Why Utah Cares is the Best Option To Help Utahns in the Coverage Gap

Last week the Utah House of Representatives passed HB446, Utah Cares, which I supported. 

As the culmination of several years of study and debate seeking to address the 0-100 percent of Federal Poverty Level (FPL) coverage gap created by the Affordable Care Act (ACA), Utah Cares provides health coverage to all poor Utahns over the long term and does it in a sustainable way, regardless of what happens with the ACA.

It is not the optimal program as far as coverage is concerned and it actually costs more to the state than Healthy Utah for the first two to three years, but it is a long-term commitment to current adults without insurance coverage. It is also sustainable and allows us to move forward, while giving us time to evaluate the program and retain the flexibility necessary to ensure that it remains fiscally viable regardless of what happens to the ACA.

Utah Cares provides full Medicaid coverage for the poorest adults in the coverage gap. For those who make more money but still less than 100 percent of FPL, Utah Cares provides coverage through a Primary Care Network (PCN). Under Utah Cares, PCN coverage would include outpatient access to primary care providers, laboratory tests, x-rays, emergency department care, four prescriptions per month and access to some outpatient mental health care including psychiatrists and psychiatric nurse practitioners. PCN does not cover specialty care or hospitalizations. Primary Care Network is not full-coverage insurance that one could expect under Healthy Utah, but it is a step in the right direction and is a long-term commitment by the state to begin addressing the problems faced by thousands of low-income Utahns who currently have no access to any health insurance.

I personally believe that if we had certainty about long-term costs and sustainability of the 90/10 federal-state ACA commitment, the ideal solution would be Healthy Utah, SB164. It provides full coverage to all currently uninsured adults in the coverage gap. The benefits of such robust coverage are significant and would likely result in reduced costs elsewhere in state government such as decreased unemployment, disability and premature death, improved mental and physical health outcomes and reduced criminal justice costs. If we knew with a reasonable degree of certainty that the federal government could and would sustain long-term its ACA commitment to pay 90 percent of the costs of providing full health insurance coverage to currently non-covered adults, then clearly we should go forward with Healthy Utah. 

However, there are legitimate and rational concerns about what might happen to the ACA during the next several years, including the federal government cutting their contribution and possible repeal of the ACA. For example, if the federal government were to change their contribution to Healthy Utah from 90 percent to 70 percent, Utah would be responsible for 30 percent of the costs instead of 10 percent.

The cost to the General Fund of continuing Healthy Utah would go from $78 million in 2021 under a 90/10 scenario to $136 million per year under a 70/30 scenario.  This could result in the need for partial or complete repeal of the benefits promised under Healthy Utah due to inadequate General Fund revenues

While retracting benefits sounds “simple” in concept, the practical aspects of such an event are not inconsequential. Each year many of the commitments we’ve already made to help the poor and needy go unfunded because there just isn’t any more money. We do little good when we can’t keep the promises we make when seeking to help those most in need. 

Other concerns I have include the effects of events that are quite certain, including future economic downturns. Downturns are cyclical and result in reduced tax revenue and increased need for social services due to increased unemployment and other problems. The 2008 recession resulted in a steep decrease in state tax revenue and increased demands on state social services. This combination required extensive use of “Rainy Day Funds,” coupled with severe cuts (up to 15-20 percent) in funding for all aspects of state government. These types of draconian cuts are going to be needed at some point in the future, and despite my enthusiasm for providing full health care coverage for all adults, the likelihood of facing deep budget cuts due to drops in tax revenue makes me more cautious.

Aside from the cyclical economic problems that create increased community dependence on Medicaid, those with complicated and expensive physical or mental health issues often find themselves financially destitute and considering the option of going on SSI disability so they can have access to Medicaid to help pay their medical bills. In my work as a physician, the majority of people I deal with on disability want to work. The problem is that once on disability, if they start earning very much money, they lose the Medicaid coverage that keeps them healthy enough to be productive.

These individuals need some form of provisional insurance that allows them to progress from unemployed and on Medicaid into the ranks of the working and eventually above the poverty level, where they then become eligible for private coverage on the federally subsidized exchanges. 

Utah Cares allows psychiatrists and psychiatric nurse practitioners to act as primary care providers through PCN. This will allow those with mental illness who want to work, the option of continuing care including prescribed medications with their mental health provider while progressing off of Medicaid and working towards getting out of the coverage gap through better employment. PCN is not perfect in this regard, but it will help many people with mental illness in their efforts to maintain employment and not deteriorate to the point of losing their job due to unmanaged mental illness. This is a vital component of health coverage for those in this under-100-percent-of-poverty population.

The legislature is also considering HB348, Criminal Justice Reform, that has broad support and implements proven programs and methods for reducing recidivism and helping individuals convicted of a crime get the help needed to deal with mental health issues and overcome addiction. An integral part of the success of these reforms is continuity of healthcare and substance abuse treatment upon release from prison or jail. It is vital that care and supervision not end upon release and programs are in place and funded sufficiently to aid in the transition from illness and addiction to productivity. Healthy Utah would be the best option to meet these treatment needs but Utah Cares will also be able to provide some of these transitional needs. If we want to see true criminal justice reform, we may need additional resources as we go forward.

If Utah Cares passes the Senate and is signed into law by the governor, no individuals or families would remain without access to some form of affordable health coverage. Many currently uninsured adults would be added to the traditional Medicaid program administered by the state. The rest of the adults in the current coverage gap would have access to the expanded Primary Care Network.

I believe that Utah Cares HB446 begins to address the problems we’re currently struggling with in healthcare and allows us to extend coverage to those most in need. It is not perfect, but Utah Cares is a good, measured and sustainable step forward that Utah can take at this time and continue long-term regardless of actions by the federal government.

Representative Edward Redd is a physician from Logan, Utah. His practice includes outpatient primary care for adults without insurance, mental health inpatient and outpatient care, public health and infectious diseases, substance abuse treatment and jail healthcare for inmates.