Is it finally time for Medicaid expansion in Utah?

State legislators have refused for years to extend the government program to cover tens of thousands of needy residents who fall in a gap between other health insurance options.

But part of that gap could be closed under a bill, HB472, set to be considered in the Utah Senate on Thursday, the final day of the 2018 legislative session. The measure has passed the House, has the backing of Gov. Gary Herbert, and includes provisions many Utah Republicans support, such as work requirements for participants and an overall cap on state spending.

Yet health policy experts say a glaring issue remains. Even if HB472 passes, they say, the federal government is unlikely to sign off on a key component that calls for expanding coverage only to those earning up to 100 percent of the federal poverty line.

Meanwhile, a proposed ballot initiative to put a Medicaid expansion before voters continues to make progress, with signature-gathering efforts by Utah Decides Healthcare, the group organizing that effort.

How many Utahns would get health coverage under these expansion proposals?

The ballot initiative would extend Medicaid coverage to people who earn up to 138 percent of the federal poverty line, which this year was at $12,140 annually for a single person or $25,100 for a family of four.

That means roughly 150,000 Utah adults would gain Medicaid coverage under the initiative proposal, organizers say, though previous estimates by the group were substantially lower. There are presently about 32,000 adults ages 19-64 covered by Medicaid in Utah, according to state figures.

HB472 would only extend coverage to those with incomes at or below the poverty line, not above it. That approach would give coverage to an estimated 72,000 people by 2020, increasing to 87,500 total people by 2024, according to an analysis of the bill.

What is the work requirement in HB472 all about?

The Trump administration says it is receptive to new regulations and tweaks proposed by states regarding their Medicaid programs, changes that previous administrations rejected. These include allowing states to impose work requirements on Medicaid recipients as a condition for receiving coverage.

The idea is that some impoverished Americans need an incentive to work, and such a Medicaid requirement provides it. Trump administration officials — and Republican lawmakers in Utah — have asserted that participation in Medicaid should only be a temporary step, meant to help people get back on their feet and into the job market.

The work requirements under HB472 could include holding a normal job, volunteering, vocational training or other similar activities. Many Medicaid recipients would be exempt from the work requirements for health reasons.

Like other special provisions in the bill, Utah will need special approval from the federal Centers for Medicare and Medicaid Services (CMS) to impose such work requirements on enrollees.

Critics of work requirements say they are only meant to deny people coverage — a way to trim the total number of adults covered by Medicaid by adding more hurdles, including more paperwork.

“Burdensome paperwork is likely to lead to loss of coverage for people already working and those who should be exempt,” tweeted Judy Solomon, health policy vice president at the think-tank Center on Budget.

Will the feds sign off on HB472?

Probably not all of it.

Trump administration officials have shown they are receptive to changes Utah wants to make in its Medicaid program as part of expanding coverage. CMS recently approved work requirements in Arkansas, Kentucky and Indiana, for example, so Utah expects it will get the same treatment.

“We are literally being encouraged by the Trump administration to do this,” HB472 sponsor Rep. Robert Spendlove, R-Sandy, said last week.

But experts say there are strong indications that CMS will not approve another key part of Spendlove’s bill, which would lower the eligibility cap from 138 percent of the poverty line to 100 percent — while still relying on 90 percent funding for the program from the federal government.

CMS officials on Monday turned down a similar waiver request by officials in Arkansas.

“They’re not going to allow this partial expansion and give the generous match,” said Matt Slonaker, executive director of the Utah Health Policy Project. “The Arkansas decision is really clear.”

Spendlove’s assertion is that people making over 100 percent of poverty can buy subsidized health insurance through the Obamacare exchange.

But that would likely be a less favorable deal for the federal government, Slonaker said, because it would be more expensive to subsidize the group of people on an Obamacare exchange than pay their Medicaid benefits.

It is also possible CMS felt it did not have the legal authority to grant such an income waiver, he said.

Will HB472 affect the ballot initiative?

Utah Decides Healthcare says HB472’s potential final passage on Thursday does not change its plan to pursue full expansion of Medicaid in Utah via a November ballot initiative. The initiative proposal, if it passed, would not require a special waiver from CMS.

RyLee Curtis, campaign director for Utah Decides Healthcare, said the group is on track with gathering the required 113,000 signatures from registered voters before a April 15 deadline.

Some 62 percent of Utah voters either strongly or somewhat support the ballot initiative, according to a recent poll.

“Anything that doesn’t go up to 138 percent of the poverty level doesn’t solve the problem for us,” Curtis said this week.