Hello everybody welcome to The County Seat
I'm your host Chad Booth today we are talking
about Medicaid expansion this has been a topic
really over the last decade since the affordable
care act came into play and the need for
Medicaid expansion. Utah has drawn up to the
idea of finding a way to or a different way to
expand Medicaid coverage trying to be fiscally
responsible. However the conversation has
taken on new light because of the problems we
have had with homeless, opioid addiction the
problem around Reo Grand and it has become
very important so we are going to pick up that
conversation today and talk about Medicaid
expansion with Utah's expert on it Dr. Brian
Shiozawa who is a Utah state senator thank you
for joining us Senator. And we have Adam
Trupp is with us as well who is the CEO of the
Utah Association of Counties who has been
active in pursuing this. So the news on
November 1st and all the newspapers were Utah
got it they got a 70 million dollar Medicaid
waver. What does that mean?
Well 2 things really and I will let Dr. Shiozawa
explain more of the details of what in the
waiver but what we have asked for and what
Utah asked for was an exception or a waiver to
the rules that govern Medicaid. That was
intended to expand our coverage of Medicaid
but only in a targeted way. Targeted way was
intended to address substance use disorder and
people who needed treatment and people with
mental health disorder who needed treatment
and were somehow in evolved in the justice
system. So you reference Rio Grande in fact it
was for a broader population of people and that
is all those people who have involvement in the
criminal justice system which is somehow
caused by and related to or involving their
substance abuse problems or their mental
health problems and that is what we are trying
to target in terms of treatment and in terms of
response that addresses those needs.
Medicaid waver Utah is not necessarily new if
people look you will see a whole list of different
areas where they have already given us waivers
like brain injury intellectual disability things of
that nature how different is this one Dr.
Shiozawa?
This is quite a bit different in that it is
specifically targeted to a population in general.
Just like Mr. Trupp has already alluded to we
are targeting and in the very timely fashion
those people with homelessness have
substance abuse and who have problems with
mental health disorders and are in fact in the
justice system and so it has far reaching
ramifications in terms of not only their health
but also the surrounding citizens and it is also
going to be a template for other basically states
around the country to look at as they address
this what you say is precisely right through
Medicaid is one of those big government
programs that is federally funded through and
administered through the department of Health
and Human Services that has specific rules set
down in federal doctrine and then in order for a
state like Utah to get a change in what is
prescribed across the country we have to apply
for a specific waiver that enables us to adapt to
the Utah way a specific request that brings in
federal dollars to help us help our citizens in a
unique way. Now whether it is a brain injury
waiver or whether it's a more expansive waiver
like the Rio Grande waiver.
if you look at Medicaid it just says we will treat
anything on a 30/70 split so how do you end up
having a quote it's understood being a cap but
you have a process that says we will match
anything 30/70?
Well let me add to that in part. There are 2
ways to do it. One you do get a waiver to your
requirement to serve anyone who comes in and
is eligible but the other aspect of it is that states
have to match the payments that come from
the federal government. So the 30/70
requirement is that the state has to pay 30% of
the bill and then they get 70% of the whole
back. So they give 30 cents they get 70 cents
that totals the whole dollar the state of Utah
has said this is the level that we will go to or the
level that they have gone to if I am not
mistaken and said the top will be 30 million
dollars of our contribution. That is a big
commitment and it's a good return but it's a big
dollar commitment no doubt about it.
So that ends up being 100 million dollars
towards addressing this problem in total.
That would be the total overall benefit to the
state.
I would like to try and figure out exactly how
you guys envision that coming into play and
how that would work when we get back we will
be right back after this break on the County
Seat.
Welcome back to The County Seat we are
discussing Medicaid expansion and a waiver
that the state got last month for 70 million
dollars of federal matching money to our 30
million to treat the quote Rio Grande problem.
To continue that conversation as I was reading
through what was entailed in this waiver and
what it said it would cover I was surprised there
were a lot of things that I would not have
anticipated being a coverable Medicaid
expense. How broad is this Dr. Shiozawa?
It's broad in the sense that it is directed to
specific population. When we think of Medicaid
in one circumstance we can say well it's going
to help those people that are poor say a women
who is pregnant or someone who has children
and they can just get general coverage. But
what this waiver does is specifically focus on a
specific population those people in the
homeless situation who have drug and mental
health problems and who have problems with
the justice system. So when they are involved
in that whether it's through the judiciary system
the mental health courts or how they find their
way into that particular category then these
dollars are then focused specific treatments to
help them. Let's say they are like substance
abuse maybe putting the into either outpatient
or inpatient treatment programs. The
residential treatment program I'll just see how
other groups are going to get funding for many
many beds they did not have before to bring
these patients ins they don't go directly from
the jail back onto the street. Or from mental
health courts out into some hotel with an ankle
bracelet but rather into a treatment program
that can give them not only treatment whether
physical or medical assisted treatment
counseling and then also getting them back into
better health and maybe even into a job so
really stabilizing here.
treatment beds and jail beds and making sure
they are expanded or capable facilities with the
jail and I noticed even some kind of elements of
police training. How that fix into the mix does
are they all crucial to make work?
It's going to be hard to have this program
succeed first of all until we know how it is going
to work but without enforcement downtown in
the Rio Grande area to protect not only those
people that are homeless but those citizens
around them and to prevent that vulnerable
population from being preyed upon by the drug
dealers. We are going to have to have more
police and then for those people who really are
drug abusers or violating the law then they have
to to into jail and we have to have under the JRI
for example the Justice Reinvestment Initiative
we have to have funding for that which we did
not get before because we never expanded
Medicaid. And then to get them from there
into residential treatment or outpatient
treatment into programs all three of these
various factors are important. So when you
look at ate judicial system what's it supposed to
accomplish. Well public safety right,
accountability and rehabilitation and if you take
away one of those three aspects you are going
to have a failure in that system and we have to
have that rehabilitation we have been pretty
good with accountability and we are pretty
good with public safety now let's get into the
rehabilitation portion.
What has changed originally at the time that
Representative Hutchins put JRI out and I
remember him telling me out on the plaza of
the Capitol if we get the Governors healthy
initiative through and get it funded which he
thought was going to happen he said it will have
the money it needs and I said what if it doesn't
he said well I have a few million dollars
squirreled away for this and because that is the
biggest concern for the counties it will not have
enough money. What has changed in that
environment with legislature about making
these commitments they did not want to get on
the hook before?
Sometimes it just takes time for all for all of the
legislature to see a problem and appreciate it.
And maybe Rio Grande had to come forward
and come to a head so finally the install of the
legislatives you know we really do have a
problem we are desperate we are seeing
problems murders for example increase in
population emergency departments jails
flooded with patients and by the way since we
did not fund the JRI the nonviolent offenders
were not in jail and we did not have the beds
funded for them there where did they go? Well
they went onto the street so we had the worst
of both situations we not incarcerating those
that really should have been incarcerated and
we were not treating them and so the problem
just got worse and worse because we failed to
take that next battle step which was funding.
I join in that assessment too, it's the idea of
people coming to see what is going on in reality
what is going on in their communities and not
people saying hey we have got to address this
beforehand it takes time for everybody to take
a look at what was done and then what the
impacts were and when you find that then you
do work on developing alternative solutions and
I think the legislature has done good job of
getting this far ahead it's a big chunk of money
to put into this and I think the next step does it
help public safety does it help the communities
and if it does we are on the right track we can
keep going and I think it's a real positive and
see how it develops and how people get the
work done.
We are going to dive into some of the details in
just minute when we come back with the
County Seat as we continue our conversation
on Medicaid expansion.
Welcome back to The County Seat we are
discussion the 70 million dollar waiver Medicaid
expansion here in Utah specifically for the Rio
Grande problem. We ended the last segment
talking about the fact that Utah had changed
the legislature our governing officials had kind
of changed their perspective on how they saw
this so my question is there a change in
Washington as well because we had to go back
before for a waiver and we have gone back this
time for a waiver how is that different?
I will tell you from the outside it appears to be
primarily different because we got an answer a
lot sooner than we did with the last
administration not certain why but I know the
Senator was involved with some of the
discussions so it may be getting some enlighten
but it sounds like there is an approach to
providing states more flexibility in how they
address their issues and how they deal with
federal programs and federal funds maybe you
can speak to that more.
What was that experience like Senator?
When I had an opportunity a few months ago to
meet with officials from CMSHHS on this
particular waiver one of the questions we asked
them is what is the process that you are taking
to evaluate our waiver to make sure it is a valid
waiver and how long is it going to take because
we have a desperate need for federal funds our
tax dollars by the way to bring back to Utah and
help this particular population. And for the first
time under this administration we heard the
words we want to be customer friendly how can
we help you? Now when I had gone back
before and spoken with the secretary under the
Obama administration it was basically this is
Medicaid expansion take it or leave it there is
no wriggle room in terms of adaptation to
Healthy Utah or anything else and now there
are many waiver being offered to CMS and they
are favorably looking at them and what they are
trying to do is to say let's give states the
opportunity to experiment to develop programs
and let's take those results and come up with
something good. That is why this Rio Grande is
so important. Is that we have been given
federal money not only federal money but
federal attention they are watching to see how
successful we are and what we can do and then
use that in other states.
contributing towards Medicaid program since
the affordable care act went in and we have not
taken those monies back out because we did
not want to do the Medicaid expansion how big
is our credit account back there?
That will vary. Let's just look at the past two
years for example. If we say that as a state we
pay 6 to 800 hundred millions of dollars in taxes
in various forms whether its medical device tax
the Cadillac tax on Medicare taxes whatever we
pay hundreds of millions of dollars back to the
federal government much which we could have
gotten back conservative estimates over the
past 2 to 3 years 1.2 billions of dollars that we
could have gotten back to the state of Utah in
terms of federal funding had we gone with the
fuller expansion.
Wow so nobody should complain about 70
million.
Not when it's really recapturing some of our
own tax dollars. That is exactly the point is if
we Utahns tax payers are going to pay this
money back to the federal government then
lets reclaim it and use it intelligently the Utah
way to help our people create high quality jobs.
We projected we created thousands of good
high quality jobs increase access points keep
people out of the ER and improve their quality if
we did this right.
The translation from somebody homeless
seeking care going through this program how
does that translate to the number of visits in
the ER, is there a close correlation between
indigent people and medical treatment through
an ER?
Unfortunately when you come to an ER it ought
to be for an emergency whether you are
critically ill or critically injured but a lot of
people come to the ER because they have no
insurance and they cannot get into a private
office or into an urgent care or because they
have simply no other place to go and its
convenient and they can. So what ER's do is we
are mandated by the federal government under
rules to take all comers and treat them and
stabilize them but the costs will be shifted to
each of us who do have health insurance and
you will end up paying for that as well. Now
what is the correlation there well you know that
if you get into medical bankruptcy what's the
number one cause of bankruptcy in this state?
Medical Bills.
The ER is a huge contributor it's at least ten
times more expensive for the similar treatment
to be done in an ER that to say an urgent care
or a family practice office.
bankruptcy because of medical bills you end up
being without work and homeless and then you
end up back in the ER for treatment there is a
dichotomy there that is interesting.
The other pieces to that is if you are and
individual with mental illness or if you have
substance abuse problems and you come into
the ER you get yourself through that process so
you have dealt with your emergency situation
or you illness for that period of time you are
going out and back into the community you are
already part of and you don't have follow up or
any wrap around services to help so the affect
that you get your sores on your leg treated or
some other medical malady taken care of in the
ER it does not mean you will have the
opportunity to go back to any other follow up
doctor unless you come back to the ER are you
likely to do that again? No because we all know
it is hard to get in its high cost etc. and what
gets treated does not ne3cessary get cured
because you do not have another option to go
this waiver is really intended to address a lot of
those parts together and hope that we can find
ways to move people towards recovery and
towards getting healthy instead of just getting
treated quickly.
Excellent we are going to take a break here for
our final thoughts here on The County Seat
talking about Medicaid expansion and our 70
million dollar waiver. We will be right back.
Welcome back to The County Seat we are
talking about Medicaid expansion and the
waiver that has been put in place for opioid
drug abuse mental health in the homeless
population you ended up with a comment
which I thought was very interesting they are
giving us a check and a chance to see what we
can do with it and how good of stewards we are
so Senator what to you does a good report card
look like? How will you know when this thing is
When we look at quality and outcomes that is
going to be my matrix as I look for success if I
was looking at this. Are we able to impact
patients in a positive way? Are we able to
demonstrate quality with our programs and
efficient use with our health care dollars that
we are using on this patients? In other words
can we take this patient population and make
them better with the amount of money that we
have been given and then take those same
processes and work on them and refine them
and improve them.
dollars are we going to recoup a hundred
million dollars if we say can take 70% of the
lives that are caught in this cycle or trap of
homelessness and drug abuse and mental
health if we can fix 70% of them is it worth
hundred million dollars?
Absolutely if we could help 70% of those
patients I would take that data and publish that
nationally and use it as a national template for
success that would be so good to help that
many people because if you put a dollar sign on
that think of the people who would be free of
drug abuse into productive lives more stable
relationships with their families and children off
the streets and healthier and our jails and our
streets safer how much would you pay for that
all for that small investment.
I just add to that if you think about the impact
on criminal justice system of addressing mental
health problems addressing substance abuse
problems and you look at what the impact is of
making those changes and making even a 50%
change in those numbers it would be huge well
over 50% of those people who go to jail or go to
prison have a substance abuse history or mental
health history that typically untreated. If you
lower those numbers you lower the cost of
corrects you lower the cost for
law enforcement you lower the costs on victims
of crime and that really is where the biggest
issue.
So knowing our nation's chief executive is a
bottom line kind of guy you think this will
demonstrate an actual return on investment
that the savings from the changed lives would
contribute more than a hundred million it took
to get them there?
If we could demonstrate 50 or 70 percent
improvement of these people's lives I think that
would be a huge return on investment not only
to the patients but to all their families and to us
as people who are trying to lead this country
and look at it in a very positive way.
You guys got the green light for this 36 days ago
how long is it going to take for this is actually on
the ground and things will start?
Things are starting because this has been a
process that has been going for several years.
The question of how soon is that money from
the federal government going to get into hands
of local providers and local organizations I
cannot tell you that for certain but it will
happen relatively quickly we have the waiver to
go forward we have to have it finalized by the
state department of health so we can start
billing for that but we already have people up
ready to bill and move forward. The reason its
already under way is that this is an approach
that the counties have been taking to move
forward on treatment that law enforcement has
been taking that the legislature and the
executive branch have bene pushing counties
on to say come up with new ideas find new
alternatives in lieu of incarceration let's get
people out of emergency rooms and into other
treatment options so the process is moving
forward but it sort of like turning an ocean liner
it does not happen quickly we have to keep
moving the right direction and if you go the
wrong direction you end up having to change
your course again.
Hopefully we are on the right path and
gentlemen thank you so much this has been a
great conversation thank you for watching The
County Seat we appreciate your participation
please like us on social media and share this
with your friends it's a great way to get
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The County Seat Live so like us on FB and we
will see you next week on The County Seat.
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