Utah: GENIUS! CMS approves scheme to cover 50,000 *fewer* for $50 million *more*.

From February:

The full expansion initiative passed last fall, of course, is supposed to cover Utah residents earning up to 138% of the poverty line, or around 150,000 people...without any work requirements.

The bill barreling through the Utah Legislature was “an effort to override the will of the people,” said Matthew Slonaker, the executive director of the Utah Health Policy Project, a nonprofit group that supported the full expansion of Medicaid.

Utah lawmakers, worried that the sales tax increase might not fully cover the costs, are rushing through a bill that would limit the expansion of Medicaid to people with incomes less than or equal to the poverty level, about $12,140 for an individual.

State officials say that the bill, which is estimated to cover 90,000 people, could be on the desk of Gov. Gary R. Herbert, a Republican, in a week or two.

...not only would this bill overturn the explicit will of the voters and cover up to 60,000 fewer people, it would actually cost more then if they just expanded Medicaid directly, as the ballot proposal demanded:

In its place, the bill directs the state Medicaid agency to seek approval for an unusual and uncertain federal Medicaid waiver that would provide Medicaid coverage to 48,000 fewer Utahans and would cost the state $50 million more over the next two years, according to a state fiscal analysis.

There exact discrepancy between the two numbers varies depending on the source, between 48K - 60K, but roughly 50,000 Utahns seems to be the concensus.

And how could it cost $50 million more to cover 50,000 fewer people? Well, technically it doesn't; it's just a matter of how the funding is split between Utah and the federal government. They had a choice:

  • 150,000 (?) people with Utah having to pay 10% of the cost, or
  • 100,000 (?) people with Utah having to pay 32% of the cost.

Assuming an average of, say, $3,400 per enrollee, that means Utah would've spent roughly $51 million/yeear to cover 150,000 people but apparently prefers to spend $109 million/year to cover 100,000. That's actually $58 million more in one year, so either the expansion-targeted population is a lot healthier than the average adult currently on Medicaid in Utah, or (more likely) those earning less than 100% FPL are a lot sicker than those earning 100-138% FPL.

Either way, the point is that Utah Republicans have chosen to spend gobs more Utah money in order to provide healthcare coverage for a lot fewer of their residents, which makes absolutely no sense, but there you have it.

In any event, until today, this waiver was in limbo waiting for Seema Verma--who just this morning was revealed to be showing that fiscal restraint that the GOP is so well known for by spending millions of taxpayer dollars to improve her personal media image--to give the waiver a thumbs up or down...and sure enough, she definitely gave 50,000 Utah residents the finger:

For the reasons discussed below, the Centers for Medicare & Medicaid Services (CMS) is approving Utah's June 22, 2018 and February 6, 2019 requests to amend its section 1115 demonstration project entitled, "Primary Care Network" (Project Nos. 11-W-00145/8 and 21-W00054/8), in accordance with section 1 l 15(a)(2) of the Act.

...This approval is effective as of the date of the approval letter through June 30, 2022, upon which date, unless extended or otherwise amended, all authorities granted to operate this demonstration will expire. CMS's approval is subject to the limitations specified in the attached expenditure authorities and special terms and conditions (STC). The state may deviate from Medicaid state plan requirements only to the extent those requirements have been listed as not applicable to expenditures under the demonstration. Per longstanding policy, CMS considers each state amendment or waiver request independently, and this action does not indicate likely approval or disapproval of any future requests.

...With approval of this demonstration, the state will have the authority to provide Medicaid coverage to adults with incomes up to 95 percent of the FPL who previously were not eligible or who were only eligible for benefits as part of a prior demonstration population (Adult Expansion Population).

Note that while the approved cut-off income point is 95% FPL, it includes the same "5% income disregard" that "vanilla" expansion does, bringing the effective cut-off point up to 100%. "Normal" expansion officially extends to 133% FPL, but is effectively 138% for this same reason.

But wait, it gets even worse:

Community engagement

With approval of this demonstration, Utah will require, as a condition of eligibility, that nonexempt beneficiaries in the Adult Expansion Population within the first three months of a 12 month benefit year or following notification that the beneficiary is subject to the community engagement requirement, whichever is later, complete the following activities: (1) registering for work through the state’s online system that helps Utahans with training and finding work; (2) completing an online assessment of employment training needs; (3) applying for employment, either directly or through the state’s automated employment application submission process, with at least 48 potential employers; and (4) completing online job training modules, as determined appropriate for the individual by the online assessment.

Yes, that's right: Not only did they lop 50,000 people out of the loop entirely, the other 90 - 100K enrollees will also be subject to...wait for it...work requirements. Well...sort of; keep reading.

First, it looks like they'll have to apply to at least 48 employers as well. So...what, if they get hired by the first one they still have to apply with 47 more?

Note that it says "and" before the fourth item, not "or"...which means all of them will have to register online, complete a training assessment, apply to at least 48 companies and complete an online training course.

So, is there any good news here (aside from the fact that at least some Utahns will receive healthcare coverage)? Well...

The state will exempt various groups: beneficiaries who are pregnant or 60 days or less postpartum; beneficiaries 60 years of age or older; primary caregivers of a family member under six years of age, members of federally recognized tribes; beneficiaries who have applications pending for or are receiving unemployment insurance benefits; beneficiaries participating regularly in SUD treatment; beneficiaries exempt from or in compliance with Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF) employment requirements; beneficiaries participating in state refugee employment services; beneficiaries who are physically or mentally unable to meet the requirements as determined by a medical professional or documented through other available data sources; beneficiaries who are responsible for the care of a person with a disability as defined by the Americans with Disabilities Act (ADA), section 504 of the Rehabilitation Act, or section 1557 of the Patient Protection and Affordable Care Act; beneficiaries enrolled at least half time in any school, college, or university or vocational training or apprenticeship program; state Family Employment Program (FEP) recipients who are issued FEP cash assistance diversion payment for that month; or beneficiaries working at least 30 hours a week or working and earning income that is at least equal to earnings for an individual working 30 hours a week at federal minimum wage, as verified through wage data available to the state. Beneficiaries seeking an exemption will be required to report their qualification for an exemption to the state only once during the 12-month eligibility period. Non-exempt beneficiaries will have the opportunity to avoid the consequences of noncompliance by demonstrating a good cause for failure to meet the requirement; a beneficiary experiencing the death of a family member living with the beneficiary is one example of good cause.

OK, so if they prove that they work at least 30 hours per week, they're exempt from...what again?

Utah’s community engagement requirement is a slightly different model than those that CMS has approved in other community engagement section 1115 demonstrations to date. In contrast to other demonstrations, Utah is not counting working 30 hours or more a week or being enrolled at least half-time in an educational/training program as a qualifying activity, but rather as exempting the beneficiary from the otherwise applicable requirement to complete the community engagement activities. Many beneficiaries who qualify for an exemption from the community engagement requirement (e.g. those who are working at least 30 hours per week, enrolled at least half-time in an education or training program, complying with TANF or SNAP employment requirements, or participating in refugee employment services) are already engaging in activities that the community engagement requirement is attempting to promote, and CMS believes that these beneficiaries are already adequately engaged with their community and that requiring them to engage in additional activities specific to this demonstration’s community engagement requirement would be unnecessary.

Hmmmm...ok, so basically if they work at least 30 hours a week, they don't have to fill out all the busywork and jump through the four hoops listed above.

That sounds pretty silly and pointless, but as the letter itself notes, this isn't as bad as states like Arkansas and Kentucky, so maybe this requirement will sneak in below the radar of yesterday's judicial decision. We'll see.

Oh by the way, one more thing: The minimum wage in Utah is $7.25/hour.

  • 30 hours/week x $7.25/hour = $217.50/week.
  • $217.50 x 52 weeks = $11,310/year.
  • For a couple, that's $22,620/year.
  • 100% of the Federal Poverty Line for 2019 is $12,490/year for a single adult or $16,910/year for a couple.

I'm assuming FPL isn't calculated until after personal exemptions and the like are subtracted. If so, this is a moot point, but if not, it means a single adult who earns even 10% more than minimum wage wouldn't qualify for Medicaid expansion anyway...and a married couple who both worked 30 hours/week even at minimum wage would have no way of qualifying.