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The Utah Health Care Landscape

The Affordable Care Act (ACA) went into full effect on January 1, 2014, ushering in health insurance reforms and new health coverage options in Utah and across the country. Although the Medicaid expansion debate is still underway in the state, Utah is experiencing changes to its health care delivery system. This fact sheet provides an overview of population health, health coverage, and health care delivery in Utah in the era of health reform.

Demographics
Figure 1: Utah is Located in the Mountain Region of the U.S.

Figure 1: Utah is Located in the Mountain Region of the U.S.

Utah is home to just over 2.8 million people, making it the 33rd most populous state in the U.S.1At over 82,000 square miles, Utah is the 12th largest state, but ranks 41st in population density.2 Utah is land-locked and is one of the eight states located in the country’s Mountain region (Figure 1).3 Utah’s topography is diverse. The Rocky Mountains run through the middle of the state, with the flat lands and deep river canyons of the Colorado Plateau to the East and South and salt beds and lakes, including Great Salt Lake, to the North and West.4 Utah is home to five National Parks, the third most of any state behind Alaska and California.5

Utah is a mostly rural state but the majority of the population lives in urban areas. Among the state’s 29 counties, only 7 had nonelderly populations that met or exceeded 50,000 in 2012 (See Figure 13, Appendix).6 Eighty-nine percent of the state’s population lives in urban areas and 37% of the total state population lives in Salt Lake City County.7 With an unemployment rate of 4.6% in October 2013, Utah has the sixth lowest unemployment rate in the country, which is lower than the U.S. average of 7.3%.8

Figure 2: Utah State Demographics, 2012

Figure 2: Utah State Demographics, 2012

Utah has a young and relatively non-diverse population. More than eight in ten (81%) Utah residents identify as White, compared to 12% who identify as Hispanic and 1% who identify as Black (Figure 2).9 Ninety-five percent of Utah residents are U.S. citizens.10 Utah is a young state, with one third of its population, or nearly 939,000 individuals, under 19 years of age.11More than one in seven individuals in Utah (15%) are living in poverty and nearly one-quarter (23%) have family income levels that qualify them for Medicaid, if the state accepts the ACA Medicaid expansion (Figure 3).12 However, like in other states, poverty in Utah is not equally distributed by race and age. Eleven percent of those who identified as White were living in poverty in 2012, compared to 34% of those who identified as Hispanic and 31% who identified as another race. In addition, among individuals under age 19, 19% were living in poverty, while only 14% of adults age 19-64 and 10% of adults age 65 and over were living in poverty.13

State Economy
Figure 3: Distribution of Total Population by Federal Poverty Level, 2012

Figure 3: Distribution of Total Population by Federal Poverty Level, 2012

Utah has experienced consecutive years of state economic growth. In 2012, Utah’s Gross Domestic Product (GDP) was $130.5 Billion, which makes it the 33rd largest economy in the U.S.14 Like many other states across the country, Utah experienced an increase in its GDP from 2011 to 2012 and Utah was among the 10 states that experienced the largest percentage increase to its state economy that year.15 Agriculture, manufacturing, and mining are major industries in the state, as well as tourism, business development, and construction.16 Like other states across the country, Utah experienced budgetary challenges during the recent economic downturn. However, the state’s economy continues to improve.17 Utah ended State Fiscal Year (SFY) 2013 with a $242 million revenue surplus.18

Utah has implemented flat individual income and corporate income tax rates, both at 5%, which are below national averages.19 Utah’s state sales tax is 5.95%, which is slightly above the national average of 5.64%, and, when combined with local sales tax, the rate ranges from 5.95% to 8.05%.20,21

Population Health
Figure 4: Health Insurance Coverage of the Total Population, 2012

Figure 4: Health Insurance Coverage of the Total Population, 2012

The overall population health in Utah is ranked above the national average. Utah ranked 6 among the 50 states for total population health in the United Health Care Foundation’s report, America’s Health Rankings 2013.22 Compared to others states across the country, Utah has a low prevalence of both obesity and diabetes.23,24 However, Utah has a higher share of adults who report having poor mental health than the national average.25 Death rates due to influenza and pneumonia in Utah are higher than the national average,26 which may in part be explained by low flu shot and pneumonia vaccination rates among children under 4 years and adults 65 years and older.27 Utah’s smoking and binge drinking rates are also lower than the national average.28

Disparities in health and health care access exist in Utah. Despite low obesity rates statewide, those who identify as Hispanic (63%) or American Indian (75%) are more likely to be overweight or obese than those who identify as White (58%) or Black (41%).29 Those who identify as Hispanic (32%) are less likely than those who identify as White (39%) or Black (38%) to report having poor mental health.30 However, those who identify as Hispanic (24%) or Black (17%) are more likely to report being in fair or poor overall health than those who identify as White (12%).31 In addition, those who identify as Hispanic (16%) or Black (15%) are 1.5 times as likely to be a binge drinker as those who identify as White (10%).32

Figure 5: Characteristics of the Nonelderly Uninsured in Utah, 2012

Figure 5: Characteristics of the Nonelderly Uninsured in Utah, 2012

Health disparities also exist in access to care. Among those who identify as Black or Hispanic, nearly half (both 45%) report that they do not have a usual source of care, compared to 23% of those who identify as White.33

Coverage

Over 400,000 people, or 15% of Utah’s population, were uninsured in 2012 (Figure 4).34 This rate aligns with the national average, which reflects the range of uninsured rates across the country from 4% in Massachusetts to 24% in Texas. As shown in Figure 14 (Appendix), the nonelderly uninsured in Utah are not equally distributed across the state’s counties. As in other states across the U.S., the majority of the uninsured have at least one full-time worker in their households, have income below 400% of the Federal Poverty Level, and are under age 55 (Figure 5).35

Among the 85% of Utahns with health insurance, the largest share (58% of the state population) have employer-sponsored coverage, followed by Medicaid (10%), Medicare (9%), and individual private insurance (6%)(Figure 4).36

Figure 6: Utah State General Fund Expenditures, SFY 2012

Figure 6: Utah State General Fund Expenditures, SFY 2012

Medicaid

Utah’s Medicaid program covers nearly 300,000 individuals, for whom the state spent 8% of its general revenue funds, or around $380 million in SFY 2012 (Figure 6).37 Medicaid is the third largest source of state general fund spending, behind elementary and secondary education and higher education. Of those enrolled in Fiscal Year 2010, 59% were children, who accounted for 27% of expenditures (Figure 7).38 Meanwhile, 16% were elderly or disabled, who accounted for 58% of total costs. The combined federal and state costs for Utah Medicaid were $1.9 billion in Fiscal Year 2012.39 Average state and federal spending per beneficiary was $4,890, which was lower than the national average of $5,563 and lower than nearby states (Figure 8).40 This fiscal year, the federal government will pay 70.3% of the cost of Medicaid in Utah; therefore, for every $1.00 that Utah spends on Medicaid, the federal government will send $2.37 to the state in matching funds.41 Utah also provides coverage to certain groups of children up to 200% FPL through a separate CHIP program, for which the federal government pays 79.3% of the cost.42

Figure 7: Medicaid Enrollment and Expenditures, FY 2010

Figure 7: Medicaid Enrollment and Expenditures, FY 2010

Utah has used a Medicaid waiver to extend coverage to certain adults. Since February 2002, Utah has had a statewide Section 1115 Medicaid Demonstration Waiver, called Utah’s Primary Care Network (PCN).43 This waiver allowed the state to reduce coverage for previously eligible parents in order to finance an expansion of a primary and preventive care benefit package for up to 25,000 uninsured adults ages 19-64 with family incomes up to 100% FPL who were no previously eligible for Medicaid. The waiver also allows the state to cover high-risk pregnant women whose income make them ineligible for Medicaid, to provide premium assistance ($50 for an individual, $100 for a family) for adults up to 200% FPL to help pay for approved employer coverage or COBRA, and to provide premium assistance to children up to 200% FPL who are CHIP-eligible but opt for employer coverage. On December 24, 2013, CMS approved an extension of the PCN waiver through December 31, 2014.44 In the approval letter, CMS specified that adults over 100% FPL who will no longer be eligible for the PCN after January 1, 2014 should be enrolled in short-term coverage in the state program and then the state should assist them with selecting new coverage in the Marketplace prior to March 31, 2014.

Figure 8: Average State Medicaid Spending per Beneficiary, 2010

Figure 8: Average State Medicaid Spending per Beneficiary, 2010

The Affordable Care Act (ACA) could extend financial assistance for coverage to a majority of uninsured Utahns if the state takes up the Medicaid expansion. A main goal of the ACA is to extend health coverage to many of the 47 million nonelderly uninsured individuals across the country, including up to 60% of the 407,000 nonelderly uninsured Utahns (Figure 9). The ACA accomplishes this through insurance reforms and by establishing new coverage pathways, including the expansion of Medicaid coverage to nearly all individuals up to 138% of the FPL ($16,105 for an individual, $27,310 for a family of 3 in 2014) and by providing premium tax credits to many individuals between 100% – 400% FPL to purchase coverage on the Health Insurance Marketplaces. However, as a result of the Supreme Court decision, the Medicaid expansion became effectively a state option.

Without the Medicaid expansion, 58,000 currently uninsured adults (14% of the uninsured in the state) who would have been eligible for Medicaid will remain in the coverage gap (Figure 10).45 The June 28, 2012 Supreme Court ruling on the ACA (known as National Federation of Independent Business v. Sebelius) decided that the individual mandate was constitutional, but that the Medicaid expansion was effectively a state option.46 As of today, Utah is not implementing the Medicaid expansion, however, deliberation on the issue is ongoing.47

Figure 9: Eligibility for Financial Assistance in Gaining Coverage Among Currently Uninsured Utahns, As of January 2014

Figure 9: Eligibility for Financial Assistance in Gaining Coverage Among Currently Uninsured Utahns, As of January 2014

If the state expands its Medicaid program, the federal government will pay 100% of the cost of coverage for those newly eligible through 2016, which will then phase down to 90% in 2020 and beyond. In May 2013, Public Consulting Group released an impact analysis for the state on the Medicaid expansion, which found that, if the state took up the Medicaid expansion in January 2014, it would save the state and counties $131 million over the first ten years and provide coverage to 123,000 previously uninsured adults.48 While the analysis predicts that expanding Medicaid would cost the state an additional $260 million through 2023, it would save the counties and state $188 million on public assistance expenditures and generate $203 million in new state and county tax revenue.49

After agreeing to study its options regarding the Medicaid expansion decision, Utah’s Governor announced in January 2014 that “doing nothing is no longer an option”.Governor Herbert released a proposal, entitled the “Healthy Utah Plan”, in February 2014.50 This proposal would require a waiver from the federal government to block grant the Medicaid program and allow the state full flexibility in distributing $258 million in federal and state funds to provide health coverage assistance to individuals making less than $15,500 per year. With the legislative session coming to a close on March 13, 2014 without passing Medicaid expansion legislation, the Governor will likely continue Medicaid expansion negotiations with CMS and, if an agreement is reached, possibly call the legislature back into special session.51

Figure 10: Nearly 58,000 Poor Nonelderly Uninsured Adults in Utah May Remain in the ACA Coverage Gap

Figure 10: Nearly 58,000 Poor Nonelderly Uninsured Adults in Utah May Remain in the ACA Coverage Gap

Under the ACA, all states are required to streamline and simplify the enrollment process for health coverage. Regardless of a state’s Medicaid expansion decisions, all states must implement new eligibility and enrollment processes under the ACA, including a transition to determining income eligibility for most groups using Modified Adjusted Gross Income (MAGI)(Figure 11).52,53 Individuals can enroll in coverage through multiple pathways, including in person, over the phone, by mail, and online. Under the new MAGI eligibility rules, the eligibility level will be 205% FPL for children, 144% FPL for pregnant women, and 47% FPL for parents in Utah.54 MAGI rules apply to coverage determinations for Medicaid and for coverage purchased in the Marketplace.

Health Insurance Marketplace

Health insurance marketplace reform was a priority in Utah prior to the Affordable Care Act. In 2008, former Governor Jon Huntsman (R) signed House Bill 133, which required the Legislature, the Department of Health, the Insurance Department, and the Governor’s Office of Economic Development to work together to develop a strategic plan for health system reform.55 Governor Huntsman signed House Bill 188 in 2009, which paved the way for the newly created Office of Consumer Health Services to expand health insurance access and increase market flexibility and transparency through the creation of the Utah Health Exchange.56 Upon taking office, current Governor Gary Herbert (R) signed additional health system reform legislation into law, including House Bill 294 in 2010 and House Bill 128 in 2011, the latter of which reauthorized the Health System Reform Task Force to evaluate options for bringing the state’s existing exchange into compliance with the ACA.57,58

Figure 11: Medicaid Income Eligibility in Utah as a Percent of the Federal Poverty Level, as of January 2014

Figure 11: Medicaid Income Eligibility in Utah as a Percent of the Federal Poverty Level, as of January 2014

Avenue H will function as the state’s marketplace for small businesses. In February 2012, House Bill 144 was introduced, which would authorize an actuarial analysis of a Basic Health Plan for individuals between 133 – 200% FPL, meanwhile, Governor Herbert was in negotiations with HHS over the extent to which the state would have to modify its exchange, renamed Avenue H, to comply with the ACA.59 Although, Utah received conditional approval from HHS in January 2013 to run a state exchange, Governor Herbert subsequently proposed that the state maintain Avenue H as the state’s small business (SHOP) exchange, while having the federal government run a Federally Facilitated Marketplace for individual coverage in the state.60 HHS granted approval for this proposal in May 2013.61,62

Utah is one of 27 states in which the federal government has set up and is running their Health Insurance Marketplace.63 Six insurance providers are offering 99 Qualified Health Plans in Utah’s Marketplace.64 At $209 per month, Salt Lake City has the ninth lowest monthly premium for a Benchmark Health plan among major cities across the country, before premium tax credits.65 Of the anticipated 331,000 individuals expected to enroll in the state’s Federally Facilitated Marketplace, 206,000 (62%) will be eligible for premium tax credits.66 As of March 1, 2014, 78,258 individuals had been determined eligible to enroll in a Marketplace plan, of which 55,994 qualified for financial assistance and 39,902 had selected a Marketplace plan.67

The Affordable Care Act also provided for the establishment of Consumer Operated and Oriented Plans (CO-OPs). CO-OPs are a new type of non-profit, member-governed health insurance. They may operate locally, state-wide, or in multiple states and must be licensed as issuers in each state in which they operate. They are intended to offer more affordable, consumer friendly, and high quality health insurance options to compete with existing health insurers. CO-OPs may offer insurance both in and outside the state Marketplaces. An October 2013 analysis by the National Alliance of State Health CO-OPS (NASHCO) found that average individual premiums in the states offering CO-OPs are 8% lower than the other states.68 While CO-OPs offer the lowest premiums in some state insurance Marketplaces, they offer among the highest premiums in others.69 Utah is one of 23 states currently offering CO-OPs. The state’s CO-OP, Arches Health Plan, received an $89.7 million loan from HHS in 2011 and began offering coverage January 1, 2014.70

Safety Net
Figure 12: Utah is Home to 41 Health Centers

Figure 12: Utah is Home to 41 Health Centers

Utah’s safety net delivery system will continue to play an important role in delivering health care to the state’s vulnerable population. Utah’s community health centers and hospitals provide access to needed primary, preventive, and acute care services for low-income and underserved residents. Utah is home to 11 federally qualified health centers (FQHCs) and 4 look-alike health centers, together operating 41 clinic sites throughout the state (Figure 12).71 In 2011, the state’s FQHCs saw over 112,000 patients and had over 370,000 patient visits.72 Fifty-six percent of patients were uninsured, while 19% had Medicaid.73 Three quarters were below 100% FPL.74,75 The Department of Health and Human Services awarded Utah’s 11 FQHCs $2.1 million for Fiscal Years 2013 and 2014 to assist with outreach and enrollment under the ACA.76 In 2009, the state’s Association for Utah Community Health (AUCH) was awarded a two-year CHIPRA outreach grant, through which the state was able to identify successful outreach and enrollment strategies, including the importance of both one-on-one assistance by an enrollment specialist throughout the application and enrollment process and the importance of collaboration and communication among the state’s Medicaid agency, Department of Health, and enrollment specialists.77

In addition, 42 of Utah’s hospitals received Disproportionate Share Hospital (DSH) payments in Fiscal Year 2013.78 Since Utah does not have designated safety net hospitals, DSH payments, which are intended for hospitals treating the uninsured and underinsured, provide insight into which hospitals are providing services to Utah’s low-income population. The hospitals, including 21 rural hospitals, received a total of $29.6 million in federal funds in Fiscal Year 2013.79

Despite Utah’s existing safety net, there are Health Professional Shortage Areas (HPSAs) and unmet need for care. As of July 2013, 68% of the primary health care need in the state was being met and Utah had 58 primary care HPSAs.80 However, only 63% of the need for mental health care services and 55% of the need for dental services were being met and the state had 37 mental health and 48 dental HPSAs.81 Utah is one of 21 states that has reduced autonomy for nurse practitioners in at least one area of their practice, while 17 states allow nurse practitioners full autonomy and 12 states allow less autonomy and increased supervision.82

Looking Ahead

With 2.8 million residents, Utah is one of the country’s less populated states; however, the state experienced the third fastest population growth rate of 3.3% from 2010 to 2012.83 Despite a low unemployment rate and high share of individuals with employer-sponsored coverage, more than one in seven Utahns is uninsured. The ACA provides the opportunity to extend coverage to the majority of these individuals; however, since the state is not expanding its Medicaid program at this time, 14% of the currently uninsured may remain without affordable health coverage options. For those who are eligible for new coverage under the ACA, outreach, enrollment, and education efforts at the state and local level are and will continue to be important to engaging individuals and helping them appropriately access and utilize care. The state’s safety net providers will continue to provide needed health care services both to the newly insured and to those who remain without affordable health coverage options.

There is much to watch in Utah looking forward. Individuals who have newly gained coverage in the Marketplace are beginning to interact with their new health plans; Governor Herbert is likely continuing conversations with CMS to work toward a final decision on the Medicaid expansion; and the state’s safety net providers will continue to adapt to the changing health coverage landscape. It remains to be seen how these and other changes under the ACA will impact the health, health care access, and health care utilization of Utahns in the future.

Appendix

Figure 13: Utah Nonelderly Population by County, 2011

Figure 14: Utah Nonelderly Uninsured by County, 2011

Endnotes
  1. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements).

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  2. World Atlas, United States, http://www.worldatlas.com/aatlas/infopage/usabysiz.htm.

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  3. U.S. Department of Commerce, Economics, and Statistics Administration, Census Regions and Divisions of the United States (U.S. Census Bureau), http://www.census.gov/geo/maps-data/maps/pdfs/reference/us_regdiv.pdf.

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  4. World Atlas, Utah: Geography, http://www.worldatlas.com/webimage/countrys/namerica/usstates/utland.htm.

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  5. For a list of U.S. National Parks by state, see: http://www.listofusnationalparks.com/national-parks-list-by-state/.

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  6. US Census Bureau, 2010-2012 American Community Survey, County Total Population Estimates. For more information about Urban/Rural definitions, see: USDA Economic Research Service, Rural Definitions State-Level Maps: Utah (2000), http://www.ers.usda.gov/datafiles/Rural_Definitions/StateLevel_Maps/ut.pdf.

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  7. USDA Economic Research Service, State Fact Sheets: Utah, 2012 Population (February 20, 2014), http://www.ers.usda.gov/data-products/state-fact-sheets/state-data.aspx?StateFIPS=49&StateName=Utah#Pf669f4c9093d4b0a843889df2cf5c5a1_2_39iT0 and US Census Bureau, 2012 County Total Population Estimates.

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  8. Utah and state figures from Table 3, Regional and State Employment and Unemployment: October 2013, and Unemployment rates by State, seasonally adjusted: October 2012 and 2013, Bureau of Labor Statistics, available at http://www.bls.gov/news.release/laus.t03.htm. U.S. figure from Bureau of Labor Statistics, available at http://data.bls.gov/cgi-bin/surveymost?bls.

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  9. UI/KCMU estimates based on March 2012 and 2013 CPS.

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  10. UI/KCMU estimates based on March 2012 and 2013 CPS.

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  11. UI/KCMU estimates based on March 2012 and 2013 CPS.

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  12. UI/KCMU estimates based on March 2012 and 2013 CPS.

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  13. UI/KCMU estimates based on March 2012 and 2013 CPS.

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  14. Bureau of Economic Analysis, Gross Domestic Product by State 2012 (June 6, 2013).

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  15. Bureau of Economic Analysis, Widespread Economic Growth in 2012 (June 6, 2013), http://www.bea.gov/newsreleases/regional/gdp_state/gsp_newsrelease.htm.

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  16. Utah Economic Council, Utah Economic Outlook 2014, http://business.utah.gov/wp-content/uploads/2014UtahEconomicOutlook.pdf.

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  17. Governor’s Office of Management & Budget, Budget Information Archive, http://gomb.utah.gov/budget-policy/budget-information-archive/.

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  18. Office of Utah Governor Gary Herbert, “Governor Announces 2013 Revenue Surplus” (September 17, 2013), http://www.utah.gov/governor/news_media/article.html?article=9341.

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  19. Tax Foundation, State Tax and Spending Policy: Utah (2012), http://taxfoundation.org/state-tax-climate/utah. Utah is one of eight states that has implemented a flat individual income tax rate, as of 2014. For a list of 2014 state individual income tax rates, see: Federation of Tax Administrators, State Individual Income Taxes (February 2014), http://www.taxadmin.org/fta/rate/ind_inc.pdf.

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  20. Federation of Tax Administrators, State Sales Taxes (January 1, 2014), http://www.taxadmin.org/fta/rate/tax_stru.html.

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  21. Utah State Tax Commission, Utah Sales & Use Tax Rates for January 1, 2014 (March 26, 2013), http://www.tax.utah.gov/sales/rates.

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  22. United Health Care Foundation, America’s Health Rankings: State Ranking Overview: 2013 (2013), http://www.americashealthrankings.org/rankings.

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  23. At 22%, Utah has the lowest share of any state of adolescents (age 10-17) who are overweight or obese, compared to a national average of 31% (Child and Adolescent Health Measurement Initiative. 2011 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website, http://www.childhealthdata.org/home). In addition, 58% of adults in Utah are overweight or obese, compared to a national average of 63% (KCMU analysis of the Center for Disease Control and Prevention (CDC)'s Behavioral Risk Factor Surveillance System (BRFSS) 2012 Survey Results).

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  24. Only 7% of adults in Utah have been told by a doctor they have diabetes, compared to 10% nationally (KCMU analysis of the Center for Disease Control and Prevention (CDC)'s Behavioral Risk Factor Surveillance System (BRFSS) 2012 Survey Results).

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  25. In Utah, 37.9% of adults reported having poor mental health, compared to a US average of 35.6% (KCMU analysis of the Center for Disease Control and Prevention (CDC)'s Behavioral Risk Factor Surveillance System (BRFSS) 2012 Survey Results).

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  26. In Utah, the death rate for influenza and pneumonia is 17 per 100,000, compared to 15 per 100,000 nationally (The Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, Division of Vital Statistics , National Vital Statistics Reports (NVSR) Volume 61, Number 4, Table 19, May 8, 2013, http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf).

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  27. Only 71% of children (ages 19-35 months) in Utah receive their vaccinations, compared to 75% nationally (Estimated Vaccination Coverage with Individual Vaccines and Selected Vaccination Series Among Children 19-35 Months of Age by State -- U.S., National Immunization Survey, Q1/2010-Q4/2010. National Immunization Program, Centers for Disease Control and Prevention). Among those 65 and older in Utah, only 56% receive their yearly flu shot and 70% have been vaccinated against pneumonia, compared to 59% and 68% nationally (KCMU analysis of the Center for Disease Control and Prevention (CDC)'s Behavioral Risk Factor Surveillance System (BRFSS) 2012 Survey Results).

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  28. The smoking prevalence for Utah is 11%, compared to 19% nationally; the binge drinking was 11% compared to a national average of 17% (Behavioral Risk Factor Surveillance System (BRFSS) 2012 Survey Results)

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  29. KCMU analysis of 2012 BRFSS.

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  30. KCMU analysis of 2012 BRFSS.

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  31. KCMU analysis of 2012 BRFSS.

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  32. KCMU analysis of 2012 BRFSS.

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  33. KCMU analysis of 2012 BRFSS.

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  34. UI/KCMU estimates based on March 2012 and 2013 ASEC Supplement to the CPS.

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  35. UI/KCMU estimates based on March 2012 and 2013 ASEC Supplement to the CPS.

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  36. UI/KCMU estimates based on March 2012 and 2013 ASEC Supplement to the CPS.

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  37. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements) and State Expenditure Report, National Association of State Budget Officers, 2013.

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  38. KCMU/Urban Institute estimates based on data from FY 2010 MSIS and CMS-64 reports, 2012.

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  39. Urban Institute estimates based on data from CMS (Form 64), as of 9/16/13.

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  40. KCMU/Urban Institute estimates based on data from FY 2010 MSIS and CMS-64 reports, 2012.

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  41. Federal Register, November 30, 2012 (Vol 77, No. 231), pp 71420-71423, at http://www.gpo.gov/fdsys/pkg/FR-2012-11-30/pdf/2012-29035.pdf.

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  42. Martha Heberlein, Tricia Brooks, Joan Alker, Samantha Artiga, and Jessica Stephens, Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (January 2013), http://www.kff.org/medicaid/report/getting-into-gear-for-2014-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-2012-2013/ and Federal Register, November 30, 2012 (Vol 77, No. 231), pp 71420-71423.

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  43. Utah’s Section 1115 Primary Care Network Medicaid Demonstration Approval Letter and Document, December 24, 2013: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ut/ut-primary-care-network-ca.pdf.

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  44. Utah’s Section 1115 Primary Care Network Medicaid Demonstration Approval Letter and Document, December 24, 2013.

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  45. Kaiser Commission on Medicaid and the Uninsured, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (Kaiser Family Foundation, October 2013), http://www.kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.

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  46. MaryBeth Musumeci, A Guide to the Supreme Court’s Affordable Care Act Decision (Kaiser Family Foundation, June 2012), http://kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-affordable/.

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  47. State Health Facts, “Status of State Action on the Medicaid Expansion Decision, 2014” (Kaiser Family Foundation, January 28, 2014), http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

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  48. Public Consulting Group, State of Utah Medicaid Expansion Assessment: Impact Analysis: 2014-2023 (May 2013), http://www.health.utah.gov/documents/PCGUtahMedicaidExpansionAnalysis.pdf.

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  49. Public Consulting Group (May 2013).

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  50. Utah Governor Gary Herbert, “Governor unveiled an alternative plan to Medicaid expansion - The ‘Healthy Utah Plan’ fixes the hole without expanding Medicaid” (February 27, 2014), http://www.utah.gov/governor/news_media/article.html?article=9747.

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  51. Lisa Riley Roche, “Governor says special session may be needed on Medicaid expansion” (Deseret News, March 4, 2014), http://www.deseretnews.com/article/865597944/Governor-says-special-session-may-be-needed-on-Medicaid-expansion.html?pg=all and Lindsay Riley Roche, “Gov. Herbert: I’m an ‘action figure’ on Medicaid expansion issue” (Deseret News, March 11, 2014), http://www.deseretnews.com/article/865598455/Gov-Herbert-Im-an-action-figure-on-Medicaid-expansion-issue.html.

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  52. Medicaid.gov, “Medicaid and CHIP Eligibility Levels” (September 30, 2013), http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Medicaid-and-CHIP-Eligibility-Levels/medicaid-chip-eligibility-levels.html.

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  53. Kaiser Commission on Medicaid and the Uninsured, Medicaid Eligibility for Adults as of January 1, 2014 (Kaiser Family Foundation, October 2013), http://www.kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014/.

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  54. KCMU analysis based on CMS, State Medicaid and CHIP Income Eligibility Standards Effective January 1, 2014 (October 24, 2013).

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  55. Utah House Bill 133 (2008), http://le.utah.gov/~2008/bills/hbillenr/hb0133.pdf.

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  56. Utah House Bill 188 (2009), http://le.utah.gov/~2009/bills/hbillenr/hb0188.pdf.

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  57. Utah House Bill 294 (2010), http://www.exchange.utah.gov/images/stories/hb0294.pdf.

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  58. Utah House Bill 128 (2011), http://www.exchange.utah.gov/images/stories/hb0128_-_Legislation_2011_Session.pdf.

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  59. Utah House Bill 144 (2012), http://le.utah.gov/~2012/bills/hbillint/hb0144.pdf.

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  60. HHS Letter to Governor Herbert Giving Utah Conditional Approval to Run at State-Based Exchange (January 3, 2013), http://www.cms.gov/CCIIO/Resources/Files/Downloads/ut-blueprint-exchange-letter-01-03-2013.pdf.

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  61. CMS Letter to Governor Herbert Agreeing to His Proposal (May 10, 2013), http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/utah-marketplace-letter-5-10-2013-508.pdf.

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  62. Avenue H website, now operating as a SHOP exchange, http://www.avenueh.com/.

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  63. State Health Facts. “State Decisions for Creating Health Insurance Marketplaces” (Kaiser Family Foundation, May 28, 2013), http://www.kff.org/health-reform/state-indicator/health-insurance-exchanges/.

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  64. For a listing of participating health insurance companies, see: U.S. News & World Report, “Utah Exchange Health Insurance Plans” (December 6, 2013), http://health.usnews.com/health-insurance/utah/marketplace-plans.

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  65. This is the monthly premium for a single, 40-year-old at 250% FPL. With premium tax credits, the monthly premium drops to $193. To see how Utah compares to other states, see: State Health Facts, “ 2014 Monthly Premiums for a Single 40-Year-Old at 250 Percent of Poverty in a Major City in Each State” (Kaiser Family Foundation), http://kff.org/other/state-indicator/2014-monthly-premiums-for-a-single-40-year-old-at-250-percent-of-poverty-in-a-major-city-in-each-state/.

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  66. Gary Claxton, et al. State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act (Kaiser Family Foundation, November 2013), http://kff.org/health-reform/issue-brief/state-by-state-estimates-of-the-number-of-people-eligible-for-premium-tax-credits-under-the-affordable-care-act/.

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  67. Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS), Health Insurance Marketplace: March Enrollment Report, October 1, 2013 - March 1, 2014 (March 11, 2014), http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Mar2014/ib_2014mar_enrollment.pdf.

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  68. Although 23 states are offering CO-OPs, due to lack of data for three states (Hawaii, Kentucky, and Massachusetts), this analysis compared 22 states offering CO-OPs to the remaining 27 states and DC. National Alliance of State Health CO-OPS (NASHCO), Exchange Weighted Average Premiums, 47 States and DC (October 2, 2013).

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  69. John Holahan, Rebecca Peters, and Kevin Lucia, The Launce of the Affordable Care Act in Selected States: Insurer Participation, Competition, and Premiums (Robert Wood Johnson Foundation and Urban Institute, March 2014), http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf411402/subassets/rwjf411402_3.

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  70. State Health Facts, Consumer Oriented and Operated Plan (CO-OP) Loans Awarded (Kaiser Family Foundation, January 1, 2014), http://kff.org/health-reform/state-indicator/co-op-loans/.

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  71. HRSA, Health Center and Look-alike Sites Facility Directory (March 3, 2014), http://findahealthcenter.hrsa.gov/Search_HCC.aspx?byCounty=1.

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  72. National Association of Community Health Centers, Incorporated (NACHC) analysis of the 2011 Uniform Data System, Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services, Special Data Request, March 2013, http://www.nachc.com/client//2012%20Key%20data.pdf.

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  73. NACHC analysis of the 2011 Uniform Data System.

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  74. National Association of Community Health Centers, Utah Health Center Fact Sheet, http://www.nachc.com/client/documents/research/UT12.pdf.

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  75. For additional information about FQHCs in Utah compared to the rest of the U.S., see: Peter Shin, Jessica Sharac, and Sara Rosenbaum, The Potential Impact of the Affordable Care Act on Uninsured Community Health Center Patients: A Nationwide and State-by-State Analysis (George Washington University School of Public Health and Health Services, October 16, 2013), http://sphhs.gwu.edu/sites/default/files/GG%20uninsured%20impact%20brief.pdf.

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  76. HRSA, Utah: Health Center Outreach and Enrollment Assistance, http://www.hrsa.gov/about/news/2013tables/outreachandenrollment/ut.html.

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  77. Jennifer Edwards, Diana Rodin, and Samantha Artiga, Profiles of Medicaid Outreach and Enrollment Strategies: One-on-One Assistance through Community Health Centers in Utah (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, March 2013), http://kff.org/medicaid/issue-brief/profiles-of-medicaid-outreach-and-enrollment-strategies-one-on-one-assistance-through-community-health-centers-in-utah/.

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  78. State of Utah Department of Health, Disproportionate Share Dollars Paid for FFY2013, http://health.utah.gov/medicaid/stplan/Inpatient/WebDSHFY2013.pdf.

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  79. State of Utah Department of Health.

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  80. Bureau of Clinician Recruitment and Service, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, HRSA Data Warehouse: Designated Health Professional Shortage Areas Statistics, as of July 29, 2013, http://ersrs.hrsa.gov/reportserver/Pages/ReportViewer.aspx?/HGDW_Reports/BCD_HPSA/BCD_HPSA_SCR50_Smry_HTML&rs

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  81. HRSA, Designated Health Professional Shortage Areas Statistics, as of July 29, 2013.

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  82. American Association of Nurse Practitioners, State Practice Environment 2013, http://www.aanp.org/legislation-regulation/state-legislation-regulation/state-practice-environment.

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  83. From 2010 to 2012, Utah’s population grew by 3.3%, behind North Dakota (4%) and Texas (3.6%)(U.S. Census Bureau’s March 2010 and 2012 Current Population Survey).

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