On Election Day, a majority of Utah voters approved a ballot initiative to expand Medicaid coverage to an estimated 150,000 low-income adults. The Republican-led state Legislature has other ideas.

The Utah Senate approved a bill Wednesday that would toss out a grassroots-driven, voter-backed ballot initiative to offer Medicaid benefits to any Utahn earning up to 133 percent of the federal poverty level (about $16,000 a year for a single person), paid for by raising the sales tax on certain goods from 4.7 percent to 4.85 percent.

The legislation instead would expand Medicaid to fewer people, enable Utah to receive less federal money for the program and impose limitations on benefits, including work requirements. And the entire plan hinges on a dubious promise of federal approval for aspects of the state Senate bill.

The Utah GOP clearly is prioritizing overturning the voters, considering the Legislature has been in session since just Monday and the bill made it out its Senate committee Tuesday and to the floor Wednesday. The fact that 53 percent of voters spoke in favor of a full Medicaid expansion at the ballot box in November is not swaying Utah Republican legislators, who have resisted the expansion since it became available in 2014 under the Affordable Care Act.

The Utah ballot initiative, known as Proposition 3, not only received majority support statewide but also in most state Senate districts, the Utah Health Policy Project reported. According to a Salt Lake Tribune analysis of the vote Wednesday, 10 Republican senators representing districts where a majority voted in favor of the expansion are supporting the bill to modify it, including the legislation’s main sponsor, Sen. Allen Christensen. A plurality of Utahns opposes changing the voter-backed policy, according to a UtahPolicy.com poll conducted by Dan Jones & Associates.

“You’ve got to defer to the will of the people at some point,” said state Rep. Brian Frank, the minority leader of the Utah House of Representatives and one of 16 Democrats in the 75-member lower chamber of the Utah State Legislature. “We should not be doing anything to substantively alter that Proposition 3 in a way that delays the implementation one more day.”

The GOP bill sends a message to voters, King said: “We don’t really care what the people of the state of Utah want to do or say they want us to do at the Legislature. We’re going to do what we want to do. That’s very troubling to me.”

These actions by Utah Republican lawmakers are reminiscent of how then-Gov. Paul LePage (R) defied Maine voters last year by refusing to carry out a Medicaid expansion they approved in 2017. LePage’s successor, Gov. Janet Mills (D), has already begun the process of implementing the expansion. In Idaho, where voters also passed a ballot initiative to expand Medicaid, a conservative organization is challenging it before the state Supreme Court.

Efforts by Republicans at the state level to undo or limit the Medicaid expansion, including the seven states that received federal approval for work requirements and the eight more seeking it, mirror the national Republican strategy on health care.

The GOP-led Congress devoted most of 2017 to attempting and failing to repeal the Affordable Care Act and replace it with plans that would have left millions without health coverage. And in December, a federal judge ruled in favor of 20 GOP state officials who argued the Affordable Care Act is unconstitutional in a lawsuit supported by President Donald Trump’s Justice Department.

Tiffiny Malo, left, and Pam Harrison, supporters of a voter-approved measure to fully expand Medicaid, at a rally to ask lawmRick Bowmer/Associated Press Tiffiny Malo, left, and Pam Harrison, supporters of a voter-approved measure to fully expand Medicaid, at a rally to ask lawmakers not to change the law during the first day of the Utah Legislature on Monday.

The Utah Senate must vote again on the bill to significantly alter the Medicaid expansion enacted by voters, which it approved once this week against the opposition of all six Democratic senators and one of the chamber’s 23 Republicans. The state House is poised to act quickly on the legislation after the Senate is finished.

“It’s moving very quickly,” said King, who expects the Utah House will pass the Senate bill by the end of next week.

Republican Gov. Gary Herbert has not taken a public position on the Medicaid bill. In response to questions from HuffPost, Herbert’s office provided a statement from a spokesman.

“Gov. Herbert has long supported the kind of common-sense guardrails for Medicaid expansion that are being discussed in the legislature. Many were components of his proposed Healthy Utah Medicaid expansion in 2015; most of these were part of legislation that he signed into law last general session. His primary concerns are that the state honor the will of the voters to fill the hole in the social safety net by helping those under the poverty line without health insurance and to implement without delay,” Paul Edwards said in the statement.

Last week, Herbert said he believed the state should allow the expansion to move forward as approved by voters and then be revisited at a later date. During his State of the State address Thursday, Herbert said only that “the much-needed Medicaid expansion passed by the voters needs to be implemented in a fiscally sustainable way. And with some common-sense adjustments, I know that we can implement this program without delay.”

Because Republicans have supermajorities in the Utah House and Senate, however, the GOP would have the votes to override a veto even if Herbert decided to oppose the Medicaid legislation.

The Affordable Care Act calls for Medicaid benefits to be available to anyone earning up to 133 percent of the federal poverty level, and the federal government finances at least 90 percent of the cost. This expansion was meant to be in place nationwide, but a 2012 Supreme Court ruling allowed states to refuse to participate. To date, 14 states have declined it. Utah, Idaho and Nebraska voters all approved expansion via ballot initiative last year, but the program is not yet in place in those states. Under the terms of the Utah initiative, benefits are supposed to become available April 1.

The Utah ballot initiative was straightforward in its approach by simply instructing the state to join the Medicaid expansion without any changes to the state’s existing program or the need for federal approval. The Utah Governor’s Office of Management and Budget assessed that the sales tax increase would raise more than enough money to finance the state’s 10 percent share of the expansion’s cost, although it noted that the revenue and costs in future years may not match up.

By contrast, the Utah Senate bill would trigger a complicated and uncertain process that would cover fewer people under Medicaid. The Senate began action on the measure before the Legislature’s budget scorekeepers could analyze the legislation’s effects, but it is designed to limit the Medicaid expansion’s reach. That’s despite the fact that the measure would leave the sales tax increase in place while also imposing a tax on hospitals that alone is intended to be large enough to cover the state’s entire share of the expense of Medicaid expansion.

Under the Senate legislation, Medicaid benefits would be available only to those with incomes below the poverty level, which is about $12,000 for a single person. Utahns with incomes higher than that would continue to have access to subsidized private coverage via the health insurance exchange in the state. Unlike the Medicaid expansion voters approved, the state would receive about 70 percent of the funding for the partial Medicaid expansion from the federal government instead of the 90 percent offered by a full expansion.

The bill lacks detail on many key elements of the modified expansion, leaving those to the state’s executive branch and federal officials to hash out. In order to maintain April 1 as the day benefits would come online, legislative Republicans are counting on all of that happening on an extraordinarily expedited basis.

“This entire thing is being rammed through the Senate and the House as quickly as possible. It is a sloppy piece of legislation that couldn’t be further from what voters wanted, and they’re rushing it because they know that they’re going against the will of voters, that they’re disrespecting voters by doing so,” said Jonathan Schleifer, executive director of the Fairness Project, a Washington-based organization that supported Medicaid ballot initiatives in Utah, Idaho, Maine, Montana and Nebraska over the past two years.

It is a sloppy piece of legislation that couldn’t be further from what voters wanted, and they’re rushing it because they know that they’re going against the will of voters. Jonathan Schleifer, executive director of the Fairness Project

The Herbert administration would have to resolve all the outstanding questions the bill poses and the federal government would have to approve waivers for standard Medicaid rules in less than two months, which is much more quickly than it typically acts.

“Nothing about how the federal government moves and operates gives me much hope or assurance that you’re going to get a waiver at all, much less one in a time frame that is going to be less than 60 days,” King said.

The biggest uncertainty pertains to the funding. Under the legislation, Utah would ask the federal government to break precedent by providing the full 90 percent funding for a partial expansion. The Trump administration last year rejected such requests from Arkansas and Massachusetts, following the Obama administration’s policy against partial expansions.

Utah has even tried this before. Herbert signed legislation last year approving a partial expansion and submitted a request for approval to federal authorities. That would have covered about half as many people as a full Medicaid expansion. The state withdrew its application after the ballot initiative passed.

The new bill also calls for work requirements and for locking out enrollees who fail to meet them, but it does not specify what they would be and how they would be enforced. It also would cap enrollment for otherwise eligible Utahns if cost projections for the expansion exceed the amount of money appropriated for the year.

The attempt to overturn voters on Medicaid expansion comes a month after Herbert signed legislation to replace a medical marijuana initiative voters approved last year with a new law. In the aftermath of voters passing the marijuana and Medicaid measures, Utah lawmakers also are eying changes to the ballot initiative process to let the Legislature alter voter-backed policies before they take effect.

This article has been updated with a statement from a spokesman for Utah Gov. Gary Herbert.

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