Medicaid proposal pegged the number of new Utahns that would be covered at about 16,000, said Micah Vorwaller of the nonprofit Utah Health Policy Project. That number has now dwindled to about 6,000 people.

Not only would the changes create barriers to accessing care, but advocates believe they also put at risk continued help for Utahns who have received drug addiction or mental health treatment while incarcerated — with potential to hamper ongoing efforts to address Salt Lake City’s homeless problems through Operation Rio Grande.

When state lawmakers passed what was called the Justice Reinvestment Initiative in 2015, its objective of expanding treatment options leaned heavily on Utah’s push for some form of Medicaid expansion. New Medicaid dollars, expected to be in the tens of millions, would have helped fund the treatment beds needed to provide care, said Deeda Seed, a homeless activist with Crossroads Urban Center.

(Rick Egan | Tribune file photo) Deeda Seed, a homeless advocate with Urban Crossroads Center in Salt Lake City, in 2016.

When it became clear a full Medicaid expansion would fail, Seed said advocates worked with lawmakers to carve out smaller-scale coverage to help the chronically homeless and those needing of mental health or substance abuse treatment.

“All of it was very hard and there was some concern that we were selling out for going with what we could get with the microexpansion,” Seed said. “The feeling among those at Crossroads and others was that it’s better to have something than nothing and at least we could help some people out of this.”

But the amendments have all but killed those plans, advocates say. Rob Westman, executive director of Utah’s chapter of the National Alliance on Mental Illness, said the new rules unfairly target people with chronic mental health problems. The amendments, he said, sacrifice a long-term strategy for providing treatment in favor of saving money short term.

“Everyone wants to say, ‘Look how much I saved,’ knowing that they might not be around as long as the people who will experience the long-term cost of their decisions,” Westman said.

But Dunnigan believes many of the options are workable and “just common sense.” He highlighted the rise in copayments for nonemergency visits to the emergency rooms, calling it “wise to help people understand there is a consequence” for using that service when they could visit a primary care doctor or an urgent care clinic.

Work requirements and coverage limits, he said, are “reasonable safeguards” and give the state more say in how it distributes new services. He urged the Trump administration to approve them.

“We’ve done our part,” Dunnigan added. “Now, the feds need to do their part.”