Utah revealed the next chapter in its drawn-out Medicaid expansion debate on May 31. Unsurprisingly, it’s yet another attempt to limit access to affordable health care coverage. Rather than heeding the will of the voters and implementing Prop 3 – which would have given 150,000 low-income Utahans access to Medicaid coverage – the state has been rolling out complicated proposals to arbitrarily limit access and undo long-standing Medicaid law.
Just over two months ago, Utah implemented phase 1: covering fewer people while costing the state more than the voter-approved plan. Rather than extending coverage to parents and other adults with incomes up to 133% of poverty and drawing down a 90% federal match, the waiver, approved in late March, limits coverage to those with incomes up to only 100% of poverty at a roughly 70% federal match. Phase 1 didn’t stop there though – it also added multiple barriers to coverage such as work reporting requirements, a lockout for noncompliance with undefined program requirements, and an unprecedented enrollment cap.
Allowing Utah to cap enrollment blatantly disregards Medicaid law. Since the program’s inception in 1965, the doors to basic coverage have been open to everyone who met the eligibility requirements. Phase 1 is a radical change in that long-standing precedent as the door will no longer be open to all who qualify. The new enrollment cap and other barriers will prevent some very low-income families from accessing health coverage. Even those people who are lucky enough to enroll may find their coverage abruptly terminated after failing to jump over every bureaucratic hurdle and then they will be blocked from re-joining the program until enrollment happens to open up again.
And yet phase 2 would make things even harder by adding a spending cap in addition to the previously-approved enrollment cap. The Trump Administration has been clear that they’d like to limit Medicaid spending any way possible, so it’s not hard to see why they’d welcome a state proposal to cap spending. But it’s not totally clear what’s in it for Utah – existing Medicaid law allows the state to change benefits and provider payment rates to lower costs and, thanks to phase 1, Utah can also limit enrollment.
It seems to me like Utah is proposing a quid pro quo with the Administration – Utah wants the 90% match they would have gotten for expanding up to 133% of poverty, but they want to stop at 100% of poverty. A “partial expansion” like this at the full match is an idea this Administration has already rejected twice. Utah is hoping they can persuade the Administration to reverse their position and give them the higher 90% match if the state agrees to a spending cap. Of course, it’s not quite that simple. Utah is smart enough to know that they don’t want to be left holding the bag if costs exceed an arbitrary cap. So, they’ve built in all sorts of limits and protections into their proposal – the spending cap would only apply to a subset of the population and only up to a certain dollar amount. They’ll take their regular match for all the costs above that amount, thank you very much.
Time will tell if the Administration thinks this is a fair trade – they get the holy grail of block granting Medicaid by first capping Medicaid enrollment and then capping some Medicaid spending in exchange for reversing an earlier decision not to pay the full match for a partial expansion. We’ll all be watching to see if they take the bait.