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Months of negotiations with those in the Obama administration, his ideological opponents, are coming to a close for Gov. Gary Herbert.
Now the tough work begins.
Utah's Republican governor must try to persuade wary lawmakers from his own party to approve his Healthy Utah plan, an alternative to Medicaid expansion that Herbert has been negotiating with the Department of Health and Human Services.
Quiet for months as they watched to see if Herbert would succeed in Washington, opponents are publishing polls and reports criticizing Healthy Utah now that Herbert says a final agreement is a week or two away.
The Sutherland Institute, a conservative think tank, last week published a survey indicating more Utahns want no action than want Healthy Utah or a full or partial Medicaid expansion. The results contradict a spate of polls showing support for the governor's plan, polls that Sutherland contends were based on oversimplified explanations of a complex issue.
"The more information and context you provide to voters, the less certain they are about Medicaid expansion," said Derek Monson, policy director for Sutherland.
Nationally, the nonprofit State Budget Solutions' Federalism in Action project issued an eight-page report saying Healthy Utah would make Utah more dependent on the federal government, destabilizing the state's economy.
Healthy Utah would use the $258 million intended for Medicaid expansion to instead provide subsidies to those low-income residents who do not now qualify for Medicaid so they can buy their own health insurance. An estimated 111,000 Utahns would get the subsidies.
Lawmakers on the Health Reform Task Force have listened this summer to a parade of advocates for Medicaid expansion or Herbert's alternative, but they increasingly express misgivings. Advocates include single, sick moms, the Salt Lake Chamber and the dean of the University of Utah Medical School.
At the August task force meeting, Rep. Mike Kennedy, R-Alpine, used an anecdote from a U. doctor as an example of why medical care is not always a good thing. Hospitals kill more than 1 million people a year and people get addicted to painkillers while being treated for broken bones, he said.
"In the medical community we often talk about access as if it makes health," said Kennedy, who is a family physician. "And we both would agree that's not true. … Sometimes access to health care can be damaging and dangerous."
Rep. Francis Gibson, R-Mapleton, said the governor has asked him to withhold judgment until Gibson sees details of the Healthy Utah agreement. But, he said after Thursday's task force meeting, "If I had to vote today, I'd vote no."
Herbert's spokesman, Marty Carpenter, said the governor is keeping legislative leaders and key lawmakers in the loop as his negotiators write the final HHS agreement language.
Rep. Jim Dunnigan, R-Taylorsville, an insurance agency owner and co-chairman of the task force, has twice traveled to Washington with Herbert, and was in on his meeting with HHS Secretary Sylvia Burwell on Sept. 9.
"We're trying not to leave it to a situation where we unilaterally cut a deal in Washington and come back and show it to them for the first time," Carpenter said.
But it's a dicey situation for the governor.
"We're a little bit in a middle, negotiating a plan with a Democratic-controlled administration and negotiating what can finally be passed by a Legislature controlled by our own party," Carpenter said.
Already, the governor and legislative leaders are divided on timing: Herbert wants to call a special session, once he thinks he has the votes to approve Healthy Utah, but legislative leaders want to save it for the general session beginning in January.
House Majority Leader Brad Dee, R-Ogden, said during a caucus meeting last week that House and Senate leaders agree it doesn't make sense to consider an alternative to Medicaid "in a vacuum." It's too weighty a decision, since Utah is being asked to kick in an estimated $40 million a year.
"If we were to wait until a legislative session, then you can view the entire budget … and compare those together," Dee said.
With elections coming up, many lawmakers will be too busy campaigning in October and some may be lame ducks in November.
Nonetheless, the governor is still hoping for a special session. "We want to get this done," said Carpenter. "We understand there are Utahns in need of care."
Utah is negotiating an alternative to Medicaid expansion because the governor and Legislature did not want to join the 28 states that are accepting hundreds of millions of federal dollars to expand their Medicaid programs.
The Affordable Care Act, or Obamacare, envisioned that all states would expand Medicaid, but the Supreme Court ruled in 2012 that states could opt out.
Twenty-one states are sitting on the sidelines, either refusing to expand Medicaid until states are given more flexibility in 2017, or waiting to see what alternatives Utah and other states are able to negotiate.
The result of opting out, as Utah so far has done, is that it creates a coverage gap for low-income residents: they earn too much to qualify for Medicaid under existing rules but they earn too little to get subsidies on the federal marketplace, healthcare.gov.
Estimates of the number of Utahns in the gap vary widely, from 45,000 to 77,000. They include single adults who don't have children and are not disabled or elderly but earn less than the federal poverty level, and those with children who make less than half the poverty level, which is $19,790 for a family of three.
Utah has wrested more flexibility for setting up its Medicaid alternative than any other state, David Patton, chief of the Utah Health Department, told the task force.
Among the concessions by HHS, he said, is a clause that will allow Utah to automatically enroll insurance subsidy recipients with the Department of Workforce Services so they can get job training or help finding a job. Pennsylvania came closest with a "work incentive" clause.
But it's not the work requirement Herbert had hoped for.
The agreement language on that point is still being written, Patton told the task force. "What we have in mind is an opt-out provision, but it won't be advertised to people," he said. "If they actually resist heavily and tell us they want out of this, then we'll have a provision where they can opt out of it."
Rep. Robert Spendlove, R-Sandy, sat in on Thursday's task force meeting and was unhappy that Herbert's work requirement has now become a "work effort."
"We are talking about able-bodied people that can work. Not having a work requirement I find very troubling," said Spendlove, an economist who formerly was the governor's director of federal relations.
While the work issue may be one stumbling block for the Legislature, there is another: Herbert's Healthy Utah plan would provide insurance subsidies to those making up to 133 percent of the federal poverty level not just those in the coverage gap who make less than poverty level.
And those with incomes from 100 percent to 133 percent of poverty already qualify for insurance subsidies on the federal marketplace.
"That zero to 100 percent (of poverty) are most vulnerable," said Gibson. "I'm more inclined to help them."
The governor is going for the larger group because millions of dollars are at stake. The feds will give the state a 90-10 match if Healthy Utah covers folks up to 133 percent of poverty, but a 70-30 match if it covers only those earning up to the poverty level.
House Speaker Becky Lockhart, R-Provo, cautioned her fellow Republicans in the caucus last week to not get too hung up on the governor's proposal, which last winter she called "straight-up Obamacare expansion."
"This isn't an all-or-nothing. This isn't the governor's [plan] or nothing," she said. "There are other options out there the task force is working on."
Robert Gehrke contributed to this story.