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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