It’s been said nothing is certain in life, but on the continuum of risk, the Trump administration approving Utah’s request for a stripped-down version of Medicaid expansion was supposed to be a sure thing.
The sun would rise, the Harlem Globetrotters would win, the president would Tweet something stupid, demeaning or inflammatory.
That sense of certainty was what lawmakers used to justify upending the clear will of Utahns just months after voters approved a broader proposal to help low-income Utahns get access to health care, a proposal that was on the ballot in the first place because of frustration at those same legislators’ stubborn unwillingness to do it on their own.
The Legislature’s entire scheme hinged on the Trump administration agreeing to pay 90% of the cost of covering an estimated 150,000 Utahns living at or below the poverty level. It had never happened before. Every other state has had to cover a larger population — those making 138 percent of the poverty level — to get 90%.
It didn’t really make much sense, if anyone actually stopped to think about it, that the federal government would be so much more generous with Utah than it had been with other states.
Never mind that. This was Utah innovating, the way Utah does. Sen. Allen Christensen, R-North Ogden, who sponsored the bill, was so sure it was a done deal, he told his colleagues: “They’ve told us we can basically count on an April 1 waiver approval.”
“Basically” was the key word. Because basically, April 1 rolled around and it looked like Utah might be on the receiving end of an April Fools’ joke.
In the meantime, Utah rolled out a limited expansion with the feds picking up 70% of the tab.
Then, over the weekend, The Washington Post broke the story that the Trump administration was refusing Utah’s request for the 90% — and they did it before Utah had even submitted its request to the U.S. Department of Health and Human Services. It was like getting shot down for prom before you even asked.
In a statement to Modern Healthcare, the Centers for Medicare and Medicaid Services said it would “continue to only approve demonstrations that comply with the current policy” of paying the 90% match to states that expand to 138% of poverty — in other words, not you, Utah.
It appears that President Donald Trump is gambling on a Texas lawsuit — which Utah Attorney General Sean Reyes has joined — that seeks to obliterate Obamacare, which is the law that created Medicaid expansion.
In December, a federal judge ruled Obamacare was unconstitutional, but the decision was put on hold pending an appeal. Earlier this month, attorneys argued the case in the 5th Circuit. Helping states like Utah implement a big part of Obamacare could conceivably undermine the case.
If Texas prevails, about 200,000 Utahns who bought plans on the Obamacare exchanges would lose their coverage. Protections for things like pre-existing conditions would also disappear. And Medicaid expansion. So be sure to thank Reyes for his part in that, too.
Regardless how the appeals court rules, it will likely end up before the U.S. Supreme Court — eventually.
Until then, Utah leaders have a real problem on their hands.
Gov. Gary Herbert and legislative leadership issued a joint statement saying those now covered by Medicaid expansion — as of Monday, 34,488 had signed up since enrollment began four months ago — will continue to be covered.
That means Utah taxpayers will still cover 30% of the cost (with the feds still picking up 70%) — three times as much per person as it would have if they had just left the voter-approved Proposition 3 alone.
The state has two other waiver applications queued up. One would impose per-capita caps to limit the growth in the program — something that was meant to sweeten the deal for the Trump administration in hopes of getting the 90% match.
The other is a work requirement, which has forced thousands of residents in other states to lose their health coverage. A judge in New Hampshire this week blocked a work requirement for that state’s Medicaid coverage.
There’s one other option: The Legislature included a fallback in their re-write of Proposition 3. If the waivers aren’t approved then they default to full expansion. And lawmakers appear to be out of options.
Christensen, the state senator, acknowledged as much to my colleague Benjamin Wood in a refreshing moment of candor.
“We probably have to implement the thing,” Christensen said. “We told everybody they were wrong and we were right. And then when ours doesn’t come through — if, in fact, it doesn’t come through — then they were right and we were wrong.”
The problem is that fallback doesn’t kick in until July 2020.
The governor and legislative leaders should recognize that, convene a special session, drop their waiver request, and accept full expansion and the federal dollars that come with it.
It would be the best solution for taxpayers, ensure coverage for tens of thousands more Utahns in need, and — oh, hey — give Utahns what they wanted in the first place.