Michael Goldberg | Apr 23, 2020

Not long after rolling out a long-awaited full expansion of Medicaid on January 1st, 2020, a pandemic swept the globe. It was only a matter of time before the virus would creep into Utah

As COVID-19 spread along with its concomitant social and economic consequences, Utah found itself administering the newly expanded Medicaid program under radically different conditions than originally anticipated.  

The state saw a 46% increase in applications for Medicaid in March. 

The move to full expansion in Utah rendered anyone earning less than 138% of the federal poverty level — roughly $35,000 for a family of four or $17,000 for an individual — eligible for Medicaid services. 

Despite the uptick in Medicaid applications since the pandemic began, the numbers still seem to indicate that a chunk of eligible Utahns have either not yet applied, or are not enrolled. 

Utah’s newly expanded Medicaid is poised to help the thousands of Utahns suffering due to the direct and indirect impacts of COVID-19.  The numbers show that too few have been taking up Medicaid, which offers great health care coverage and financial protection against unforeseen medical bills,” said Matt Slonaker of the Utah Health Policy Project. “State leaders ought to be advertising Medicaid a whole lot more. Too many Utahns don’t realize they are eligible.”

The state has not reached the 70,000-90,000 individuals that were estimated to be eligible for the program when expansion was given the green light

Policy analysts like Slonaker attribute the low numbers largely to a lack of outreach from the state.

I don’t think there have been any statewide efforts to promote Medicaid expansion. Unfortunately it’s been pushed down to the community level and even the organization specific level,” said Laura Summers, Senior Health Care Analyst at the Kem C. Gardner Policy Institute. “I think particularly as people are losing their jobs and moving to unemployment, having a greater outreach would be beneficial to helping people understand that there is this safety net program where they can have access to insurance.”

Low enrollment numbers were also explained by some to be downstream of the strong economy before COVID-19 struck.

That was the Legislature’s argument: enrollment is low because the economy is doing so well,” said the Utah Health Policy Project’s Courtney Bullard. “But we also know how important outreach is to getting people enrolled in the program and there was no outreach done by the governor or the state, so we’ve been encouraging them to ally with enrollment organizations to help spread the word.”

The reluctance to shore up enrollment in Medicaid exists in the context of a tumultuous fight over how the program should be administered and to what extent it should be expanded.

In the 2018 November election, a majority of Utahns voted to pass Proposition 3 – a Medicaid expansion ballot initiative providing Medicaid coverage to low-income parents and other adults.

Proposition 3 attempted to provide Medicaid to Utahns under the age of 65, whose income level was equal to or below 138% of the federal poverty line. The measure also vowed to increase property taxes from 4.70% to 4.83% in an attempt to finance the state’s portion of the cost of Medicaid. 

But in the 2019 legislative session, a Republican led effort to “adjust” the expansion resulted in an alternative law being signed that replaced Proposition 3. Senate Bill 96 adjusted the Medicaid expansions that were approved via Prop 3 to make changes to eligibility and the administration of Medicaid. It also capped the income eligibility to 100% of the federal poverty level.

As a result, fewer people were to be covered.

With the replacement law in place, the state wanted to do a partial expansion yet still receive the enhanced federal funding wherein the federal government pays 90% of the total cost of expansion and the state pays 10%. 

In the end, this approach proved to be ill-fated as the state was denied a series of CMS waivers to carry out its adjusted version of Medicaid expansion. 

The state was then left with a fallback plan, which Bullard says can be credited to the work of advocates and the same people who supported Proposition 3 pushing the Legislature to include a fallback provision in case their adjustment plan proved unsuccessful.

On November 4, 2019, Utah submitted to CMS its Fallback Medicaid Waiver that would expand Medicaid to 138% of the federal poverty level and would continue some other provisions in the earlier waivers, including an enrollment cap.

The fallback plan also included provisions that were absent from Proposition 3, most notably a work requirement. Nevertheless the work requirement would later be suspended by UDOH due to the economic impacts of the COVID-19 pandemic.

Following the failed adjustment plan and the implementation of the fallback plan, the state rolled out its full expansion on the first day of 2020. 

While overall enrollment numbers are only gradually increasing, Summers pointed out that they are expected to spike in April as people move from the application process into enrollment. There is typically a several week span between application submission and enrollment which might be why the spike in applications has not been met with a comparable spike in enrollment.

There have not been reports of a significant backlog at the Department of Workforce Services (DWS) in moving through the surge in applications, but analysts are monitoring how effectively DWS will be able to keep up with further increases in demand.

The issue has not featured prominently at the special session which began last week.  

While most of the legislation has been focused on other areas, Bullard said that a lot of the changes that are required to increase health system capacity and make Medicaid work effectively during the pandemic can come through UDOH administrative changes or can come just from the governor. CMS has issued guidance to states for how to increase Medicaid capacity. 

Outreach is another area where coordinated efforts are taking shape outside of the Legislature. 

A lot of big health systems – ACOs, consumer advocates, the Department of Health – a lot of us are working together very well right now which is really awesome after going through a lot of turbulent times with Medicaid expansion. The ACOs are working together to do an outreach campaign for Medicaid and they’re going to put some money behind it which is great to push that message. We hope the Legislature is on board, but luckily a lot of this stuff doesn’t require legislation,” said Bullard.

Analysts say the question swirling around Medicaid expansion will be Utah’s approach to shoring up enrollment while balancing the budget in the face of COVID-19.

The concern over Medicaid expansion has always centered around cost. 

Fortunately the state moved in the direction of providing the safety net in the knick of time before this unforeseen pandemic. So I do think there will be public sentiment that we needed this safety net, and that this was good to have in place,” said Summers. “The potential opposite to that is there’s always been a concern about the affordability of Medicaid. If we ever moved into a recession, that is when people start accessing the program and when costs go up, and there’s definitely concerns about Medicaid taking up more of the state budget and putting pressure on other services. It will be interesting to see which side wins out.”

Sounding off on budget-related concerns with expanding Medicaid, Bullard said not doing so is the fiscally irresponsible move. 

If you fully expand Medicaid, the federal government pays for the majority of programs, and right now they’re paying even more with policy changes that have happened at the federal level. We were actually paying more money not to expand because of the partial expansion. So had the Legislature not expanded Medicaid, the state would be paying 30% of the program instead of 10%.” 

For this reason, Bullard suggests that given the context, Medicaid expansion should be understood as a fiscal boon, not a burden.

It’s a relief to everyone who understands the finances behind Medicaid expansion because like all other states our economy is tanking and we need all the help we can get for health programs. It would further devastate the state’s budget to not expand.”

Go to Source

Medicaid expansion in the age of COVID-19 – State of Reform – State of Reform