Leonard Bagalwa, a Congolese immigrant who helps Utahns find health insurance through federal programs, said he was excited when voters approved Proposition 3 last year, believing it would mean Medicaid coverage for his family beginning April 1.
“Making enough money to survive is not always easy for us,” Bagalwa said.
But on Monday, he said he continues to lack access to affordable health care after Utah lawmakers replaced Proposition 3 with a partial Medicaid expansion that leaves him and many low-income Utahns to purchase private insurance.
“I do this every day, enrolling people, and we shouldn’t be fooled by our politicians,” Bagalwa said. “There is a reason why [full expansion] was put on the ballot and a reason why people voted it for. And it should be respected as well.”
Beginning Monday, Medicaid coverage is open to between 70,000 and 90,000 Utahns who earn up to 100 percent of the federal poverty level. And under a federal waiver approved Friday, the state is responsible for 30 percent of the cost for those beneficiaries.
But had Proposition 3 taken effect, Utah would have paid 10 percent of the cost for roughly 150,000 Utahns earning up to 138 percent of poverty.
“We’ll be spending more of Utah’s hard-earned taxpayer dollars, yet covering fewer people,” said Jessie Mandel, senior health policy analyst for Voices for Utah Children. “That should give us all pause.”
While a roughly $90 million sales tax increase was included in Proposition 3 to support full expansion, lawmakers argued the longterm costs would threaten the state’s budget, and that changes were needed to maintain sustainability.
The state expects to eventually achieve the same 90-10 cost share with the federal government for its smaller enrollment population by requesting a series of concessions from federal administrators. But critics say those concessions, if approved, are legally questionable and impose unnecessary hurdles on otherwise eligible people.
“We started off with Proposition 3,” said Stacy Stanford of the Utah Health Policy Project, “and instead we have our new broken bridge.”
Stanford said the state plan’s combination of work requirements, caps on the number of people enrolled and to-be-requested per-capita funding from the federal government will exclude some low-income people, creating new health care coverage gaps.
And because Utah stopped short of the income level established in federal law — 138 percent of poverty — Utahns who expected coverage under Prop 3 must now wait until the next open enrollment period to purchase insurance on the Affordable Care Act individual marketplace.
“There’s a whole lot of people that thought they were eligible,” Stanford said. “And now they have to wait until next January because they’re falling through this missing plank.”
The approval for Utah’s wavier came one day after a federal judge struck down work requirements in Kentucky and Arkansas, which had led to thousands of otherwise eligible patients being removed from the Medicaid rolls.
Nate Crippes, an attorney with the Disability Law Center, said he was disappointed that the Centers for Medicare and Medicaid Services (CMS) followed that court decision by approving Utah’s waiver, which includes a requirement that beneficiaries prove they are working, looking for work, or engaged in educational and workforce training.
Crippes said those requirements fall outside the federal Medicaid law, which is intended to provide health coverage.
“Unfortunately, work requirements don’t do anything to provide health coverage," he said, "they really act as a barrier for people to access health coverage.”
Utah lawmakers say the state’s plan includes a work “effort” requirement, and includes various exceptions for students, parents and the mentally and physically ill.
But Crippes and other full expansion advocates say the problem lies in requiring beneficiaries to report their work effort to the state, creating an additional administrative hurdle that, if violated, can cost someone their access to health care.
“There’s nothing about seeking work that is health coverage,” Crippes said.
Bagalwa echoed that concern, saying the refugees he works with and other non-native English speakers already face challenges in accurately completing their Medicaid paperwork and requirements.
“Small things can make you lose your Medicaid if you didn’t understand the language,” he said.
And Mandel suggested the combination of Utah’s cost-saving provisions could create a domino effect for beneficiaries, as temporarily losing eligibility because of failing the work requirement could lead to a long-term loss of care when the state caps its overall spending.
“They could be eligible, miss a piece of paperwork, fail to comply with something, go to re-enroll and find out that they’re capped out,” Mandel said. “That’s what we’re left with.”
Stanford said she expects Utah’s next waiver — seeking the 90-10 split and per-capita funding cap — to be rejected by the federal government. If it is, a fallback provision in state law could see the state fully expand its Medicaid eligibility to 138 percent of poverty.
But while she supports a full expansion, she said the delay while Utah exhausts its effort to restrict eligibly will have serious consequences.
“The people who are falling through these gaps have very real issues right now,” Stanford said. “And they can’t wait until a fallback plan that might come 18 months from now.”
Kolbi Young, a Utah Medicaid spokeswoman, said more than 19,000 Utahns were enrolled in the expanded program as of Monday afternoon. Of that group, most were part of the state’s Primary Care Network and automatically transitioned into Medicaid as part of the expansion, Young said, while roughly 1,500 were early applicants whose Medicaid eligibility had been authorized in advance by the Department for Workforce Services.
“Their benefits would start today,” she said. “We are monitoring it really closely.”
In a prepared statement, Chase Thomas, executive director of Alliance for a Better Utah, credited the work of advocates, activists and voters for getting the state to its current place of expanding health care access to low-income Utahns.
But Thomas added that the efforts of lawmakers means roughly as many people are left out of Medicaid expansion as are included in the current, partial program.
“The number of Utahns who would have been able to enroll in Medicaid today would fill the Vivint Smart Home Arena four times over," he said. "Yes, today is a win in many ways for those Utahns who will be able to see a doctor for the first time in years. But let’s not forget how hard the Legislature worked to keep that same healthcare from tens of thousands of Utahns.”