Gehrke: We can refine Utah’s Medicaid expansion without undermining the will of voters

Several hundred people turned out Monday for a rally opposing changes to Utah’s Medicaid expansion initiative — just a fraction of the more than 555,000 who vote for Proposition 3.

But after fighting expansion since 2012, Republican lawmakers were not going to go quietly, and Tuesday, they took the first step to rewriting an initiative-passed law for the second time (the first being the medical cannabis bill).

There is some legitimacy to the lawmakers’ concerns. When the economy is churning, Medicaid enrollment is low and things are fine. But when the economy sputters, enrollment surges and costs skyrocket, just as tax revenues drop.

That’s exactly what happened in the last recession, and legislative leaders who rode out that crash aren’t eager to write checks that will bounce next time the economy goes in the tank — and there are warnings that the downturn may not be too far off.

To that end, here are three things in Sen. Allen Christensen’s bill that passed out of the Senate Health and Human Services Committee on a party line 6-2 vote Tuesday that are not just good ideas, but are absolutely essential fixes.

1. It brings back a requirement that hospitals help pay for the expansion.

Back in 2015, when Gov. Gary Herbert and legislative leaders were trying to come up with $78 million to pay to expand Medicaid, one of the big pots of money — about $26 million — was supposed to come from a hospital assessment.

That makes perfect sense, since — aside from patients — the biggest beneficiary of expansion is the hospitals, which will no longer have to eat the cost of treating uninsured patients. The hospital assessment was not part of Prop 3, and Christensen’s bill would make hospitals pay $15 million for the expansion costs. (They probably should pay more.)

2. It fixes the inflation adjustment.

Under Proposition 3, medical providers would be guaranteed an annual cost-of-living increase, but the language is being interpreted to guarantee a 5 percent increase — a level that is not sustainable. Christensen’s bill rolls it back to 2 percent.

3. It guarantees up to one year of care.

Christensen’s bill includes a provision that assures that a patient who gets a better job or gets a raise and is suddenly making too much to qualify for Medicaid won’t be cut off for a year. Leaving that provision out would provide a disincentive to take that job; including the coverage extension provides certainty for workers and their families.

There are, however, other changes in Christensen’s bill that are more problematic. Here are two:

1. It (sorta) launches April 1.

Proposition 3 would have enabled about 131,000 Utahns to start enrolling for Medicaid coverage on April 1. And some advocates worried that a reworked Medicaid expansion would delay enrollment until the state could get approval from the U.S. Department of Health and Human Services for a whole litany of special exemptions.

Christensen’s bill will start enrolling people under the poverty level April 1, but that will leave about 40,000 people who are above poverty but below 138 percent of poverty on the private market with federal subsidies.

And the state would be paying about 30 cents of every Medicaid dollar to cover those below the poverty level — about $12,000 a year for an individual — instead of 10 cents of every dollar if Utah goes with full expansion. In other words, Utah taxpayers will be paying more money to cover fewer people.

The reason lawmakers are fine with that is they think it will be temporary, just until HHS approves their waivers. On Tuesday, Christensen and Rep. Jim Dunnigan said they’ve been assured by the federal government that the waivers would be approved by the end of the year.

Given that they’re asking for a package of waivers that hasn’t been approved anywhere else, it seems wildly optimistic.

Former Gov. Mike Leavitt, who was HHS Secretary during the Bush administration, isn’t ruling it out under the Trump administration.

“They’re operating in an atmosphere in Washington where waivers that would not have been granted four years ago may well be considered now,” Leavitt told me on Tuesday. “So I don’t think you can look at the past and say, ‘They’ve never done that before,’ because there’s a different ideology.”

There is a simpler solution. Implement Prop 3, as the voters wanted, and seek the waiver as you enroll people. It gets coverage in place for more people at a lower cost without relying on the unreliable federal government for permission.

That, by the way, is exactly what Virginia did when it implemented Medicaid expansion, and we should do the same here. That way, at least, the state can make adjustments, if necessary, based on actual enrollment data and not squishy projections.

2. Brace for a work requirement.

Utah lawmakers love the idea of a work requirement, and such requirements been approved in other states. It seems likely that we’ll get one here, but if it’s narrowly crafted to require a job search or training and to give leeway to single parents or people with disabilities, it doesn’t have to be onerous or contentious. Herbert’s Healthy Utah proposal, for example, had a work requirement and still had the backing of a broad array of low-income advocates.

That actually brings up an interesting point: If Christensen’s bill goes through and the state eventually gets its waivers, what we end up with is almost exactly what the governor proposed in his Healthy Utah plan back in 2014.

Despite broad public support for the plan back then, Republicans in the Legislature killed it.

Had they listened to their constituents then, how many billions of Utahns’ tax dollars could have stayed in the state? How many poor residents could have received health care? How many people with addiction or mental health issues could have received treatment? How many lives could we have saved?

Now the voters have spoken, and lawmakers owe it to the state to at least stay true to the spirit of Proposition 3 and make sure those Utahns get the coverage they need.