by Bill Tibbitts, Associate Director

There are many concerns and criticisms of the Medicaid waiver application that Utah's Department of Health is currently accepting public comment on.  This waiver application asks the federal government to fully implement SB 96, which the Utah Legislature passed earlier this year in order to scale back the Medicaid expansion proposition that was approved by Utah voters in November of last year.

One big  problem with SB 96 and this waiver implementing it, is that it asks the Trump administration to approve changes to Medicaid that have been explicitly rejected by Congress.  Separation of powers is fundamental principle of the United States Constitution.  Congress is supposed to write the laws and the Executive Branch of government is supposed implement the laws as written.  Congress can delegate finalizing the details of legislation at the administrative level but the Executive Branch cannot use its ability to write administrative rules that overrule decisions made by the Legislative Branch.

SB 96 includes several ideas that have been rejected by Congress.  The biggest of these ideas is imposing a "per capita cap" on federal Medicaid spending that would sever the connection between federal Medicaid spending and healthcare costs-- which have consistently been growing faster than inflation.  The idea of capping increases to federal Medicaid spending at a lower rate has been championed by Ronald Reagan, George W. Bush, Newt Gengrich and Paul Ryan but Congress has consistently rejected their proposals-- in a large part because the majority of Governors have  opposed the idea.  

Given how clearly and consistently Congress has voted against this idea, the Trump administration cannot claim the decision about how Medicaid funding is structured is something Congress intended to delegate to the Executive Branch.  This makes it likely that a decision to approve Utah's waiver application will be successfully overturned in court.  

Our biggest concern with the per capita cap proposal is that if it is implemented it will make our state government solely responsible for determining how to react to the escalating costs of healthcare.  If future governors and state legislators fail to find a way to slow the growth of costs then they will have to choose whether they wish to cut services, reduce eligibility, cut provider rates, raise taxes or increase premiums and copayments for Utahns in poverty.   The fact that the Legislature passed SB 96 tin a year in which they seriously discussed cutting taxes by over $200 million suggests which of these options are most likely to be adopted if current legislators are still in office five years from now..

Aside from these long term concerns, there are more immediate reasons why states show not be applying to experiment with per capita caps.  If the per capita cap is approved by the feds, and not overturned by the courts, then we have entered into an era in which Congress is irrelevant to questions of healthcare policy.  That means that if a new President is elected next year we have the risk that this year's approval will be withdrawn in an abrupt and arbitrary way.  It is unwise for our state to volunteer to be on the leading edge of something that unpredictable.

Medicaid saves and changes lives.  It makes it possible for people  to receive the surgery they need to return to the workforce.  It gives people with chronic health conditions like diabetes a way to obtain the healthcare and medication they need to manage those conditions.  Our state's economy is booming and so we are able to invest in the health and well being of the people of our state without experimenting with untested and unwise funding mechanisms.   

Efforts to reduce child homelessness in Utah will fail if they are based on the assumption that every homeless parent is able to work the 79 hours per week necessary to be able to consistently afford an apartment while earning the minimum wage.   More than one out of every five homeless parents has a disability. That is 2.6 times higher than the rate for the general parent population and 1.5 times the rate for all adults with children in families with incomes under the poverty level.  This should not be surprising.  People with disabilities deal with economic stresses that others do not face.

Unfortunately, the economic stresses of caring for a child with disabilities also increases the risk that an entire family will become homeless. 21 percent of children identified as experiencing homelessness by their school have a disability-- over 60 percent higher than the 13 percent for the general student population. (Get more facts about disability status and child homelessness on page 4 of this report).

The Coalition of Religious Communities is currently challenging candidates and elected officials to sign the Pledge to help reduce child homelessness.  The reason the Pledge talks about the need for more permanent supportive housing for families is that housing with on-site case management and other services is what some parents with disabilities need to provide a stable environment for their children.  The reason the Pledge talks about the need to produce and preserve more housing that is affordable and appropriate for families is that other parents with disabilities may not need services where they live but they are unlikely to ever be able to earn enough money to afford an apartment that costs $2,000 a month.  It is important that we find ways to build and preserve more multi-bedroom housing that costs $800 or $1,000 per month so that children do not become homeless because their parents are unable to earn enough to afford the housing available in many cities in Utah.