Friday, March 9, 2018


by Paul Gibbs

So, the Utah State Legislature, after years of not passing a substantial Medicaid expansion (sorry, I appreciate the good that the micro expansion which came from the Utah House of Representatives has done, but it's too small and has been too increasingly chaotic and hard for even the most deserving to get coverage through for me to call it "substantial), the Utah State Legislature finally passed one. The new expansion is a big step in the right direction. It is not, however, a truly viable solution to the problem.

Why? Perhaps the biggest reasons is that there is almost no chance it will actually happen in its current form. The pared-down Medicaid expansion requires considerable waivers from the federal government, and one of the biggest things that made it acceptable to legislative Republicans will not get federal approval: the scaling back of the expansion to cover only up to 100% of federal poverty level. How do I know this? Simple: the recent Arkansas Medicaid expansion waiver was granted mulitple concessions by the federal government department of Health and Human Services, but not this one. If it it didn't fly in Arkansas, it won't fly in Utah.  This leads to the question of why the Utah State Legislature would even pass a bill for an expansion that it had just been established would not pass. In most years the Arkansas expansion decision would have killed this bill. However, in most years there isn't a looming ballot initaitive to let the people of Utah choose to accept the full Medicaid expansion. The simple reality is that there is no way a Medicaid expansion as substantial as this one would ever have made it to a vote in the Utah House of Representatives if it weren't for the fact that they were afraid of the ballot inititaive and trying to head it off. Make no mistake, credit for anything the sick and the poor do eventually get from this expansion (if indeed they get anything at all) goes not to the legislature, but to the healthcare advocates who have relentlessly pushed to keep this issue alive so long.

So, having now established that the new partial expansion can't get federal approval in its current form, let's talk about what's good and bad in it:

GOOD: It brings back federal tax oney Utahns are currently paying, and brings coverage to roughly 70,000 Utahns who don't currently have it. I openly and very happily acknoweldge that this is a considerable good, and I gratefully commend those legislators who genuinely supported it because they knew it was the best that would get passed in the Utah legilature.

BAD:  Aside from the aforementioned "Can't Get Federal Approval" problem (which is important enough that we need to keep coming back to it), there is the fact that this version of expansion includes a work requirment that can most diplomatically be reffered to as misguided. Endless studies show that 64% percent of those who would recieve coverage under full expansion already work. And the most diplomatic term to use for the argument legislators use about the rest being "able-bodied people who choose not to work" is "lie". The fact ois (and I've documented this in multiple states), many disabled people who need Medicaid coverage (whether traditional or expanded Medicaid) are not able to qualify as disabled to get the coverage. Why? Because they can't afford to see a doctor to get the diagnosis to qualify them as disabled. Free clinics and other currently available charity programs don't cover specialty care or expensive tests like MRIs. A poor person could rack up thousands of dollars of medical bills just trying to get qualified for Medicaid, with not certainty that they eventually will. SO the work requirement is bad solution to a problem that doesn't exist, and is only there to satisfy an ideological contingent that is more concerned with a fear that somebody else will get coverage they have to work for than with simple human decency or the moral imperative to care for those who legitimately can't care for themselves.

Additionally, this version of expansion includes caps on the number of people who can be covered and the amount of money that can be spent on it. This means when that point is reached, people get left out no matter how desrving or badly in need they are.

Then there is the issue of only covering up to 100% fpl instead of 138%: while legislative Republicans are techincally correct in their assertion that the people above 100% are eligibile for ACA subidies, the argument some of them like to make that this is giving them "double coverage" is flat out wrong. You can't reciveve both Medicaid and ACA subisidies, period. Besides that, there is a very sound reason for the overlap: hard lines inherently create cracks. And where there are cracks, people will fall through them. That's inevitable.

Finally, despite the Republican legislators continued use of their favorite catchphrase, "fiscally responsible", this expansion doesnt qualify as such in the way that the ballot initative does. The ballot initative includes a funding mechansim for the 10% of the costs Utah will have to pay, in the form of sa very small sales tax increase on non-food items, an increase which amounts to only 3 cents on every $20 spent. Surely this small increase is worth it to give people access to life-changing (or even life saving) healthcare, and to protect Utah's state budget into the bargain.

The Utah Decides Healthcare ballot intitiave closes the coverage gap with an overlap to make sure people don't fall through the cracks. It leaves out ideologically appealing but pointless and harmful hoops for people to jump through. It has a mechanism to pay for it. And it requires no special waiver to be implemented. None of those things can be said about the bill passed by the Utah State Legislature.

So, while I sincerely appreciate the good that will be done  IF the legislature's plan somehow manages to secure federal approval (in whatever form it would have to take to get that, because the current one can't get it), the job isn't done and the problem isn't solved. The ballot initiative is the only way to do that.