Medicaid expansion, an issue thought long dead on Utah's Capitol Hill, is rising from the grave this session thanks to a change in rules from the Trump administration.

The Trump administration recently signaled to states that they could impose work or training requirements for recipients, which got the attention of Utah lawmakers and opened the door for an expansion on a limited basis this year. 

Rep. Robert Spendlove, R-Sandy, is leading the effort this year. He says the eventual bill will address a number of concerns that made Republicans reluctant to expand Medicaid in the past.

"Number one, it's expansion up to 100 percent of the federal poverty level. We also have budget caps and risk mitigating mechanisms to make sure we don't spend more than we're anticipating," says Spendlove. 

The Affordable Care Act required a state to expand Medicaid coverage to residents who were up to 138% of the federal poverty level. That meant the feds would pay 90% of the expansion while the state would only pay 10%. Under traditional Medicaid, the split was 70/30. 

Spendlove is confident that the state can get the feds to sign on, even though they aren't getting to that 138% poverty threshold.

"If you look at the coverage gap, those people that were essentially left out by the ACA are living below the federal poverty line," he says. "Everyone above 100%, especially that group from 100 to 138 percent, already have a Medicaid equivalent benefit from the federal government. What we're saying is let's cover those people that really need help, and leave those above 100-percent to the federal government."

Spendlove says the new proposal will expand Medicaid coverage to about 60,000 Utahns with the federal government covering 90-percent of the cost while Utah will kick in 10-percent. 

An important part, maybe the most important part of the still unfinished bill is a limit on how much Utah would spend if the legislature expands Medicaid. Under the original ACA proposal, the state's financial commitment was essentially open-ended with no limit on how much it would cost. Lawmakers want some certainty on how much the expansion would cost the state.

Spendlove says they're still not totally sure how much expanding Medicaid will cost the state, but the number they're working with is somewhere in the neighborhood of $50 million per year.

"We think by repurposing some of the money that the state has already set aside for similar uses, we are hoping we can do it for no new state money," says Spendlove.

Lawmakers were able to push through a limited Medicaid expansion in 2017 that cost Utah about $30 million. Spendlove says if they can repurpose those funds, plus the $20 million they're spending annually on the Primary Care Network, then that should get them the money they need to pay for the new Medicaid expansion proposal. Since it would be funded on the 90/10 split under the ACA, that means a potential $450 million in matching funds from the federal government for the program.

Spendlove says lawmakers are considering a managed care model for those covered by the program, which will focus on preventative care rather than a "fee for service" model.

"It's a model that is being used nationwide. It's a game changer," says Spendlove. "If our goal is to really help people have the best health care possible, then we want to be able to work with them and say, 'What can we do to improve your care?' We want to work through clinics instead of emergency rooms so we can improve their overall health and try to reduce costs."

If lawmakers do pass the Medicaid expansion this session, they will still need to get a waiver from the Health and Human Services department to move ahead. Spendlove says he's running the bill this year primarily because he's received an indication from the federal government that they would be very open to Utah's proposal.