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Latin music blasted and attendees of the Latinx/Hispanic Health and Heritage Festival wandered by with snacks and bags full of free goodies as volunteers with the Utah Health Policy Project answered questions about Medicaid and health insurance.

The festival last weekend sprawled across The Gateway in downtown Salt Lake City, and was the organization’s largest outreach event of the year. The community outreach is part of its vision for a future in which all Utahns have access to high-quality and affordable health care.

That includes focusing on Utah’s Medicaid population, which data shows is a smaller proportion of the population than nearly every other state — despite having expanded eligibility.

Utah’s strong economy and low unemployment rate likely keep Medicaid enrollment low compared to other states, advocates said.

But they said other factors — from a nearly two-dozen-page application for Medicaid to negative cultural and political views on using social services — also contribute to the state having lower enrollment rates compared to most other states.

Utah has a “high level of barriers to accessing Medicaid,” said Carrie Butler, executive director of the nonprofit Utah Public Health Association.

Matt Slonaker, who heads the Utah Health Policy Project, agreed there are “lots of barriers.”

State policies making it harder for people to stay enrolled, a lack of advertising, less cohesion between the government and health systems and a focus on efficiency contribute to putting Utah behind despite the state having expanded Medicaid, he said.

But that isn’t Utah’s vision for residents who are eligible for Medicaid, countered Jennifer Strohecker, the state’s Medicaid director. The state “absolutely” is trying to remove barriers and obstacles, she said.

Strohecker said members “are entitled to this benefit” and the Utah Department of Health and Human Services (DHHS) wants people who are eligible for Medicaid to receive the service.

There are areas where DHHS can improve, Strohecker said, and the state agency is committed to using data and member feedback to make the Medicaid experience better.

Low enrollment rate compared to other states

Utah has the lowest or among the lowest proportions of its residents on Medicaid, depending on the data source.

According to the U.S. Census Bureau, 11.3% of the state’s population was enrolled in Medicaid in 2021. That was the lowest percentage of any state and more than nine percentage points below the average of 20.5%.

Data from KFF puts Utah second lowest with 11.0% of the state enrolled in Medicaid in 2021. Only North Dakota was lower with 9.8%.

Neighboring Wyoming was close with 11.5% of the population enrolled in Medicaid. The remaining states and Washington, D.C. averaged 20.5% of the population enrolled and went as high as 34.4% in New Mexico, according to data that Kaiser got from various sources.

The majority of Utahns covered by Medicaid are children, said Ciriac Alvarez Valle, a health policy analyst with the nonprofit Voices for Utah Children.

In contrast, Utah has among the highest portion of residents enrolled in employer-based insurance. Nearly 64% of Utahns had insurance through their job in 2021, according to the Census Bureau, trailing only New Hampshire.

The data likely is out of whack because of the coronavirus pandemic, Slonaker said.

He added Utah had a fast growth rate in Medicaid enrollment in 2022 but thousands have dropped off the rolls as a pandemic-era federal policy that barred states from removing people from Medicaid continues to unwind.

There probably won’t be a clear picture of where the state stands until next year, Slonaker said, but he thinks Utah will probably “still be in the lower ranks.”

Strohecker said it’s hard to compare but pointed out Utah had some of the top growth in Medicaid enrollment in the country last year before the unwinding started.

Utah expanded Medicaid in 2019, and now the maximum qualifying income ranges from $19,392 a year for an individual to $67,278 annually for a family of eight.

Application is ‘really difficult’ to fill out

Utah’s flourishing economy is likely part of why available data shows the rate is lower because people don’t need to lean on Medicaid as much, Slonaker said.

Butler agreed the low unemployment rate helps.

But they and others said Utah doesn’t do enough outreach or give enough applicants adequate help, and there’s a stigma around receiving social services.

Utah has high barriers to access Medicaid, Butler said, though she wasn’t sure if they’re higher than obstacles in other states.

Applicants often struggle to fill out 23 pages that require a lot of repeat information, she said.

“It’s really difficult to try to fill that out, especially if English isn’t your first language or if you have a lower language-processing capability,” Butler said.

Valle agreed it isn’t simple for people to go through enrollment by themselves and said there are families who haven’t been able to finish it or don’t even want to start it because they know it’s not easy.

Further, once people are enrolled, they don’t have continuous eligibility, Slonaker said. That means coverage isn’t automatically guaranteed for an entire year. Instead, any time the state gets information about new income, it could spark a new inquiry that a Medicaid member must answer.

Utah generally isn’t as good at streamlining the process as states like Oregon, New York and New Mexico. Each has higher enrollment rates, Slonaker said.

The state also is missing advertising around Medicaid programs, Slonaker said, though he recalled some recently for the portions covering children.

Daryl Herrschaft, who manages the policy project’s program Take Care Utah, described Medicaid programs as “kind of like our state’s best-kept secret when it comes to letting people know it’s available.”

Take Care Utah and other organizations fill that critical role, Herrschaft said, by educating people about eligibility and benefits.

‘Almost a taboo’ about enrollment increases

Advocates also point to state culture as a factor impacting Medicaid enrollment.

Slonaker has seen a pivot in the last decade to lawmakers “accepting some programs as a vehicle forevermore to make sure underserved, low-income folks have access” to health care.

Generally, though, he thinks there’s a stigma around Medicaid, including a lack of branding like California has with Medi-Cal or Oregon has with its Oregon Health Plan.

Butler described legislators getting concerned when enrollment numbers go up like there’s “almost a taboo” about it.

She said some legislators and economists think barriers help keep out people who are likely to abuse the system but that “doesn’t pare out in the data, especially when we’re talking about children.”

In states where access is easier, Butler said, people are more likely to rotate through and use the programs as a leg up until they can get stable again.

Valle said there are “worries about being on Medicaid and just like social services in general” because of the stigma and, sometimes, because of misinformation about the impact on immigration status.

Herrschaft added there’s a sort of “knee-jerk reaction” to suggest people don’t qualify for Medicaid and other social services when every person’s circumstances are different.

That’s despite evidence showing social service programs benefit families and health insurance makes a huge impact on kids, Valle said.

And Butler said there’s a “deep misunderstanding” about health insurance risk pools and that culture wars impact how Utah is able to serve its most vulnerable citizens.

Utah’s policymakers seem not to realize that access to health insurance reduces cost for everyone, Herrschaft said.

Seeking Medicaid member feedback

Strohecker pushed back against the critical narratives and said it’s the state’s goal to make sure everyone enrolled in Medicaid has access to high-quality care.

She’s passionate about serving the Medicaid population and addressing barriers they face in accessing coverage and care.

Strohecker also wants to make sure Utah is doing that in a way that incorporates member feedback. The state is starting consumer panels to hear about members’ experiences and use that information to “inform our work and build a better Medicaid program,” she said.

Utah DHHS already knows about two issues that the Centers for Medicare and Medicaid Services has called out during the unwinding, she said:

• Higher procedural closures than other states. According to a DHHS dashboard, of the cases reviewed in July, nearly 40% of members had their Medicaid coverage renewed; about 2% were ineligible to keep their plans; 4.3% of cases were still pending; and more than 50% lost coverage for procedural reasons — the state wasn’t sure if they were still eligible or not because they were unable to contact the recipient.

• Long wait times for customer service. State Sen. Jacob Anderegg, R-Lehi, noted during a committee meeting last month that his son had recently lost his Medicaid coverage and gave up on finding out why after calling several times and facing hours-long wait times. Anderegg, who last week announced his October retirement from the Legislature, did not respond to requests for more information.

Strohecker said the state is working to automate its ex parte review system. That’s when states attempt to renew coverage by reviewing available data sources to confirm ongoing eligibility instead of sending out renewal documents and requiring members to respond.

That goes live soon and will automate about 10% of the thousands of cases still needing review. It could mean fewer closure notices going out and less work for members, she said.

Automation also can improve the process long term, Strohecker said. That could include improvements to the application process by using information the state already has to pre-fill certain fields or create drop-down menus to lessen errors, she said.

The state is looking at other ways to improve the application, she said, including using customer calls to identify issues people are having with the application and develop quick-tip videos.

Utah also has committed to looking at the application’s complexity, Strohecker said.

“What we’re understanding right now is that some of the forms are really confusing for members,” she said.

Some elements, such as federal government disclaimers, are required, Strohecker said. But a work group has been looking at the forms for two years to see where the state could improve some of the sections it can change, she said.

Advocate: Embed navigators in the system and fund them

DHHS also is building up a navigator network, Strohecker said.

Take Care Utah, an existing navigator service, started because “scrappy nonprofits pieced together funding from everyone and anyone” to work on getting people enrolled, Slonaker said.

Staff members try to reach out to people who get the least access, he said, including the unhoused, people who were recently incarcerated and those learning English.

That should be state-sponsored, Slonaker said, and Utah is missing an opportunity for Take Care Utah and other community-based organizations to provide resources with ongoing funding.

Navigators “need to be embedded in and funded by the system,” he said.

Megan Banta is The Salt Lake Tribune’s data enterprise reporter, a philanthropically supported position. The Tribune retains control over all editorial decisions.