The County Seat – Discussing Medicaid Expansion

The County Seat – Discussing Medicaid Expansion


Chad Booth: welcome to the
County seat I’m your host Chad Booth today we’re
going to talk about something that is been a
topic of conversation for almost 10
years. It is called Medicaid expansion it comes as
part of the Obama care legacy that was
passed in 2011. And ever since that time there
have been controversy here in the state or
controversies here in the state over whether
we should participate in Medicaid
expansion, which is part of the entire bill with Medicaid
expansion. It helps people that are basically
at a percentage of poverty level get medical
coverage through the federally subsidized health
care system states had to pay part of it.
We’re going to cover how we got from that point where
we got to proposition three and from where
we are today with the bill to modify it,
let’s start with the basics of the history. Medicaid was signed into law in
1965 as part of President Johnson’s “Great
Society” effort. It provided insurance for people of
all ages who did not have enough income or
resources to pay for health care. States
were not required to provide Medicaid but all 50 of
them eventually chose to do so. Medicaid was a direct benefit
plan originally, which means as medical bills
were accrued by qualified individuals, the
government would pay for the care directly. In the 1980s there was a debate
about the efficiency and waste of the
government program and an attempt to
“privatize” the medicaid system, which led many
states to get waivers from the federal
government to create Medicaid Managed Care Programs,
These programs allowed states to use
their funds to enroll eligible people into
private health plans. That became the Status Quo for
most states, including Utah. Then came the
Patient Protection and Affordable Care
Act, or Obama Care as it has been nicknamed,
which passed and was signed into law in 2010,
This law originally required states to
expand Medicaid to cover all people making up to
133% of the officially recognized poverty
level, not just categorized groups as had been
defined in the past In exchange for states
expanding coverage, the federal government
would increase their share of the cost
to 100%. A gradual decrease would then
occur each year from 2014 -2019 eventually
sitting at the permanent level of 90% federal
coverage, and 10% state. Many state were
opposed to this additional burden on a plan that
they already paid a significant portion of
and even at the 10 percent legislators in many less
affluent states a long with more conservative ones
were opposed to the idea of being
mandated to provide coverage. This led to A
supreme court challenge and a ruling that made
it clear that the states could not be forced
to provide the program under threat of a loss
of existing federal dollars for their
current plans. In Utah there were factions that argued
the state should participate in the
program because Utahns were paying into the
system anyway whether the state was getting
money or not , other factions were concerned
that, as the law was structured, the federal
government could chose to change the terms or
worse, be unable to pay for the program. Utah’s
governor sought a compromise waiver that
would allow Utah to manage the program with modifications but he could not
get support of the fiscally focused legislature
or the federal government, which left the state
in a Medicaid stalemate. Last year, voters
took the issue into their own hands and gathered
enough signatures to put a petition on
the ballot to expand Medicaid with proposition
3, which passed by a 12 percent margin. The proposition we got was not
perfect it had loop holes in it, it had
problems in it we couldn’t solve otherwise. We put a bill
together that solved those problems. One of
the largest problems of course was the
funding there was only enough for less then one
year, and then we started to go in the red. We
have to balance our budget I cant take 100 million
dollar deficit and then just turn it around and
find the money. People say well there is plenty
of money in the budget, I spend more money then
any other budget in the state, including
public education six billion dollars. Its not
like I am being tight fisted with the money. It has to
go to the places that needs it the most. One
state that I can think of is Michigan had a 1.2
billion dollar deficit in their budget, it was
more then what they planned on. And it cost
them a ton. We cant do that in Utah, we gave
expansion we covered everybody some with
insurance some with Medicaid they all have that
option, and we did that in a financially
stable way so for long term we can actually afford it,
otherwise somebody is going to go without
Medicaid when the whole program implodes,
Now that we have it expanded we have it
on the correct track that it can last long term
at a reasonable expense. So
what impacts will this new law have on counties
and their health care systems? We will explore
that question when we return. For the County
Seat, I’m Maggie K Chad: now to your up to speed.
We are going to take a break get your notepads
out. Get your pencils ready and will come back
with the conversation about where we go
from here on the County seat. Chad: welcome back to the County
seat were having a conversation today
about Medicaid expansion the fact that it is
passed in proposition three has been modified by the
Utah state legislature it’s under
consideration right now with some tweaks as legislators are
calling it joining us for the conversation about
the impacts it has on County government is from
Tooele County their Sheriff Paul Wimmer and
representing behavioral health in Davis
County Brandon Hatch guys, thanks for joining
us. Paul and Brendan: thank you. Chad: okay, I’m going to start
because Paul we’ve had this conversation and
your predecessor about the J.R.I.
Justice reinvestment initiative and
funding that was really reliant upon Medicaid
expansion that hasn’t happened this point how
important is this to move forward for you in law
enforcement? Paul Wimmer: it has the
potential to impact recidivism significantly because
if an inmate comes in and they receive
medical and mental health care from any given
facility (jail) what do they do when they get released?
And often they’re not released with a job
they don’t have insurance and how do they
maintain a similar level of treatment or medicine
that they were used to in the facility and so
often they end up reverting back to their old
habits which is what brought them into jail in the
first place. And so, we think that the ability for
them to receive ongoing treatment could impact
the recidivism rate in jails. Chad: what kind of impact does
it have on the mental health picture in a
broader perspective have you guys really been
crippled since the whole law changed. Back in 2011? Brandon Hatch: well, we have a
number of individuals especially in the
county system who come to us who are uninsured or
underinsured and how do you treat them you
know how do you fund treatment for that
population that comes out of the jail with some
medications or some treatment that’s begun
there and how do you continue that on without
funding and so Medicaid expansion really does
allow us to start treating more of those
individuals who not only we’re seeing that are unfunded
or underinsured, but also those that aren’t
seeking help at all because they don’t think that
they can pay for so and expansion of some kind is
really going to benefit a lot of people and help
us provide opportunities for treatment for
100,000 individuals moving forward. Chad: I remember a Salt Lake
County Sheriff told me a few years ago that his
basically narcotics Bill or his drug bill
to treat patients exceeded $80,000 a month. So,
your class 2 County or right close behind
Salt Lake is that a realistic figure to think that
jail is going to be approaching that kind of cost to
run its operation and keep people healthy? Brandon: I think so. Probably
between the substance abuse treatment
component of that the treatment side and the
physical health side. I mean, a lot of those individuals
are coming in with some poor physical health
and yeah, I can see the costs going pretty high. Paul: it doesn’t surprise me a
bit. The facility that is the size of Salt Lake
County’s facility $80,000 is probably fairly typical cost. Chad: in the past in this
interim. Where has the funding come from to treat
patients that are involved in this. I mean how are
you paying before this from 2011 to today
you budget for it at a County budget does the
state set aside money. Is there any federal
money? How do you do it? Paul: it’s on the counties dime.
It’s the County taxpayer that’s funding our
pharmaceutical bill our care in our facility. Chad: does that work the same
for the contracting from mental health? Brandon: we get some state
general funds in order to provide treatment for
the uninsured or underinsured population and as
well as counties in those counties that can and
not all can but those it can pay a little bit
more are able to provide in the jail for us in
Davis County, we have our County is a great
partner. We get some state funds it’s just
probably not enough to do the extended amount of care
that is needed. Chad: so, with what’s being
considered right now are we actually going to see
some of that burden that the County is
currently picking up to handle medications across the
board. If there on Medicaid and they go off to
jail. Does the coverage that they haven’t
Medicaid carryover into jail treatment or are they
cut office and is they going to jail like private
insurance carriers? Paul: typically, they get cut
off when they become incarcerated, we would
certainly love to see a provision within the bill
that would allow them to continue to be insured
because that would help out a great deal in
providing the care to them. While, there
incarcerated. Chad: so, this may not be a fair
question for you, but we’ve been involved in this
conversation in the past. When JR I was passed
Eric Hutchins was counting on that healthy
Utah initiative to help fund a lot of what he was
trying to accomplish and so for Medicaid
expansion at that point to try to make this
happen and he said if I don’t, I’ve got a pool to
tap. And I think that’s how come it’s been underfunded
to this point. How did that all come together.
If you’re not getting it now. And you’re not
going to get it under Medicaid expansion did
that really solve a problem or will it really solve
a problem or only after they’re released? Paul: JR I was designed to send
them down a pathway of treatment and well we
do have a mental health provider that
comes in and provides some services within
the facility where we really failed them is upon
release and so yes there is still benefit to be had
from the expansion in that we can provide them
resources upon their release that hopefully
they will take advantage of through the
Medicaid expansion. Brandon: and I agree in JR I the
purpose was to identify high and low risk
offenders before they go into jail. And while they’re
in jail and then when they come out, they’ll be
able to provide some treatment and that is
happening you really want would benefit jails the
accountable care act has a provision in it that
allows for Medicaid enrollment 30 days before
release from jail. But it’s going to have to take some
kind of a bill a state-sponsored bill in order to
get that enacted in Utah. So, we need a
legislature or to write a bill requesting those funds
through the ACA. Chad: and that doesn’t exist in
the tweaks that they’re making to prop three at
this point? Brandon: it doesn’t. Chad: all right that the
conversation to take up right after this break. We’ll be
back with the County seat we will continue our
conversation in just a minute. Chad: welcome back to the County
seat. Good thing your back because this
conversation almost took off without you. So,
let’s get back to what we were talking about. What
was the promise of JR I and how is this
going to help Paul? Paul: well, the promise was that
we needed to provide some sort of treatment
for those that suffer from addiction and mental
illness and so as part of that we would screen
inmates as they come in and that was supposed to
in which pathway to send down that
particular person so that they could benefit from the
assessment. The problem was that it wasn’t
funded to where the pathway never thought built
so we would do these assessments, and no one
would ever get them and so they were not put on
a pathway because it really wasn’t a
pathway as there was no funding fund the pathways
which were treatments. Chad: so basically, they got
released to courtyard and then wandered
around until they came back in? Paul: yes. Chad: okay. You had a thought t
I also stopped you on. Brandon: I think that one of the
things that concerns us as County providers
is with Medicaid expansion they’re
looking for a way to pay for the match the federal
match piece of it in order to draw those dollars down
well in order to do that they’ll have to find
funding somewhere JR I funds are some of those
funds that are being discussed right now and so
even the removal of some of those funds
to help pay for Medicaid expansion. So, if JR I
funds are removed or if the division of
substance use and mental health chooses to take
away those funds and gives it back to the state
to pay for match those of us that are providing
services in the jail using JR I funds have no way of
providing treatment any longer. Chad: so basically, Medicaid
expansion could actually hurt where we were
headed down a path of rehabilitating people
and getting them on the correct path and cutting
recidivism right? I mean, am I saying that
correctly? You’re not talking. Brandon: it could hurt in the
jails. Honestly those funds that we use for criminal
justice purposes being taken out of some of the
jails are being able to provide those services
because Medicaid dollars aren’t going to be
coming into the jail. So where are we using those funds
currently to provide those services and a lot
of it comes from JR I Chad: so, if the state
legislator hadn’t come in to tweak proposition three what
would’ve happened? You don’t know? Paul: I don’t know. Brandon: I don’t think anything
would’ve changed with the jail I think
the full Medicaid expansion up to 138% of federal
poverty would have stayed the same but the
question is that match piece because what’s being
proposed now is a 70/30 match 70% the
funding coming from the federal government the
County matches 30%. That is the bridge
plan that is in place now, but if with full
Medicaid expansion. It would have been 90/10 split more
people would be covered, costing a little bit
less. Chad: I’m going to take another
break and when we come back. I want to talk
about the fairness of this all because there is an
issue that’s always been on the table sense this
whole thing started and it probably could use a
light of day. In this conversation. Will be right back
with the County seat. Chad: welcome back to the County
seat were discussing the impact Medicaid
expansion may potentially have on the counties
particularly in jails and mental health. So, I
do want to come back and address the question
because people sitting at home they’re going to
go. I remember something about this when it all
happened are we paying tax dollars to go into
this system already. And because we did not
do Medicaid expansion, we’ve been
shortchanging ourselves for this 90% that’s supposedly
in that match. What say you guys about that? Brandon: well, the funding is
going somewhere it’s going back to the federal
government and has been since the ACA past and
it’s being held there, I guess. I don’t know
what they’re doing with their money now but yeah,
so Utahans have been sending their tax dollars
back for this purpose. For years. Chad: is the state right or are
they in a position to be concerned about the fact
that yeah sure it’s 90/10 right now and we can
probably cover that and find a way to make our
match, but it may change in the future it may end
up being 70/30 it may end up being 50/50. And if
you listen to some people, they might say well
the government’s going to go broke
anyway and then will have to pay for all of
it. So, is that a fair and legitimate concern for them
to try to fine tune this or should we just be
taking the whole match? Brandon: I think it’s the
responsible thing to do to take a look at citizens clearly
past Medicaid expansion but there is a funding
concern right. I think once it passed. Then they
started looking at the numbers and realize that
there is not enough funding to pay for that
full Medicaid expansion. Let’s take a look at
some other options. And so that’s a hard
question you know, I’m not sure how they do it or
what the right answer is. I tend to lead toward
if the citizens want it, we should find a way to
get it. Paul: I do think that is a
legitimate concern it just is very typical within
government or larger government to initiate and start
a program by funding it properly and then
backing off of it, leaving the funding mechanism to
be determined by the lower level of
government, whether it’s from federal to state or
state to County we experience that. Chad: what is your inmate
population look like review float about for Tooele
County? Paul: I have about 225 inmates
in my jail right now. Half of them are contract. Chad: okay so you’re trying to
get 220 people on a right path are you worried
that what money you do have coming in in JR I
which is not enough might be taken away? Paul: we are always worried
about any funding mechanism that diminishes or
goes away. It’s always a concern and it’s very
common for that to happen so I can see why the
legislature is very concerned about this not
being fully funded in the long-term. Chad: not wanting to be a scare
tactic but a mask both of you from your
different perspectives the same question.
If the funding stops how do you change the way
the jail operates? Do you just turn
people out? Paul: I don’t want to do that.
That’s been one thing I’ve been able to do, and
we’ve had the capacity to do so is to not turn
away. We have enough beds for our population,
and it would be very painful for me to start
turning away regardless of the reason. Chad: and what about your
program I mean the funding stopped what would your
option be? Brandon: we feel like we’ve been
doing this anyway for a number of years and
County behavioral health finds a way
and we haven’t had a good funding system in
place for a long time. So, if funding went away
we would still find a way to be able to serve
them it wouldn’t be easier, maybe reduce the number
of services available to them are expanding
how much a citizen might have to pay in
order to get the services but we would find a
way. Chad: gentlemen thank you for
your time. It’s been a good conversation. It
seems like there should be a little bit more but
maybe the bill needs to advance for couple
weeks we might come back and visit it again.
Thank you very much for joining us. Remember
local government is where your life
happens be involved be part of the solution
and will look for you next week on the County
seat.

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