Most members of Utah’s Medical Care Advisory Committee oppose the state’s plan to partially expand Medicaid through the imposition of service reductions, spending and enrollment caps and patient work requirements.

Ten of the advisory committee’s 19 members — who are appointed by Utah health care entities — signed on to a June 30 letter addressed to the state Department of Health asking local and national administrators to reject proposed changes to Utah’s Medicaid program, which “could risk the health and security of many Utah Medicaid beneficiaries.”

“These are unprecedented changes with the potential for serious consequences in Utah and across the nation,” the letter states.

Bill Cosgrove, a retired pediatrician and the advisory committee’s chairman, said some of the panel’s members are unable to take a public position on policy issues due to their employment with public and private health care agencies. For that reason, Cosgrove said, the letter was circulated for co-sponsors to add their name rather than being brought up for a public debate and vote during an advisory committee meeting.

“We, as a committee, have sort of assumed responsibility for oversight of the Medicaid process,” Cosgrove, chairman of the Salt Lake County Board of Health, said. “It made sense that we have an opinion and we should state it.”

The advisory committee’s objections were made as part of the public comment for a waiver that Utah is seeking from the federal government to implement a scaled-back version of Medicaid expansion approved by lawmakers earlier this year. The Legislature’s plan, SB96, replaced Proposition 3, a full Medicaid expansion initiative approved by voters last year that would have extended Medicaid services to tens of thousands of additional low-income Utahns.

In its letter, the advisory committee highlights four areas of concern with Utah’s waiver request: a per-capita funding scheme that could leave the state liable for increased health care costs without matching federal funds; enrollment caps that could exclude otherwise eligible patients from Medicaid if funding runs dry; a requirement that patients prove they are working, looking for work or engaged in other qualifying activities to participate in Medicaid; and the elimination of some Medicaid benefits for 19- and 20-year-old patients.

“The proposed changes will make it more complex and difficult for Utah Medicaid participants to access the care they need to improve their circumstances and become self-sufficient,” the letter states.

Among the letter’s signers are advisory committee Vice Chairwoman Jessie Mandle and committee member Danny Harris — who campaigned for Proposition 3 in their private roles with Voices for Utah Children and AARP Utah, respectively — and individuals who opposed SB96 during legislative deliberations, like Cosgrove and advisory committee member Stephanie Burdick.

Advisory committees are required by federal Medicaid laws, but Cosgrove said the makeup and authority of those panels vary from state to state. In Utah, the committee is strictly advisory, he said, with members seeking information from and offering recommendations to state Medicaid administrators, but having no enforcement powers.

“We don’t get much influence,” Cosgrove said, “but we’re going to use as much as we have.”

While Utah’s waiver includes elements that are not explicitly outlined in SB96, the broader elements — per-capita funding, work requirements and enrollment caps — were mandated by the Legislature, giving the state Department of Health limited ability to respond to public feedback. But whether Utah’s partial expansion program will be approved by the federal Centers for Medicare and Medicaid Services, or CMS, is unknown, because many of the elements in the state’s waiver are outside the requirements of federal law.

Similar proposals in other states have been denied by CMS, or approved and later overturned in court. And Medicaid expansion supporters have indicated that a lawsuit challenging SB96 is likely if its more restrictive elements are approved and implemented.

Last month, the Utah Health Policy Project released a report suggesting that per-capita funding could cause Utah’s Medicaid program to face a $39 million budget shortfall by 2024. Budget constraints were among the primary motivations cited by lawmakers in repealing and replacing Proposition 3 with the scaled-back expansion of SB96 intended to control costs.

In a prepared statement, Courtney Bullard, Utah Health Policy Project education and collaborations director, said per-capita caps are not the fiscal solution that Utah legislators are seeking.

“Per-capita caps create a growing gap between the money that Utah’s Medicaid program needs, and the money that the federal government will give," Bullard said. This feature, she added “will never operate within the interest of the state and state’s health care consumers."

If CMS or the courts were to reject Utah’s waiver, a fallback provision in SB96 could see the state allow full Medicaid expansion to take effect, similar to the structure of Proposition 3.

Cosgrove said his goal in signing and submitting the June 30 letter is to prolong the approval process to the point that SB96′s fallback expansion is triggered.

“If we can pause it long enough," he said, “then they run out of time."

Cosgrove said he is most bothered by the work requirements of SB96 — sometimes called a “work effort” or “community engagement” requirement by lawmakers — which positions subsidized health care as a transactional good, rather than a right or privilege.

“You have to work, and, according to these rules, you have to work this much, before we will allow you to have access to health care,” Cosgrove said, “which is just dumb for so many reasons.”

Utah Department of Health spokeswoman Kolbi Young said state officials are going through the comments received from the public to sort and respond to them, at which point the state’s waiver request will be formally submitted to CMS, likely in the coming weeks. At that point, an additional public comment period will be opened at the federal level ahead of either approval or denial of the state’s waiver.

Utah’s Medicaid program currently is operating under a temporary waiver, often referred to as the “bridge” plan, which includes a limited expansion population and approval for work requirements, but those work requirements have not been implemented.

Young said it is unclear when CMS will rule on Utah’s permanent waiver. So far, roughly 10,000 Utahns have enrolled in Medicaid under the bridge expansion, on top of another 20,000 who were previously enrolled in state-run health care programs and moved into Medicaid.

“As with any application or waiver request that we’ve made in the past,” Young said, “the time frame for response from the federal government has varied wildly.”