WHY WE STILL NEED THE BALLOT INITIATIVE

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.

CHECK OUT THE WEBITE FOR THE BALLOT INTIATIVE AND FIND OUT WHERE TO SIGN

In Presidential Election, There Is Only One Choice For Healthcare

by Paul Gibbs

I dread presidential election years, and Facebook has made it so much worse. It used to be easier to get away from the vitriol and avoid political tension with friends. And this year it got very intense very early, as the primaries were more heated than usual. I found myself in the position of staying fairly quiet about my preference, and doing my talking mostly with small monetary contributions. But with the primaries over and our choices narrowed, I feel I can't do this anymore in good conscience, because not only are we in danger of not moving forward with any improvements in health care, most of the candidates would destroy any and all progress that has been made in recent years (and both the numbers and the personal experiences of people like me and many others I've encountered as an activist show we have made considerable progress). As a health care advocate, there is only one possible choice I can make for my vote, only one candidate who shows both an understanding of healthcare issues and a longstanding desire to improve America's health care system. Only one who won't throw away all of the work we've all been doing. And that candidate is Hillary Clinton. 

It's obviously not Donald Trump. Trump doesn't have a realistic, solid or detailed proposal for anything. He tells us his healthcare plan would be great, it would be wonderful, it would do everything for everybody. But he's given us next to nothing in terms of details. And there's not a consensus among Republicans to accept a Trump plan, especially with House Speaker Paul Ryan having proposed his own plan. Both Trump and Ryan want to repeal the Patient Protection and Affordable Care Act, and with a Republican president and congress, it would happen. The exchanges would close, causing tens of millions to lose their healthcare coverage.  Pre-existing conditions would again block people from being insured, which would have a devastating effect on people like me with chronic conditions (while I could theoretically fall into Ryan's "except for those with continuous coverage" exemption, there are any number of ways my coverage could get interrupted, and the lack of online exchanges would make getting new coverage that would count as "continuous" much harder.). This, of course, doesn't even go into the myriad of other problems with Trump, an unambiguous racist who has been caught in more lies than all other 2016 presidential candidates combined, and whose dangerous views on foreign policy have caused former officials from Republican administrations to endorse his Democratic opponent.  

What about Libertarian Gary Johnson? Sorry, but Johnson, while seemingly a solidly honest and upstanding guy, shows a frightening lack of understanding of healthcare issues. He even wants to abolish most forms of health insurances, relying on an absurdly naive and unsupported belief that the free market would drive prices down to an affordable range. As an activist who's been working with people who in some cases can't afford the possibility of $10 co-pays or other such expenses but are suffering from devastating ailments, I find this to be the most ridiculous statement on healthcare I've heard in recent years. This is based on an ideological deification of the free market, not on any kind of logic or evidence. He also favors making huge cuts in Medicare and turning Medicaid into a block grant program which would allow states to cover fewer people than they are now, anathema to a Medicaid expansion supporter like me. Johnson seems to me to be a far better human being than Trump, but on the issue of health care, he's not a better candidate. 

And Green Party candidate Jill Stein? While she's a physician, she's also an advocate for fringe pseudo-science and panders to the anti-vaccination crowd. I don't trust someone with such a questionable grasp of medical science to take care of healthcare issues. Besides, while she supports universal health care, any progress that is going to be made on proposals like a "Medicare for all" single payer program would require a huge majority of votes in congress, one which seems incredibly unlikely to happen no matter who wins. And since a third party candidate can't carry down ballot votes with them, any third party candidate inherently helps the "repeal Obamacare" status quo. I find many supporters of Stein or Johnson seem to be voting that way as a moral stand against two major party candidates they see as corrupt or embarrassing.  Sorry, but I cannot let my vote contribute to the risk of taking health care access from tens of million of people so I can feel pure or stick it to the establishment.  I see no morality in that. 

So that leaves us with the much-maligned former Secretary of State. I could go into why I think she's the best candidate on foreign policy and overall economic issues, and at very least the best middle ground on social issues,  but that's not the subject of this blog. So I'll stick to why I believe she's the only reasonable choice for a healthcare activist like me: with Clinton in the White House, the ACA will not be repealed, but it will likely be improved. Those of us who support and defend the ACA are well aware that it's a flawed piece of legislation, and there are problems that need to be fixed. But tell the millions of people who suffer from chronic or potentially deadly illnesses who can now get insurance they couldn't get before that it's not helping anyone. Tell the tens of millions of people who are now insured and weren't before. All credible evidence supports the idea that millions of people have been helped by this law.

Hillary Clinton supports reducing the cost of insurance plans on the healthcare exchanges by extending tax credits up to $5,000 to help families struggling with premiums and and deductibles. And reviving the "Public Option" through an optional state by state process that would not require passing congress.  Through these provisions she'd improve the "Affordable" part while preserving the "patient protection" part.

For me, choosing a president is first and foremost about what they'll do and whether they're qualified and capable to do the job. The only candidate I feel has good ideas on health care and is capable of implementing them is Hillary Clinton. I believe the other three would set us back in ways I can't accept. And that's why, from my healthcare activist perspective, she's the only candidate I can choose.

NEW SESSION, NEW PLANS

by Paul Gibbs

With the 2016 Utah General legislative Session about to begin, the debate over whether Utah will implement a form of Medicaid expansion to cover the 44,000 Utahns in the coverage gap rages on, and less clearly than before. Because unlike 2014, this isn't a debate over a straight-up expansion of traditional Medicaid under the Affordable Care Act. And unlike 2015, it's not about Gov. Herbert's Healthy Utah plan. Both of these unfortunately failed to pass our legislature (and for about the 50 billionth time, no, Gov. Herbert can't just unilaterally pass either one without the legislature. Railing against Herbert on this is a waste of time, effort and breath that we can't afford). What we have now is multiple different potential bills which attack the problems from different directions. Some of these have the potential to be effective. Some, frankly, don't.

We'll learn more about each of these proposals as the session progresses, but here's a preliminary rundown of what we do know, who is sponsoring them, and their respective pros and cons. Along with the basic facts of each bill, I've offered my personal opinion of it's potential effectiveness.  While these opinions are admittedly subjective, I hope you'll notice that they're non-partisan. My support or opposition for these or any other proposals is based on their effectiveness in providing much-needed healthcare coverage to people who can't get it somewhere else. not on which party it comes from.

DUNNIGAN'S BILL

House Majority Leader Jim Dunnigan, architect of the failed "Utah Cares" plan and a member of the Gang of Six who devised the failed "Utah Access +" plan, is proposing a partial expansion which would cover a very small percentage of the gap population, 0-10%.

I've disagreed with Rep. Dunnigan more often than not in this debate but unlike some of his colleagues further to the right, he seems to recognize that there is a serious problem here in need of a solution, and I believe he sincerely wants to solve it. But this plan doesn't even come close to doing that. When Dunnigan acknowledged to a house committee that the coverage provided under "Utah Cares" wasn't "a Cadillac plan", I expressed the opinion that it wasn't even a "Pinto plan". This new plan is one roller skate with a broken wheel. It leaves tens of thousands of Utahns without insurance access and leaves millions of dollars of our tax payer money going elsewhere instead of helping Utah citizens in need. And the promised potential to put higher income people in the gap on PCN (Utah's Primary Care Network) doesn't make it better. PCN offers very limited coverage with no specialty care at all. My aunt who was on PCN had to wait over a year to even get the necessary tests to diagnose an illness that turned out be cancer of the esophagus. She passed away in late 2015.

CHRISTENSEN'S BILL

The bill from Sen. Allen Christensen (R-Ogden) looks to make Dunnigan's look good by comparison. It also only covers a small percentage of those in the gap, and only if they qualify as "medically frail". Aside from fitting the same problems of leaving far too many uninsured and not bringing back tax payer money, it does nothing to address one of the current problems faced by many in the gap who face serious problems: inability to get the healthcare needed to diagnose them as qualifying for help. Christensen has long been one of the most staunch ideological opponents of Medicaid expansion/Healthy Utah/Any version of expansion that uses federal funding, and this bill caters to that ideology, not to fixing the problem. This is the weakest of the plans being proposed.

 


DAVIS' BILL

Sen. Gene Davis (D - Salt Lake City) is again proposing the straight-up expansion of traditional Medicaid provided under the ACA. This certainly would accomplish the goals of providing quality coverage to all those in the gap, and bringing back the maximum amount of tax dollars. The is problem is, it just doesn't stand a realistic chance of going anywhere. The straight expansion has failed in the legislature for three consecutive years and is anathema to the far-right legislative contingent that has stalled previous efforts to cover the gap. Nothing has changed over the past year to give us any reason to believe the result will be any different. I've met personally with Sen. Davis before to discuss the coverage gap situation and the various plans to address it. I appreciate his commitment to providing quality healthcare coverage to those in need, and I certainly don't oppose this bill. But I feel that in this case idealism has to be tempered with practicality in order to achieve results, and that efforts are better spent on plans which would offer comparable coverage (Healthy Utah, for example, would have covered the same number of people and brought back as much federal funding) but stand a greater chance of passing a vote. I'd love to be wrong and see this go further than I expect it to, but I'm not holding my breath.

WARD'S BILL

Rep. Raymond Ward (R-Bountiful), a physician who has dealt with many patients in the coverage gap, plans to propose a plan which has been described by some as a mix between Healthy Utah and Utah Access +, bringing back the maximum federal funding and covering up to 138% of the federal poverty level. Of all of the proposed bills, this is the one which has me most optimistic. Rep. Ward has been one of the most tireless supporters of helping those in the gap since before he was even elected to the House of Representatives, and this sounds like potentially the best deal in terms of providing real coverage,  returning tax dollars, and actually having a chance of going somewhere. The downside is that since Ward is in the house, that's where the bill will start, and opposition to expansion in the house is strong to say the least. I'm afraid it may take quite a bit of pressure to convince Speaker Greg Hughes to even give this one a fair chance, and we need to make sure that pressure is there.
 

CHAVEZ-HOUCK'S BILL

Rep. Rebecca Chavez-Houck (D-Salt Lake City) is another legislator I greatly respect, and if we can't get something like Rep. Ward's bill passed in this session, her proposal to put the issue on the 2016 General election ballot (the result would be a recommendation to the legislature, not a binding decision). This would be a full expansion which, like Ward's bill, would cover up to 138% fpl and bring back the 90/10 match rate from the federal government. If it passes, it will be interesting to see if the staunch ideological expansion opponents in the legislature will exceed my expectations and put the will of their constituents ahead of their agenda.

SHIOZAWA'S BILL

Sen. Brian Shiozawa (R-Cottonwood Heights), last year's sponsor for the healthy Utah bill, plans to introduce a message bill, telling the federal government Utah would implement a partial expansion of of up to 100% fpl if the government were to extend to us the 90/10 match rate, instead of the 70/30 that would normally come with such an expansion. While I'm in favor of a full 138% fpl expansion, I certainly understand where Sen. Shiozawa (who as much as anyone is responsible for keeping the idea of a from of Medicaid expansion in Utah alive and is one of my favorite Utah elected officials of either party) is coming from. Expansion opponents or doubters have frequently expressed that they would be willing to support or at least consider such a partial expansion, therefore this one might have a chance of passing if the federal government would approve it, which they have previously refused to do. Even if this one does manage to get over its many hurdles it's not the best plan, but it's far superior to Dunnigan or Christensen's, and I hope expansion supporters don't mistakenly turn against one of our biggest allies for trying to do the best he can under very difficult circumstances.

SPENDLOVE'S BILL

The bill proposed by Rep. Robert Spendlove (R-Sandy) is similar to Shiozawa's, but adds a purely ideological requirement that people receiving benefits would work. I, like all expansion supporters, am exhausted by now of pointing out to opponents that the data clearly establishes that the majority of people in the gap already work and most of those who don't are disabled or otherwise unable to work. A work requirement serves no legitimate purpose and would make the plan less likely to get federal approval, as the federal government has already refused to accept a work requirement.


With 45 days to go in the legislative session, it's difficult to predict which, if any, of these potential solutions or non-solutions will gain gain support. But it's certain that tens of thousands of Utahns will suffer needless until a solution is found. Contact your legislators and tell them you support a real and substantial Medicaid expansion plan.

Watch ENTITLED TO LIFE and learn about the people in the coverage gap

THE TROUBLE WITH SECRECY

by Paul Gibbs


If there are two things which kind of define my personality these days, it's that I'm a healthcare activist and a film geek. As such, a lot of my attention is divided between two different approaching events: the unveiling of the new Gang of Six Medicaid expansion alternative plan and likely subsequent vote in a special legislative session, and the release of Star Wars: The Force Awakens. I mention these two unrelated topics because the people behind them are approaching them in surprisingly similar ways: under a protective layer of secrecy, revealing only as much as they have to every now and then. This approach works for Star Wars. J.J. Abrams knows the anticipation and surprise are half the fun, and keeping us hooked with a little bit of information but leaving the big questions unanswered will help us enjoy his film all the more. But with the Gang of Six, I'm concerned that this approach leads to serious and negative consequences.

Because the gang of Six is playing their cards so close to the chest, it's very easy for opponents to jump in and fill in the information gaps. The problem is that the groups who are doing this organizations like the Koch brother's Americans For Prosperity, the Sutherland Institute. the Foundation For Government Accountability, and the Libertas Institute, or  pundits or former legislators who share their ideological outlook. These groups have two things in common: they're all very far to the right, and they all vehemently oppose any Utah healthcare expansion which accepts federal funding. Let make sure I'm being clear on the emphasis of the word any. They don't oppose the Gang of Six plan because they're afraid it won't do what Healthy Utah or straight up expansion of traditional Medicaid will. They oppose it because they're afraid it will. This leads to a situation most of us would never see coming: proponents of expansion, including Democrats and other progressives, are buying into Koch brothers propaganda, because for once the people they're bad mouthing are Republicans.

As I said before, a big part of the responsibility for this comes from the frustrating lack of information coming from the Gang of Six. It's understandable that expansion proponents are wary of a plan coming from a group which includes such notable Healthy Utah opponents as House Speaker Greg Hughes and House Majority Leader Jim Dunnigan. And the lack of inclusion of any Democrats, liberal, moderate or otherwise, in any part of the negotiation, also invites distrust. It's not a matter of partisan pride or ego, it;s just not a good approach to public policy. It wasn't a good approach nationally when a Democratic super majority pushed through the Affordable Care Act unilaterally, and it's not a good approach for Utah now. I've chosen my comparison here very deliberately: I may not be the biggest fan of the way the ACA was passed, but while the ACA is imperfect, it's a huge improvement on the way things used to be, and I support the law. What I'm hearing from non-Koch related sources on the Gang of Six plan tells me that, while imperfect, it also offers a great deal of good.

Here are a few genuine facts we know about the new plan:

-It covers up to 138% of federal poverty level the same as Healthy Utah or expansion of traditional Medicaid.
-It returns the maximum available amount of Utah tax payer money.
-It will reimburse providers and hospitals at private market rates, which are higher than traditional Medicaid rates, which is beneficial to hospitals and providers.
-The coverage benefits would be required to be Medicaid equivalent (Silver Level)
-There would be no new caps, no coverage gaps, or reductions in benefits as long as the federal funding remains intact.

If this doesn't sound much like the horrible scenario we're hearing from opponents, it's because it isn't. The doomsday scenarios are at best based on wild speculation, and it's important to reiterate that they're coming from those who want to stop any kind of expansion, not from people looking for the best way to do it to benefit the poor. As frustrated as I frequently get with Utah's legislature and other leaders, these ultra ideological groups are the ones we should be seeing as inherently and eternally untrustworthy. I don't believe that we should or can afford to stubbornly and blindly stick to the idea that a plan supported by Greg Hughes and Jim Dunnigan has to be a bad one. But I believe we can and should inherently question any "information" which comes from these groups.

In the coming weeks, as details of the new plan are unveiled first behind closed doors to the House GOP Caucus, and then publicly to the Healthcare Reform Task Force, we should learn a lot more about it. It's very possible that we'll learn things we don't like. But I strongly suspect that we'll also learn things we do. Based on what we already know, I'm prepared to support and even fight for the new plan. Because, as I've said again and again, it's absurd for us to keep clinging to the notion that defeating a more conservative friendly compromise is going to get us straight up Medicaid expansion (or even Healthy Utah at this point). At best it keeps stretching out and slowing down the process while legislators come up with new plans that will keep moving us further away from what we want, not closer to it.

I understand if some expansion supporters aren't as eager to support the new plan as I am.  But don't jump to opposing it. That's exactly what the Koch brothers and like-minded groups want us to do, and we can't let them control this debate.

OUTSIDE GROUPS ATTACK UTAH HEALTHCARE EXPANSION WITH FALSE ARGUMENTS

by Paul Gibbs

As we get closer and closer to the possibility of a special legislative session to resolve the Medicaid expansion issue in Utah, opponents of expansion are getting increasingly desperate. And they're relying on outside groups that are making the same misleading, cookie-cutter claims to fight expansion in all states. Instead of looking at the reality of Utah's situation, they're simply tossing out the same silly and paranoid claims

Despite what groups like the Libertas Institute and the Koch brothers Americans For Prosperity claim,  refusing federal Medicaid expansion money in Utah will do nothing to decrease federal spending. The money the people of Utah are already paying in taxes will go toward Medicaid expansion in other states. It will still get spent,just not to help people in Utah.  Opponents are also using inflammatory and inaccurate terms such as “sick tax” to describe the proposed tax to be paid by healthcare providers.  This is a ridiculously misleading term, as no proposal has been made to tax "sick" people, only the healthcare industry which will benefit from the expansion. Their argument is misleading and leaves out important facts.  The new plan would reimburse providers at a higher rate than traditional Medicaid, and the financial benefit of the revenue coming in would outweigh any expenditure from the tax.  What rejecting healthcare expansion in Utah will do is leave 53,000 people with no reasonable access to necessary healthcare coverage, and keep Utah taxes going to the federal government without us receiving anything in return. 

 The stories of Utahns like Carol Frisby show us just how serious this issue is. The only way to get these people the help the need is to implement a plan which will return the maximum possible federal funding by covering up to 138% federal poverty level. Don't believe the propaganda coming from these groups that are willing to let people die just to score some points against Barack Obama. These groups don't represent Utah or its values, and they simply aren't telling the truth.

Still Waiting

A TIME FOR UNITY

by Paul Gibbs

When I first decided to make Entitled to Life, I started to meet with people who were working to support Medicaid expansion or what was just then becoming known as Healthy Utah. The 2014 Utah general legislative session had just ended, and a straight up Medicaid expansion hadn't even made it to a vote. One of the first people with whom I met asked me a question that took me completely by surprise: "What's the purpose of your documentary? Is it to express angry at the legislature for not passing Medicaid expansion? Or is it to raise awareness and try to support getting the best possible plan through?" I had to do some serious thinking about that. But I decided that the second option was by far the more productive. That's what I've tried to stick to since.

The reason I tell this story now is because we're at a very important turning point. A week ago statements from House Speaker Greg Hughes and House Majority Leader gave most of us the impression that a plan which would cover up to 138% of the poverty level and bring back the maximum possible amount of Utah tax money from the federal government was no longer a serious possibility.  Now, the so-called Gang of Six (including Hughes and Dunnigan) has announced an agreement for the "framework" of a plan which does just that. We don't know much about the details at this point, and a lot of questions have to be answered. But there's no denying this is a huge step in the right direction. Now, pending those details,  we have to ask ourselves some important questions as well.

The plan isn't going to be a straight up expansion of traditional Medicaid. It's not going to be exactly the same as Healthy Utah. But from what they're telling us, it's closer to both than I frankly thought had any chance of happening at this point. Real coverage for up to 138% fpl and getting back the maximum federal funding has always been the goal. That's what the "Utah Cares" plan we so disliked failed to do. And they can't exactly bring back the controversial work requirement that's already by rejected by the Obama administration. And with the support of Hughes and Dunnigan,  this plan has a real chance of passing. I've made my frustrations with Hughes and Dunnigan very clear in the past. I couldn't have much more strongly disagreed with their approaches during the 2015 legislative session, and nothing I was seeing or hearing from them between now and then changed my mind. But if the details of the new plan are workable (and I join most of my fellow activists in being optimistic that they are), I'll happily consider the two of them allies. Anger over past issues will serve no purpose and distrust and antagonism will be counterproductive.  If we're working toward the same goal, I'm happy to work with them.

At this point there will be no purpose served by dividing into camps and opposing each other to fight over the plan which best suits our respective pure ideologies, or in worrying about what we call the plan or who gets credit. It is necessary to unite in the common effort to get this past both houses of our state legislature,  where the Allen Christensen's and Jake Anderegg's are likely to be no more friendly than before . Any confusion or disunity will be potentially disastrous. But by working together, we can help influence compromise and positive change. It's important that we remember that neither Dunnigan or Hughes have stated an absolute ideological refusal to accept federal funding, and therefore this doesn't constitute an out of character change of position from them which would give reason to be suspicious. If they really have found a solution that silences their fears about sustainability while bringing back the federal funds and providing quality coverage, that will be hard for House Republicans to fight against, especially with the backing of Dunnigan and Hughes. The people many of us thought of us as the biggest obstacles a week ago may very well turn out to be crucial to getting this through. The irony may be equally poetic and frustrating, but what really matters is getting this passed.

For anyone who wonders why, given what I'm saying here, I didn't join with those who supported Utah Cares as "better than nothing" or "the best we can get", the reason is that plan plain and simple didn't get the job done. But in 2014,  I moved from holding out for straight expansion to supporting Healthy Utah because it did, and it appears now that this plan may very well do the same.  And if burying the hatchet with Jim Dunnigan and Greg Hughes helps that happen, then I won't give it a second thought. If the details bear out that this plan offers quality, comprehensive coverage to up to 138% fpl, we need to support it and get the job done. What we needed to do now is push the Gang of Six to give us those details, to be sure that this is real and comprehensive coverage that doesn't fall back on PCN or some other weak and inadequate form of coverage. And, as they've given us no timeline for announcing these details or calling a special session, we need to keep up the pressure that this be done quickly. As we just saw with the untimely death of Carol Frisby, a cancer patient who didn't get the care she needed soon enough, people waiting for this don't have the luxury of time, and therefore these legislators have no right to ask for it either. That's how we can stay involved, and where continued pressure serves a purpose. We don't have all the answers yet, and just as legislators kept insisting they needed to know the details of Healthy Utah, we need to know the details of this. But it's crucial that we
hear them with clear and open minds, not a cynicism that tells us this plan is bad just because of our past feelings toward or experiences with some of the legislators who support it. Some people are going to feel I'm being naive for even considering the idea that Dunnigan and Hughes may now be allies. But all that kind of thinking has the potential to do is kill a solution before it even comes to a vote. I'll take bipartisan hope over partisan cynicism any day.

As I've said in the past concerning Governor Herbert, there will be a time and place to hold people accountable for not acting sooner. But just as we've been asking our opponents to choose between their politics and the needs of tens of thousands of people, we need to be prepared to the same thing. It doesn't matter whether this is victory for Democrats or Republicans.  What matters is a victory for poor and sick people.

THE HIGH COST OF WAITING

by Paul Gibbs

"How much of human life is lost in waiting?" Ralph Waldo Emerson's question takes on new meaning when viewed through the lens of the Healthy Utah/Medicaid expansion debate. Human lives are being lost because Utah legislators insist on delaying action.

On Tuesday June 4, 2014, at the premiere screening of Entitled To Life, Dr. Raymond Ward (now a GOP House Member from Bountiful) announced that Emily Young, one of the patients he spoke of in the film, had passed away. Emily was 43 years old and had not been able to receive the need treatment for breast cancer because she was uninsured. Emily would have been covered by either straight Medicaid expansion or Healthy Utah.

On Wednesday, July 15, 2015, Rep. Ward informed Utah House Speaker Greg Hughes that Carol Frisby, a colon cancer patient Hughes had met with, had passed away, also unable to receive the care she needed.  The fact that we're still experiencing exactly the same problem over a year later is not only heartbreaking, it perfectly illustrates the cruelty of the continual delays which seem to actually be embraced both by Hughes and House Majority Leader Jim Dunnigan. While Dunnigan keeps asking Utahns for patience and saying it's good to have some time, innocent people are dying simply because they have low incomes. And while Emily and Carol put a human gace on the issue, they're far from alone. Harvard Medical School estimates that 316 Utahns per year will die due to lack of coverage without medicaid expansion or Healthy Utah. Considering this debate has drug on for three years, that means that as many as 948 people have have died while it stretches out. If we really are forced to wait until the 2016 legislative session, as now seems a distinct possibility, then it is statistically likely that well over 1,000 people will have died because we waited. It's unthinkable that legisators can live with that figure, but apparently they can. While UtahPolcy.com's account indicated that Hughes was disturbed by the news of Carol Frisby's death, I hold out little hope that it will mark a significant change in his or Dunnigan's approach. They and every other legislator are (or at least should be) aware of the real human faces of the coverage gap. I know this because I'm one of the many people who has brought those faces to them. At this point it would take considerable effort to avoid knowing, though likely some legislators have gone to that effort. I mam quite sure Speaker Hughes is legitmately upset by this tragedy. As I've said many times before, I believe the opposition to Healthy Utah is guilty more of denial than heartlessness. And perhaps this will illustrate the problem in a personal way which makes an impact. But no matter what the reason for the delay, no matter what the motivations of the people who are delaying, the undeniable fact is that people in Utah are dying because the aren't getting the medical care they need. That cost is far too high.


Read Rep. Ward's Deseret News Op-ed

MISSING THE POINT

by Paul Gibbs 

Today yet another economic study was released which showed that Healthy Utah's approach to closing the coverage gap and solving Utah's Medicaid expansion problem was a no-brainer. What else can you call a plan which returns $500 million from the federal government every year, grows our state's economy by $874 million, and gives us 6 times the dollar value of the rival plan? Sadly, a no-brainer seems to be beyond the grasp of Utah House Speaker Greg Hughes and House Majority Leader Jim Dunnigan, who quickly issued a press release making it clear that they consider Health Utah off the table.

While Hughes and Dunnigan are fond of stating that this is no longer a debate between Healthy Utah and Utah Cares, this argument is a silly and condescending insult to the intelligence of Utah voters: it's abundantly clear that these plans represent the two different approaches to closing the gap, and one works and one doesn't. Whatever they're considering has to more closely resemble one or the other of these two plans. The new data underscores the point that any plan which doesn't do what Healthy Utah does isn't a real solution. So the so-called "Gang of Six" continues to meet behind closed doors, with Hughes and Dunnigan claiming to work for a solution to the problem. But what sense does it make to claim you are working to solve a problem, and at the same time dismiss what expert economic evidence objectively shows us is the solution?

Since the end of the 2015 general legislative session, we've been told a plan couldn't proceed until the Supreme Court ruled in the King v. Burwell case. Well, they ruled. Now Dunnigan is shifting the focus to the 2016 election, stating: "If we get a Republican president I think they would give us more flexibility." Does this mean he expects 53,000 people to keep waiting? And what happens if, as every poll tells us is the likely outcome, a Democrat is elected President? What then will become the excuse to wait? Hughes and Dunnigan keep talking about "flexibility", but both economic science and public opinion keep telling us that this flexibility is not needed or wanted. Healthy Utah solves the problem, and every other approach which has been discussed (short of a straight up expansion of Medicaid under the Affordable Care Act ) is at best the equivalent of a Band Aid over a gaping wound from a sawed-off shotgun.

To claim comparing Healthy Utah and Utah Cares is not relevant brings the debate down to a new level of absurdity, which frankly shouldn't be possible at this point.
Speaker Hughes and Rep. Dunnigan's actions and attitudes simpy don't make sense if they are concerned about the needs or wants of the people of Utah. Real leadership requires doing your job, not coming up with new reasons to delay doing it.  And in the meantime, 53,000 of Utah's working poor are left with nothing to but wait and pray that they'll still be able to be helped when (and if) help finally comes.

THUMBS DOWN TO "OPEN LETTER"

by Paul Gibbs

Arguing with opponents of Healthy Utah (or any similar variation of Medicaid expansion which brings back the maximum possible amount of Utah taxpayer money from the federal government) is a lot like arguing with people who insist we never landed on the moon. Every one of their arguments has been effectively shot down over and over again, but they don't stop clinging to them. This has never been more true than the recent open letter from four right wing groups: the Sutherland Insitute, the Eagle Forum, the Libertas Insitute, and Americans For Prosperity. It's full of the same old stereotypes about "able bodied" people who don't want to work, and offers nothing new to the discussion. But aside from the fact that it's pretty laughable to expect anyone to be impressed by four virtually interchangeable ideologically based groups joining together in opposition when literally dozens of diverse groups have come together in support, there is one specific argument that needs to be countered: charges that Healthy Utah and/or Medicaid puts Utah "under the thumb" of the federal government.

The scary specter of Big Brother is a favorite target of opponents who like to make cries of "government tyranny", but who really is advocating putting us under a government's thumb? Not only have the aforementioned dozens of groups voiced support of Healthy Utah, multiple polls show that an overwhelming majority of even conservative Utahns support Healthy Utah. In fact, every poll not commissioned by a right wing group like Sutherland shows that. Aren't we supposed to be a government by the people, for the people and of the people? How is  a legislature which fails to listen to its voice (not to mention the needs of tens of thousands of uninsured citizens) not putting the people "under their thumb"? The point of state's rights isn't just to give state governments freedom to do whatever they want regardless of the needs and will of their citizens, but by advocating rejecting Healthy Utah, that's what these groups are asking for, intentionally or not.  Freedom and democracy are not about moving power to the hands of a state government whose administration seems more friendly to your politics and therefore more ideologically palatable, and then letting a small but vocal minority over ride the will of the majority of people. State's rights are meant to protect the people of those states and their voice, not just to give their governments detached autonomy to choose an ideological course.

 Yes, these groups have the right to have their say and be heard, and nobody is suggesting otherwise. But even with four of them, they represent a very small contingent compared to those voicing support, and it hardly adds credibility to bring four of them together when anyone of sound mind would expect them to agree. It reminds me of a scene in the film The Ladykillers, when one member of a group of criminals planning a heist insists he deserves a larger share of the loot, then points out that his wife agrees "so it's not just one person's opinion."

Don't be fooled by what plays like a pretty desperate attempt to set the debate back to before studies were done and polls were taken. Support Healthy Utah.

OUTSIDE INTERFERENCE

by Paul Gibbs

One thing I have never found myself thinking during our extended campaign for Medicaid expansion/ Healthy Utah/Whatever the next solution is called is "You know what Utah really needs? Another right-wing foundation that cares more about ideology than facts getting involved in this." But we keep getting them anyway. The latest is a new chapter of Americans For Prosperity, a the principal political advocacy group established by the billionaire Koch brothers, two of the more controversial figures in American politics. The the group is just barely getting started, they've already listed Medicaid expansion as one of the issues they plan to target.

What's so troublesome about this development is that it means yet another non-Utah run, ideologically based group getting into this fight to serve a political agenda rather than to do what's best for the people of Utah. We've already seen the Florida based Foundation For Government Accountability run a campaign here which was based on stock photos and stock arguments. About the only thing the seemed to bother to learn uniquely about Utah was the name of the Governor they were picking a fight with. It's one thing to have Utah legislators whose idea of how to solve this problem differs drastically from the majority of Utah's citizens. It's another to have outsiders who have no stake in Utah try to mess up healthcare for tens of thousands of people as part of an agenda to mess with Obamacare, regardless of the cost.

Can anybody reasonably doubt that the conservative voice is being heard?  Sure, opponents such as Rep. Jake Anderegg (R-Lehi) love to act as if their voice isn't getting a chance to be heard on this, but if the voice in favor of Healthy Utah is louder, it's only because there are so many of us, from such a wide variety of of political, religious, medical and business backgrounds, speaking as part of a true grassroots effort and echoing the voice of the majority of Utahns. No matter what groups like the FGA or Americans For Prosperity want us to believe, this isn't grass roots activism, and it isn't the voice of the people of Utah.  The Koch brothers modus operandi is to spend so much money that the voices of two people with an ideological axe to grind are louder than the united, informed and educated voices of concerned citizens. We can't allow that to happen in Utah. Our voices have to be louder, and we can't stop talking.

WHY WE HATE PCN

by Paul Gibbs

Recently Utah House Majority Leader Jim Dunnigan, creator of the proposed "Utah Cares" plan and a member of the six person committee devising a new plan for Utah's coverage gap population,  made the point that those of us who have been critical of Utah Cares have focused almost exclusively on the less "robust" coverage provided Utah's Primary Care Network (PCN), and not on the high quality coverage his plan would offer to a large number of the people being helped. On one level, Rep. Dunnigan has a solid point: we absolutely have focused on PCN. However, I think that Rep. Dunnigan is conviently brushing aside the fact that the competing proposal, Healthy Utah, and any solution most of us are pushing for, would give that high qulaity coverage to everyone getting this assistance.  Taken in full context his defense loses its power. And because PCN remains among the discussed possibilitess for coverage, it's important to keep talking about its inadequacies.

So, what exactly is wrong with PCN? Why do we hate it so much? Why do so many people (and the people I've heard this from have been doctors and nurses) refer to it as "Pretty Crappy Network" or "Practically Covers Nothing"? The reason is that PCN is very limited in the coverage it provides. To quote their own website, the network covers:

• Visits to a primary care provider
• Four prescriptions per month
• Dental exams, dental x-rays, cleanings, and fillings
• Immunizations
• Eye exam; no glasses or contacts
• Routine lab services and x-rays
• Emergency room visits (restrictions apply)
• Emergency medical transportation
• Birth control methods

Those things it does not cover include:

Prescription eyeglasses, contact lenses, MRI’s, CT Scans, Dexa Scans, outpatient hospital services, specialty care, pregnancy related services, mental health services, occupational therapy, physical therapy and chiropractic services (emphasis added by me).

First, let's talk about those restrictions to Emergency Room care. The website description is as follows: If you feel you are having a life-threatening medical emergency, PCN will cover an ambulance ride (ground or air) to the nearest hospital. But, in order for PCN to pay for the ER visit and visit with ER provider, the final diagnosis must be an “approved” medical emergency. Even if your primary care provider tells you to go to the ER, the final diagnosis must still be approved by PCN . . . PCN does not cover MRI’s or CT Scans even if it is during an approved ER visit. Also, if a specialist is called into the ER to visit you, that service will not be covered. For example, if you have an injury and you were seen by an orthopedic specialist along with the ER doctor, then you must pay for the orthopedic specialist.

This is highly problematic and goes beyond the obvious intention to prevent unecessary ER use. For example, in February of this year my father went to the emergency room because of symptoms which he thought may have been a heart attack. Thankfully they weren't. Had he been under PCN coverage, he would have been left worrying whether this vist would be deemed a legitimate emergency (to avoid confusion for those who know me, the accident which lead to me father's untimely death a month later was completely unrelated, and insurance coverage was in no way a factor).

Now let's deal with some of the other issues. Coverage for Pimary Care visits is great. Nobody is disputing that. But lack of specialty care and important tests like MRIs or CT scans is obviously an enormous drawback. Essentially PCN will help you with smaller issues, but not the big stuff.

Let me give you two real life examples of the difficulties created here: My cousin Ben is on PCN, and it will let him visit a doctor, but it won't help him with removal of the 45 lb. growth on his leg which makes it nearly impossible for him to walk, let alone work. It won't help with the rental of the C-PAP machine he needs to care for his potentially fatal sleep apnea.

My chronically ill friend Clare Richardson describes her experience with PCN this way:  PCN was great for the most minimal possible needs: doctor visits were $5, blood tests covered, prescriptions were $5, it paid for one eye exam a year (not frames/lenses) and very basic dental (cleanings/fillings). When it comes to hospital stays, emergency rooms, or any further testing, you are out of luck. PCN didn't help me with a basic medical procedure like ingrown toenail removal, for example, and I have been unable to see specialists that could help me because specialists absolutely are not covered under PCN . . . . PCN is truly, absolutely the bare minimum that Utah can do for its citizens, and when you are on PCN, you feel that each time you turn around. You're better off than you would have been, but you're not healthy. If you are a chronically ill person, PCN places you in stasis. This far and no further.

Part of Dunnigan's defense was that the far more complete Medicaid coverage qould have gone to the lower income "most needy" people under the plan, and I have no doubt that something similar will be true of any plan which involves PCN. Again, to a degree that's a solid point. But it places an awfully high burden on the rest, people who still have low incomes (otherwise they wouldn't be eligible). The great irony here is that this concept, championed only by conservative members of our legislature, inherently goes against some of the more prominent pieces of conservative dogma we've been hearing it recent years: it penalizes people for having higher incomes, and it "rations" healthcare.

Our criticism of PCN is not based on trying to emphasize the negative. We appreciate that it's better than nothing. But it's not a real solution, and shouldn't be a part of the compromise between the members of the committee. Solving this Medicaid expansion issue requires solid, comprehensive coverage, and not just for the poorest of the poorest of the poor. PCN should not be a part of the discussion.

PATIENTS ARE RUNNING OUT OF PATIENCE

by Paul Gibbs

The Thursday, May14 panel discussion on "Designing a Medicaid Expansion That Is Fiscally Responsible" offered some reasons to feel encouraged and hopeful. Some of these came from House Majority Leader Jim Dunnigan (R-Taylorsville), of whom I've been pretty critical in recent months. But there were also causes for concern, and for me, the biggest of these also came from Rep. Dunnigan, who, when asked for reasons he's hopeful, stated his belief that "The people of Utah will be patient for us to get it done right." "Getting it done right" has been a popular refrain from Dunnigan, and it's a laudable goal. But he's mistaken (and distressingly out of touch) in thinking that the attitude of Utahns toward this porocess is one of patience. Polls show us that the public (as well as businesses and organizations) overwhelmingly support Healthy Utah, and, frankly, patience has worn thin to the point of exhaustion. More to the point, when people are suffering without healthcare, as so many currently are (the extensive testimony that was offered to the former Utah Healthcare Reform Task Force makes this an objective fact), it's not resonable to ask them to be "patient." Many of these people literally can't wait.

But Dunnigan's assertion that is not strictly opposed to accepting federal funding was great news, and the most hopeful sign I've seen since the end of the legislative general session. The biggest obstruction to the Medicaid expansion proccess has been the rigid and stubborn ideological opposition offered by by far right members of the legislature. The mantle of poster child for this has moved from Sen. Allen Christensen to Rep. Jake Anderegg. Anderegg (whose recent op-ed for the Deseret News merely reiterated the same old objections without strong fact or logic to back them up) was present as a member of the audience, and his prescence and the question he asked about the waiting list for disability benefits felt more like grandstaning than an actual attempt to understand an issue or present a solution. His query "Shouldn't we do something about that first before expanding?" was ably aswered by multiple panel and audience members, who pointed out that disability benefits are very different program from Medicaid. And RyLee Curtis, a policy analyst for Utah Health Policy Project,
pointed out that the majority of those on the waiting list for disability benefits are, in fact, in the coverage gap, and therefore will benefit by an expansion. In short, Anderegg's point was specious and just another excuse to obstruct expansion efforts. The contrast helped underscore that while there's little I agree with about Dunnigan's approach to the problem, I believe he's serious about wanting to find a soultion.

I actually felt defensive of Dunnigan based on his opening point that he'd been recieving letters asking him why he "hates children." First of all, as he correctly pointed out, children cannot be in the coverage gap. Second, that's an absurd and vicous attack with no basis in reality. While I have no personal aquaintance with Rep. Dunnigan beyond a small ammount of interaction in legislative meetings, I am aware of his personal life as a devoted family man, and he patently does no "hate children." I don't think that's a remotely fair accusation toawrd anyone in the Utah State Legislature, and that sort of cheap attack is harmful to our cause, not helpful toward it. However, Curtis' point about how children are being effected by the delay is airtight: a large portion of those in the coverage are parents, and it should be a no-brainer in a "family oriented" state like Utah that leaving parents without access to healthcare is harful to their children. Additonally, the information from other states (and from Utah) shows us that children are more likely to be enrolled in Medicaid or CHIP if their parents are enrolled in medicaid coverage or something like it. Dunnigan even made this point himself in trying to challenge the assertion made by other members of the panel that Utah was unlikely to experience the "woodwork effect" expansion states have, where people who didn't know they were eligible for coverage discover they are and "come out of the woodwork", thereby inflating enrollment rates. Nevertheless, while I think it's clear that the delay genuinely is harmful to Utah children, I strongly object to claims that Dunnigan or any of the other members of the legislature "hate children."

Another area where Rep. Dunnigan's reason seemed flawed was his statements of concern that states which have expanded Medicaid (either straight up or with variations) have seen much higher levels of enrollment than expected. This is true, but as Leavitt Group Director of Intlelligence Lara Summers responded, those states have also found that not only did that not translate into higher than expected csosts, states have also found that the costs are coming in below expectations, which negates the substance of this argument. Summers also pointed out that the "woodwork effect" was occuring in states such as Washington, where it was more of a "Welcome Mat" effect, in that they are seeking out and enrolling as many people as they can, something Utah is clearly not going to do.

In general, as has consistently been the case, statements painting expansion in a problematic light tended to be full of holes, and the real substance of the panel showed that it's good for Utah as a whole, not just those in the gap. But I was left with a hieightened feeling of unease that Rep. Dunning and House Speaker Greg Hughes are less willing to compromise than the federal government is, and this came from Dunnigan's own assertions that he would not only be looking to "build ladders"  to get over the "fences" set by federal rules, he'd also be trying find the blind spots of the guard towers. This attitude clearly isn't conducive to good faith negotation or give and take, and despite the assertions of anti-Fed hardlines like Anderegg, reaching a solution will have to involve give and take from both sides of the argument.

So the day was full of both hopeful signs and troublesome red flags. And despite Dunnigan's admission that "everybody wants a solution two months ago", the truth is most wanted a solution two years ago.

SECOND OPINIONS

When I was told in November of 2009 that I was in end stage kidney failure, I had a large group of top quality physicians presenting me with a solution: primary care doctors, surgeons, and kidney specialists all agreed that the best course of action was a kidney transplant. Not long after, I ran into a friend with whom I’d taken some college courses, and she was convinced that a transplant was a bad idea. She gave me a pamphlet about an alternative therapy involving herbs and other “natural remedies.” I read the pamphlet, but in the end, couldn’t give it the same consideration I gave to the opinions of my doctors. When I had a consensus of experts using facts and science, it hardly made sense to go with an ideologically based opinion which didn’t seem to have any strong evidence or concrete methodology behind it. Besides, it didn’t really offer a solution to the problem, just a way to put off a solution it didn’t like.

The case we’re encountering with the differing approaches to closing Utah’s healthcare coverage gap. The Healthy Utah plan is the result of two year’s worth of study and deliberation by top state and federal officials as well as the medical community and insurance industry. It fits research which has been conducted by Phds at the University of Utah and other credible organizations. It’s supported by top officials in both of Utah’s major political parties, and has been endorsed by dozens of local organizations ranging from medical groups such as the Utah Hospital Association, Intermountain Healthcare, University of Utah Medical Center  to political, religious and business leaders . And it solves the problem of Utah’s coverage gap,  providing quality, comprehensive insurance coverage to those who do not qualify either for traditional Medicaid or premium assistance under the Affordable Care Act.

On the other hand, on the anti-Healthy Utah side of the spectrum, we have a much smaller and less impressively diverse group of spokespeople. Aside from the exclusively far right Republican legislators who support either another plan such as House Majority Leader Jim Dunnigan’s “Utah Cares” plan, or doing nothing, the only organizations we hear speaking up are groups like the Sutherland Institute, which are admittedly ideologically based, and are therefore looking only to support ideas within their belief system. And even their actual proposals, such as Utah Cares, don’ actually provide access to quality, comprehensive healthcare coverage. They simply put off implementing a solution they don’t like, in this case Healthy Utah. 

There’s an enormous credibility gap between those who support Healthy Utah and those who oppose it. To follow the opposition would be like taking the advice of that pamphlet, and choosing not to pursue a kidney transplant and instead go for something that sounded less scary and more superficially convenient. But in both cases, this would not fix the problem, and the end result would be something all concerned parties would regret.