Utah: Congrats! After a year of jerking you around, your state gov't is finally doing what you voted for them to do...mostly.

A brief recap of ACA Medicaid expansion in the great state of Utah:

• November 2018: Utah voters pass Proposition 3, a "clean" Medicaid expansion ballot initiative, by a solid margin, 53-47. "Clean" expansion means just that: The program would be expanded to every legally documented Utah resident earning up to 138% of the Federal Poverty level, without requiring additional barriers like work requirements, etc.

• February 2019: The Utah state legislature, blatantly defying the clear will of the people, votes to effectively ignore Prop 3 by replacing it with Senate Bill 96, which would only partially expand Medicaid to those earning just 100% FPL (around 50,000 fewer low-income residents) while also tacking on work requirements to boot.

• Adding insult to injury, while you might think this would at least save the state a few bucks (under ACA Medicaid expansion, the federal government pays 90% of the bill for the expanded population while the state has to pay the other 10%), this would actually cost the state around $50 million more, because the partial expansion, if approved by the federal government, would mean the state would instead pay the 32% portion they already pay for other Medicaid populations. The state put in a separate waiver request asking for the feds to agree to the 90% match rate anyway.

• March 2019: CMS Administrator Seema Verma approves the partial expansion scheme, complete with absurdly stupid work requirement provisions including enrollees having to submit applications (and rejections from at least 48 different employers in order to be approved for the program...but they hold off on the 90% match waiver.

• August 2019: CMS Administrator Seema Verma gets a good chuckle at the Utah government's expense (literally) by denying them the 90% match rate, meaning if they want their only-up-to-100% FPL expansion, they will indeed have to pony up the dough.

• December 2019: I'm honestly not sure which waiver this one was (I kind of lost track of them for a bit), but just before Christmas, CMS formally approved another one of Utah's Medicaid waivers, meaning that full expansion (all the way up to 138% FPL) will go through effective January 1, 2020 after all...although it will still include the work requirements:

Utah will kick off the new year with a fully expanded Medicaid program, covering residents earning up to 138% of the poverty level, up from the current 100% cutoff for the state’s limited expansion. But it will require some adult participants to work or look for work, the Utah Health Department said.

Monday’s announcement means as many as 120,000 Utah adults who didn’t qualify for Medicaid at the beginning of 2019 will be eligible starting Jan. 1. The cutoff is at 138% of poverty, which translates to $16,753 for an individual and $34,638 for a family of four.

It gets a bit more complicated yet due to the timing of the approval, however. Because CMS didn't issue their approval until after the 2020 Open Enrollment Period wrapped up, that means that around 43,000 Utahns earning between 100-138% FPL have likely already signed up for heavily-subsidized ACA exchange policies instead...who will now, ironically, be shifted off of those policies onto Medicaid itself at some point.

IF these folks are moved over to Medicaid right away, that means Utah's 201,000 QHP selection tally for 2020 will likely drop by 21%.

Howver, Louise Norris reminded me that as long as you're eligible for a subsidized exchange policy at the time you actually sign the contract, you remain eligible for the same subsidy level for that calendar year regardless of what other legal changes happen. This means those ~43,000 enrollees will remain eligible for heavy ACA exchange subsidies through the end of 2020 as long as they don't drop coverage and keep making their (subsidized) payments, and won't be required to make the move to Medicaid until 2021.

Some might choose to switch over mid-year, but for most, it won't be until 2021 that Utah sees a substantial ACA exchange enrollment drop...assuming the ACA itself survives the Texas vs. Azar lawsuit, that is.