Ravell Call, Deseret News
Vincent Garcia clears snow at the Capitol as the state Legislature begins its 2013 session, Monday, Jan. 28, 2013.
Disease doesn't ask whether you're covered or not before it attacks you. As long as we have health care as a commodity, it will still continue to be a problem for those who can't access the care they need. —Rep. Rebecca Chavez-Houck, D-Salt Lake City

SALT LAKE CITY — Health care access must be made available to every family before the year is over, and the responsibility for that lies in the hands of state lawmakers.

"Depending on your perspective, it may be the most important issue," said Rep. Jim Dunnigan, R-Taylorsville, of the work facing legislators as they balance health care reforms with the state's other pressing issues.

The Patient Protection and Affordable Care Act, passed in 2010, is intended to decrease the number of uninsured American citizens, as well as drive lower health care costs by enforcing various mechanisms, including mandates, subsidies and tax credits, all controversial measures.

It brings about several deadlines and decisions for states, including for the conditionally approved state-run health insurance exchange and Medicaid expansion, that the Legislature may take into consideration during the 45-day session that began Monday.

"Either we make the decision to run Affordable Care Act programs that will benefit and cover all citizens, or we fail and that role falls to our federal government," Sen. Gene Davis, D-Salt Lake City, told a gathering of stakeholders and citizens at a pre-legislative health reform discussion earlier this month.

Avenue H, Utah's existing health insurance exchange, is only available to small business employers and not individuals. Individuals need to be included in the online insurance marketplace by Oct. 1 in order to meet the federal deadline.

The law, however, contains a mandate that requires that all individuals not covered by insurance through their work place, Medicaid or Medicare, or other public insurance program, to obtain a private health insurance policy or pay a penalty, unless a waiver is secured first. A waiver can only be obtained through application and denial through the law's projected insurance exchange system, which would likely net anyone eligible for Medicaid coverage.

Utah's exchange does not include provisions for individuals to sign up for Medicaid, which Rep. Rebecca Chavez-Houck, D-Salt Lake City, said will ultimately neglect "the individuals who fall through the cracks in our current system."

"Disease doesn't ask whether you're covered or not before it attacks you," she said. "As long as we have health care as a commodity, it will still continue to be a problem for those who can't access the care they need."

The minimum standard insurance plan, as designated by the state, may also contain some inadequacies, according to Utah Health Policy Project director Judi Hilman. She said weaknesses of the "Public Employees Health Plan basic plus plan" include limited visits with a mental health care provider, restrictive rehabilitative care and a lack of oral health care provisions for kids.

In 2011, 411,926 Utahns were uninsured. Approximately 34 percent of those uninsured are believed to be eligible but are not enrolled in state and federal programs such as Medicaid. If the governor opts to expand Medicaid, there is a concern that the "woodwork effect" would dramatically increase costs, Dunnigan said.

Chavez-Houck said she believes the complicated process of applying for Medicaid will still keep a large number of eligible individuals from joining the program.

Utah Gov. Gary Herbert has submitted various letters to the United States Department of Health and Human Services asking for flexibility in implementing parts of the Affordable Care Act, including the health care exchange. So far, the department is working with him, but the state has much to do to make it all work.

Some, including advocates with the Utah Health Policy Project, believe the minimum standard insurance plan lacks coverage in needed areas and should be tweaked in others. But Judi Hilman, UHPP director, said even Medicaid "has issues."

The Utah Department of Health has commissioned a cost analysis to determine what costs and, if any savings, may apply to a potentially expanded Medicaid system. 

Utah is one of 12 states still undecided on Medicaid expansion, which stands to bring additional federal match dollars — albeit maybe not enough to cover potential enrollment growth and the costs for changes in benefits — to the table.

Freshman lawmaker Rep. Mike Kennedy, R-Alpine, works as a family doctor called Medicaid "obstructionist" and limiting in what can be ordered for certain patient groups as reasons it perhaps should not be expanded.

"There are a lot of road blocks," he said. "It's really difficult to deliver care under Medicaid."

The federal government has promised reimbursements to states that opt for Medicaid expansion, leaving the state to foot the bill for administrative costs in the first three years, beginning this year. But the payments wane to 90 percent of costs over the next decade and nothing is determined beyond that time frame.

Hilman said, "the longer the state waits, the more money is left on the table."

However, Dunnigan said, "the state can do it better." He is also hoping for the federal government to grant Utah flexibility.

"This is not easy," he said. "There is so much in the Affordable Care Act, this is one area where ignorance is bliss." Dunnigan said.

Sen. Todd Weiler, R-Woods Cross, said Medicaid expansion is an important issue for Utah lawmakers, but he believes they won't discuss it until after the federal government resolves the federal budget, ultimately designating what each state will receive for the upcoming fiscal year.

"We will not pass a budget spending money we don't know we have," he said.

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