Utah’s Waiver Proposal–Join Us in Speaking Up for Kids

By Joe Touschner

Like many states, Utah has been working to redesign its Medicaid program in an effort to contain costs–the state submitted a Section 1115 demonstration waiver application to CMS earlier this month. As my colleague Joan Alker has blogged about in the past, waivers are often adopted with little public transparency even though the stakes are very high for Medicaid beneficiaries.  Utah is the perfect example of why children’s advocates need to speak up when a state starts taking about pursuing a Section 1115 waiver.  And we’re asking national kids’ advocates to do just that on the Utah application–read on to find out how you can add your voice to a letter urging CMS not to approve waiver provisions that will limit children’s access to needed care.

As a bill moved through Utah’s legislature to authorize the waiver, much of the public discussion focused on reforming provider payments and the incentives they create.  The formal waiver application, however, reveals that the state is also seeking to remove important protections for children enrolled in Medicaid. In particular, the state seeks to impose unprecedented levels of cost-sharing on children with the lowest incomes and to limit children’s benefits when the state hits an arbitrary spending target. 

Utah’s waiver application seeks to move its Medicaid payments closer to an accountable care organization model, where payments to health plans are based on the number and health of enrollees and the quality of care they receive, rather than on the volume of services providers perform.  Since the waiver does not apply to Utah’s Primary Care Network or to Medicaid beneficiaries who reside in nursing homes, most of the beneficiaries impacted by the changes will be children.  Kids make up 57% of all Utah Medicaid enrollees and a substantially higher percentage when nursing home residents and PCN beneficiaries are excluded.  But they account for less than a third of Utah’s Medicaid spending.  So while kids are a large majority of those affected by the waiver, most of the program’s spending is elsewhere.  

As Say Ahhh! readers know, EPSDT is the Medicaid benefit for children that assures they have access to medically necessary services.  Utah proposes to waive the requirement that it provide children with EPSDT whenever growth in the state’s per capita Medicaid costs exceeds growth in its general fund spending.  This means children would be on the hook for losing benefits if either state spending grows slowly (as in recessions) or per person Medicaid spending grows quickly, whether that spending is on behalf of children or not (and most of it is not).  EPSDT is a key foundation of Medicaid’s commitment to serving children’s unique needs–Utah should not be permitted to waive this vital protection.

In addition to putting some benefits at risk, the Utah proposal would also give health plans authority to impose co-pays, deductibles, or other cost-sharing on services for children in Medicaid.  Medicaid law largely protects the lowest-income children from cost-sharing, but Utah proposes to remove those protections and substitute cost-sharing amounts up to its CHIP cost-sharing limits–some of the highest in the nation.  We’re not aware of any other states that charge anywhere near this level of cost-sharing for kids in families with such low incomes (below 133% of the federal poverty level), nor has the federal government ever approved such a request.

Utah’s application states that the reason for this change is to give plans the ability to encourage healthy behavior among enrollees.  When thinking about kids, though, this idea makes little sense–are kids expected to alter their behavior and make healthier choices because their parents have to pay more for them to see the doctor or get an x-ray?  Removing these protections seems unlikely to bring about the desired result, at least for kids, again the majority of those affected by the waiver proposal.

To raise these concerns with CMS, we here at CCF have drafted a letter to Secretary Sebelius and we hope your organization will sign on, as well.  Right now, we’re looking for national groups to sign on to show their support by August 3.  You can use this web form to add your organization to the list.  Thanks for considering it and stay tuned for more info as Utah’s proposal is negotiated with CMS.