Trump Wants States to Experiment With Medicaid—Up to a Point

Utah wants to make significant changes while expanding its Medicaid program. Although the Trump administration is open to breaking with precedent, it is not ready to embrace all of Utah’s proposals.

Utah wants to make significant changes while expanding its Medicaid program. Although the Trump administration is open to breaking with precedent, it is not ready to embrace all of Utah’s proposals. Shutterstock

 

Connecting state and local government leaders

Utah may be a bellwether showing how far states can go in customizing Medicaid.

This article originally appeared on Stateline, an initiative of the Pew Charitable Trusts.

After a series of zigzags, Utah is about to expand Medicaid under the Affordable Care Act. At least 10 red states have done the same, but Utah’s experience may be a bellwether showing how far the Trump administration will let states go in customizing Medicaid, the joint federal-state health care program for the poor.

Utah voters approved Medicaid expansion last November, by a 53% to 47% margin. But after the state’s Republican-dominated legislature convened in January, it scaled back the voter-approved measure. Instead of covering childless adults making up to 138% of the federal poverty level — the standard in the ACA and the ballot initiative — Utah lawmakers wanted to cover only those making up to 100% of the poverty level.

Legislators also wanted to add a work requirement — even though courts have thwarted that in other states. They wanted Utah to “lock out” beneficiaries who intentionally received services to which they weren’t entitled — and to allow state Medicaid officials to remove them without a court finding. And they wanted Utah to be able to cap enrollment if it ran into budget problems.

Though Utah needed federal waivers to make those modifications, it had reason for optimism: The Trump administration has heartily endorsed the idea of giving states maximum Medicaid flexibility.

But the mixed reaction of Trump’s Centers for Medicare and Medicaid Services to Utah’s plan has demonstrated that while the administration is open to breaking with precedent, it is not ready to embrace all of Utah’s proposals.

The denials surprised and disheartened Utah Republican lawmakers who sponsored the legislation.

“CMS was very encouraging,” said state Sen. Allen Christensen, chairman of the Senate Health and Human Services Interim Committee. “They said, ‘Think outside the box. Ask, ask, ask and it will be done.’”

State Rep. James Dunnigan, the Republican who managed the legislation on the House side, said he and his colleagues devised the bill’s provisions after consulting with the Trump administration. “We didn’t do this as a lark,” he said. “We had a number of conversations with CMS, and they indicated there would be a favorable reception.”

CMS did not respond to Stateline’s request for comment.

In April, CMS told Utah it could exclude childless adults making between 100% and 138% of the federal poverty level from its Medicaid expansion. But several months later, the agency clarified that if Utah did so, the federal government would not cover 90% of the new enrollees’ costs, the normal match rate for states that expand Medicaid under the ACA. Instead, it would cover only 68%, which is Utah’s regular Medicaid match rate.

CMS made clear that its denial wasn’t an indication of support for Medicaid expansion, a core feature of President Barack Obama’s ACA. In a statement over the summer, CMS expressed concern that if it granted the higher federal match rate to Utah’s partial Medicaid expansion, other non-expansion states might try to follow suit.

“Unfortunately,” CMS wrote in July, granting the higher rate for a partial expansion “would invite continued reliance on a broken and unsustainable Obamacare system.”

Late last month, Utah revealed it is amending its expansion plan to cover childless adults making up to 138% of the poverty level. But the amended proposal also would force some Medicaid enrollees to pay monthly premiums and copayments for some emergency room visits.

Utah got better news on its request for a work requirement. CMS granted that request, even though a federal judge has struck down similar requirements in Arkansas, Kentucky and New Hampshire.

Federal officials still haven’t reached a final decision on whether Utah will be allowed to cap Medicaid enrollment. That would be a momentous change, since until now Medicaid has been an entitlement program, open to anybody who qualifies. Both Christensen and Dunnigan said they doubt now that CMS will grant that request.

Utah also is waiting to hear about its lockout proposal, which would make it the first state with the authority to kick people out of the program for up to six months for committing “intentional program violations.”

Matt Salo, executive director of the National Association of Medicaid Directors, said other states have been closely watching the outcome of Utah’s proposals.

“People know this administration is willing to be very flexible when it comes to things like work requirements, but they’ve been waiting for direction on some other things,” Salo said. “It looks like Utah is helping provide some of the answers.”

Utah’s work requirement, premium and lockout provisions would apply only to the Medicaid expansion population, though the state has indicated it might try to extend them to all Medicaid enrollees if the administration approves them.

Christensen said legislators felt they had to scale back the measure voters had approved because even the sales tax increase it included wouldn’t have covered the costs of a full Medicaid expansion. The state’s Office of Management and Budget said full expansion eventually would have left the state nearly $65 million a year short.

“People can ask for all kinds of things at the ballot box,” he said, “but when it comes to paying for it, that’s another thing.”

Dunnigan said the current proposal does not include a cost-of-living increase for medical providers, which he said will save the state 30% of the ballot measure’s projected cost.

Utah’s original proposal to exclude childless adults making between 100% and 138% of poverty, or $12,490 and $17,236 a year, would have reduced the Medicaid expansion rolls by 40,000 people, according to the state.

Under its proposal, Utah would charge a monthly premium — $20 for individuals, $30 for couples — for people in the expansion population. Those enrollees also would be charged a $25 copayment for non-emergency visits to the emergency room.

Not all the state’s proposals would cost beneficiaries money or keep people off the rolls. Utah also is asking federal permission to allow 7,000 more people experiencing homelessness or receiving mental health or drug addiction treatment to remain in Medicaid for a full year even if their income at times exceeds the limit. The state also is seeking to provide housing assistance to those same groups through its Medicaid program.

But the health care advocates who spearheaded the ballot initiative last year say that on balance, Utah’s proposals would still deny care to people who desperately need it. They strongly oppose the enrollment cap, the lockout provision and the proposed premiums.

Jessie Mandle, a senior health policy analyst with Voices for Utah Children, said the limitations Utah seeks reflect a view that people in Medicaid are trying to get something they don’t deserve when the reality is they simply cannot afford to pay for the care that would keep them and their families healthy.

“These provisions contribute to this perception that there’s a stigma associated with being in Medicaid and that it is not a welcoming program,” she said.

Advocates also say the lockout provision would apply not just to people who intentionally make false claims about their eligibility, but also those who fail to promptly alert officials when a change to their family or income circumstances makes them ineligible for Medicaid. They also say the provision is unnecessary because there are criminal laws against Medicaid fraud.

The state estimates that the measure would affect about 750 people a year.

Courtney Bullard, education director for the Utah Health Policy Project, said she expects the state will have a hard time proving intentional violations. But Bullard fears people will be thrown out of Medicaid through no fault of their own. That is exactly what happened in Arkansas, she said, when that state implemented work requirements before the federal court ruling.

“We should be looking to pull more people into health care,” she said, “not putting up obstacles.”

Michael Ollove is a staff writer for Stateline.

NEXT STORY: Food Stamp Rules Would Eliminate Benefits for 4 Million, Reduce State Autonomy

X
This website uses cookies to enhance user experience and to analyze performance and traffic on our website. We also share information about your use of our site with our social media, advertising and analytics partners. Learn More / Do Not Sell My Personal Information
Accept Cookies
X
Cookie Preferences Cookie List

Do Not Sell My Personal Information

When you visit our website, we store cookies on your browser to collect information. The information collected might relate to you, your preferences or your device, and is mostly used to make the site work as you expect it to and to provide a more personalized web experience. However, you can choose not to allow certain types of cookies, which may impact your experience of the site and the services we are able to offer. Click on the different category headings to find out more and change our default settings according to your preference. You cannot opt-out of our First Party Strictly Necessary Cookies as they are deployed in order to ensure the proper functioning of our website (such as prompting the cookie banner and remembering your settings, to log into your account, to redirect you when you log out, etc.). For more information about the First and Third Party Cookies used please follow this link.

Allow All Cookies

Manage Consent Preferences

Strictly Necessary Cookies - Always Active

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data, Targeting & Social Media Cookies

Under the California Consumer Privacy Act, you have the right to opt-out of the sale of your personal information to third parties. These cookies collect information for analytics and to personalize your experience with targeted ads. You may exercise your right to opt out of the sale of personal information by using this toggle switch. If you opt out we will not be able to offer you personalised ads and will not hand over your personal information to any third parties. Additionally, you may contact our legal department for further clarification about your rights as a California consumer by using this Exercise My Rights link

If you have enabled privacy controls on your browser (such as a plugin), we have to take that as a valid request to opt-out. Therefore we would not be able to track your activity through the web. This may affect our ability to personalize ads according to your preferences.

Targeting cookies may be set through our site by our advertising partners. They may be used by those companies to build a profile of your interests and show you relevant adverts on other sites. They do not store directly personal information, but are based on uniquely identifying your browser and internet device. If you do not allow these cookies, you will experience less targeted advertising.

Social media cookies are set by a range of social media services that we have added to the site to enable you to share our content with your friends and networks. They are capable of tracking your browser across other sites and building up a profile of your interests. This may impact the content and messages you see on other websites you visit. If you do not allow these cookies you may not be able to use or see these sharing tools.

If you want to opt out of all of our lead reports and lists, please submit a privacy request at our Do Not Sell page.

Save Settings
Cookie Preferences Cookie List

Cookie List

A cookie is a small piece of data (text file) that a website – when visited by a user – asks your browser to store on your device in order to remember information about you, such as your language preference or login information. Those cookies are set by us and called first-party cookies. We also use third-party cookies – which are cookies from a domain different than the domain of the website you are visiting – for our advertising and marketing efforts. More specifically, we use cookies and other tracking technologies for the following purposes:

Strictly Necessary Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Functional Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Performance Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Social Media Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Targeting Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.