Utah has been a leading conservative state that has actually been trying to engage in constructive healthcare policy for most of this century. Utah did not accept straight up Medicaid expansion, but there has been a variety of efforts to form several different waiver applications to cover the people who make less than 138% Federal Poverty Line. It looks like the governor and the Center for Medicare and Medicaid Services (CMS) have come to an agreement. The state legislature still needs to approve the expansion.
The agreement looks reasonable from both a conservative policy objective point of view, and from a liberal coverage expansion without poor shaming point of view. This is an agreement that we could have seen in fifteen or twenty states after Chief Justice decided to rewrite the law to fuck over poor people if we had a coherent political process of trade-offs. Conservatives get some policy reforms, liberals and moderates get coverage expansion, and the public gets a bit better off. Not a bad deal at all, but it is still unfortunately a rare deal.
There are a couple of major things going on in the proposal. The first is that there are effectively two seperate programs. The first is an expansion and modification of Medicaid for people making under 100% Federal Poverty Line. There will be small ($4 to $8 per service) co-pays for this group that are within normal Medicaid standards. People who make between 50% and 100% FPL will have an inpatient service co-pay as well. But fundamentally, these people will be getting straight up Medicaid expansion.
The other major program being proposed is for healthy people who make between 100% and 138% FPL. Here the proposal hews far closer to the Arkansas premium assistance model (see page 15) and away from traditional Medicaid. People who have insurance offered at work but can not afford it will receive premium assistance to pay for the employer sponsored coverage. People who are not offered coverage at work are subsidized to purchase a cost-sharing Silver Exchange plan with limited cost sharing. 2% of income is expected to pay for health insurance and then the state covers the rest. People who are “medically frail” but make more than 100% FPL are enrolled in traditional Medicaid as a means of keeping the Exchange risk pools healthier. For people buying on the Avenue H exchange, there aer two plan configurations available. The first is a no emergency room co-pay model with slightly higher premiums. The second model has lower premiums but a $50 emergency room co-pay. The goal is to drive down emergency room visits with the co-pay.
People who don’t have coverage at work are in good shape here. They are getting coverage that scores out at 94% to 96% acturial value where standard cost-sharing Silver plans have an acturial value of 94%. This is an improvement over current conditions. The people I would be worried about are the people who work at places which offer Silver level insurance. They can get that policy at an out of pocket premium of 2% of their income, but they will be facing a $2,500 deductible and a $6,500 out of pocket maximum. That is massive underinsurance as the maximum exposure is half of their annual income.
There are a few other minor bells and whistles in the waiver application, but it is fairly straightforward.
This is, in the current political and legal environment, a pretty good deal for all stakeholders who have been involved so far. It should be implemented.