As The Utah Department of Health submits Medicaid "Per Capita Cap" waiver, advocates warn of harmful effect on consumers
May 30, 2019

Stacy Stanford

SALT LAKE— Tomorrow, th e Utah Department of Health will submit its "Per Capita Cap" Medicaid waiver for consideration, which is the next phase of the legislature's partial Medicaid expansion bill, SB96. Local advocates, including Utah Health Policy Project, warn of the devastating effects that per capita caps, enrollment caps, and work reporting requirements will have on consumers who rely on Medicaid to receive access to necessary health care.

The key feature of this waiver is the per capita cap , which is a way of cutting Medicaid that shifts the financial risk of rising health care costs from the federal government to the state of Utah (and Utah taxpayers) by allocating a set amount of federal dollars for the state's Medicaid program instead of the current open-ended match-rate system. The current match rate system guarantees that Utah will never pay more than 38 percent of the program's cost, and no more than 10 percent under a full Medicaid expansion. Due to the limiting nature of the arrangement, there has never been, and never will be a per capita cap deal that is as good as the current match rate system that allows open-ended flexibility and risk-sharing between the federal and state government.

Under a per capita cap structure, the state receives a limited amount of federal dollars, and in exchange, receives permission to make cuts to Medicaid that are normally not allowable-- meaning, that the only flexibility gained, is the flexibility to cut services and eligibility to Medicaid.

Further, per capita caps make it harder to provide services during emergencies or economic recessions -- when our community needs help the most. These caps are problematic on the first day, but those problems will compound over time as the growth of the cap fails to keep up with actual rising costs. The trend of per person cost is exploding as health care costs are exploding, even in good or stable years.

Per capita caps do not cut health care spending, they simply shift the risk of already-rising health care costs onto the states, without any safety net. Instead of addressing the root causes behind rising health care costs, these caps will only cut Medicaid spending by cutting vulnerable people off of their insurance, or cutting the services Medicaid provides.

Response from Utah health care advocates:

"Instead of expanding Medicaid in a straightforward fiscally responsible way, or working to reduce health care costs, Utah is chasing unlawful changes to the Medicaid program that would take away existing flexibility, cut people off of care, and place all of the risk on the state-- and therefore onto vulnerable Utahns. A per capita cap does not address Utah's rising health care expenses, but pretends the problem will go away if you cut enough services and enrollees from the Medicaid program."
  • Stacy Stanford, policy analyst with Utah Health Policy Project

"Funding cuts and harmful limits to coverage only make it more difficult for Utah kids and families to get the health care they need. We need to realize full Medicaid expansion, without caps or barriers, to help parents and kids across the state thrive."
  • Jessie Mandle, senior health policy analyst with Voices for Utah Children

"A per capita cap and a limit on enrollment, both requested by the State in this waiver, will be harmful to Utahns, especially those with disabilities. Not only will individuals be denied access to coverage when the State runs out of funding because of enrollment limits, which it will, but the other likely outcome of a per capita cap is cuts to services. This highlights why these proposals cannot be lawfully approved by the federal government, because these proposals will do nothing to further the objectives of the Medicaid Act, which is to provide health coverage. We're disappointed that the State of Utah continues to put forward unlawful ideas that are more concerned with dollar signs than the health coverage of Utahns."
  • Nate Crippes, staff attorney with Disability Law Center

What is the public comment period?

States are given the opportunity to request flexibility outside existing Medicaid law through an 1115 waiver. As part of SB96, the state is pursuing a series of these waivers since they are requesting a variety of untested, unlawful changes to the state Medicaid program. Part of the 1115 procedure includes a state and federal public comment period, 30 days each, following by a period of time where administrators at both levels are required to respond to concerns brought up by the public.
The state-level comment period opens Friday May 31st and will run until June 30th.
During this time, local advocates will be soliciting comments from the public via a survey linked on the UHPP website: /

They can also be submitted directly either online: or via email:

There will also be two public hearings, June 6th from 2-4 PM, and June 17th from 4-6 PM.

More information on per capita caps:

UHPP will also be releasing a Utah-specific report on per capita caps on June 6th.

The bottom line:

  • Per capita caps shift the financial risk of already-rising health care prices onto the state, and then the state in turn will be forced to pass the risk onto Utahns.
  • There has never been a per capita cap deal that was as good as the current state/federal flexible budget share.
  • The Trump administration and Utah legislature are not addressing the root issue of rising health care costs in Medicaid, and are instead cutting services from the most vulnerable.
  • Medicaid caps will always equal Medicaid cuts.

For more information contact:

Stacy Stanford
Policy Analyst, UHPP

Nate Crippes
Staff Attorney, DLC