Good News for Utah’s Children: CMS Upholds Key Affordability and Benefit Protections


By Lincoln Nehring, Voices for Utah Children

In 2011 Utah passed SB 180, Medicaid Reform.  As with many Medicaid reform efforts happening across the country, SB 180’s broad theme was good:  control costs through improved care management and quality.  However, also like many Medicaid reform efforts happening around the country, Utah’s “improved quality” theme came attached with many provisions that put families at risk and potentially limited kids’ access to care.  

The meat of Utah’s reform involved expanding the state’s use of Medicaid managed care and encouraging these organizations to develop delivery models designed around accountable care.  There was great consensus among providers, insurers, and consumer advocates for this change.  Done correctly, accountable care holds much promise to improve quality and control costs in Medicaid and in our health system in general. Unfortunately, however, the Utah legislature did not stop there.  SB 180 required Utah to seek a waiver that would allow the state to eliminate many cost-sharing protections for families; increase co-pays that families must pay to access care; and, if Medicaid costs outpaced growth of the state’s overall budget, eliminate coverage of certain services, including EPSDT.  Needless to say, these proposed changes created great concern among families, advocates, and providers. For those of you who are interested in reading such things, Utah’s original waiver submission can be found here:

Fortunately, through the hard work of many – including our friends at Georgetown – we were able to help the federal government understand the myriad of problems with Utah’s waiver proposal.  And, to the great relief of all, last month CMS denied Utah’s waiver request.

I believe there are several lessons that can be learned from our experience here in Utah:

1. Time – Medicaid reform is complicated business.  Utah tried to put together its waiver request in under 3 months. This did not provide sufficient time for the state to receive meaningful input from stakeholders and develop reforms.

2. The federal government is big, but not faceless – After recognizing that state officials were not being responsive to our issues raised, the advocacy community realized our only hope lay in stopping the harmful components of Utah’s waiver at the federal level.  We were very pleasantly surprised by how accessible CMS was and their interest in hearing our concerns.  

3. Be insistent and persistent – The negotiation process between the state and CMS is not transparent. The only way advocates were able to learn which elements of the waiver were being considered and which ones were off the table was to speak with state officials. The need for more consistent transparency in the waiver process was clear and we hope that federal regulations on this are forthcoming. 

Utah is still moving forward with Medicaid reform and the creation of accountable care organizations–but, thanks to CMS, we are doing so without the harmful distractions.  I am optimistic that low income Utah families and our state’s budget will be served well by CMS’s insistence that we focus on what is really important.