How a Ballot Initiative to Expand Medicaid in Utah May Be Denied

Republican lawmakers don’t want to fully implement a ballot initiative passed in November. One health-care advocate called it “trampling on … representative democracy.”

Bonnie Bowman, a supporter of a voter-approved measure to fully expand Medicaid, at a rally at the Utah legislature in Salt Lake City on Monday. (Rick Bowmer / Associated Press)

SALT LAKE CITY, Utah — In November, Utah’s voters defied their state legislature and moved to adopt Obamacare’s Medicaid expansion in the state. With strong majority support, Utahns passed Proposition 3, a ballot initiative that would expand Medicaid coverage to all poor and near-poor adults. Joining Idaho and Nebraska, Republican-led states that passed similar initiatives in November, Utah reflected a divide between political leadership in ruby-red states—which has often opposed anything to do with Barack Obama’s signature policy—and the will of even Republican voters, who often like the plan and the prospect of more affordable coverage for more people.

But Utah, like some other Republican-led states where the Medicaid expansion has received support from the electorate, is now seeing immediate challenges to the law passed by popular democracy. With legislators tasked with crafting the sales tax and the budgetary changes needed to implement Proposition 3’s coverage, the GOP is pushing to add restrictions to benefits and eligibility of the expanded Medicaid program. Citing budgetary concerns, Republican legislators say they are doing what they can to advance the wishes of voters and the mandate to expand insurance, while also being fiscally responsible. But supporters of the proposition see in these plans a stealthy maneuver to repeal and replace the expansion before it even exists, and see it as part of a larger movement by Republicans nationwide to stonewall the progress of expanded health insurance, even when it runs counter to what their constituents want.

On Monday, hundreds of protesters descended on the state capital, intent on preserving the exact letter of what voters approved with Proposition 3 in November. That ballot initiative expanded Medicaid coverage to all non-elderly adults with an income under 138 percent of the federal poverty line and would pay for that expansion with an increase in the state sales tax, which state analyses found would raise about $90 million in revenue. If the initiative were implemented as expected, it would go into effect on April 1, extending free coverage to about 150,000 people, including many like the low-income workers who showed up Monday to protest.

Republican lawmakers, who control both houses and the governor’s mansion in the state, were never keen on the plan to begin with. But faced with undeniable public support in polls for Medicaid expansion, in 2018 the state legislature passed a bill that would expand Medicaid to some adults below poverty, an expansion of some 70,000 covered lives, but less than half of what proponents of Proposition 3 pitched. But that bill required a novel waiver from the federal Centers for Medicare and Medicaid Services (CMS).

It was clear then that Republicans viewed their partial expansion as a way to circumvent public sentiment. In a June 2018 confidential memo to the White House and to President Donald Trump, the state warned that “there is significant risk that Utah will vote to expand fully with a November ballot initiative” and that “allowing partial expansion would result in significant savings over the 10-year budget window compared to full Medicaid expansion by all.” But in the end the Trump administration viewed a decision to grant waivers for partial expansions as a capitulation to Obamacare. CMS did not make a decision on granting that waiver by the time Utah voters on November 6 went out and passed the much more expansive version of the expansion.

Now, as the start date for Utah’s Medicaid expansion approaches, proposals in the state House and Senate that mirror some parts of the original partial expansion are back on the table. Last week, State Senator Allen Christensen told the Deseret News, “We’re going to make the program work within the money the proposition provided.” The bill Christensen introduced that’s currently under consideration in the state Senate would apply only to people in poverty, establish caps on spending, make eligibility and verification more complicated and restrictive for applicants, establish work requirements for beneficiaries, and introduce lockout periods for people who violate the conditions. A bill under consideration from the state House would roll back the Proposition 3 version of the Medicaid plan so that Christensen’s could take its place. Both bills were under consideration by the Senate Health and Human Services Standing Committee on Tuesday.

Republican lawmakers have cast these moves as ones that would save the Medicaid expansion that voters wanted, not dismantle it. According to the Associated Press, Senate President Stuart Adams, a Republican, indicated that Utah’s legislature intended to pass a Medicaid expansion, but that it needed to be accomplished in a “fiscally prudent way.” Republicans point to a predicted $10.4 million budget shortfall for the state in 2021.

But proponents of Proposition 3 see this as a rejection of the self-determination of voters. “These politicians are trampling on the most fundamental principles of representative democracy,” said Jonathan Schleifer, executive director of the Fairness Project, a group that advocates for statewide Medicaid expansions and spearheaded several ballot-initiative efforts in GOP-led states in 2018. “Legislators who vote for this bill would be disrespecting the voters of Utah, disrespecting the struggling families who were expecting access to health care, and disrespecting the basic principles of representative democracy.”

Other objections to the GOP’s plan also mention that it—like the 2018 attempt to circumvent the ballot-initiative process—relies on the grant of a waiver from CMS that may never come. According to the liberal-leaning Center on Budget and Policy Priorities, “CMS denied earlier requests from Arkansas and Massachusetts that they receive the enhanced matching rate to cover only part of the expansion population. Thus, there’s a high chance that CMS wouldn’t approve a new waiver proposal from Utah with the same type of request and, consequently, no coverage expansion would ever occur.” In addition to the real, probable risk of the proposed expansion never materializing, even if the federal government does go against precedent and approves Utah’s proposed waiver, it would take months to be able to implement it properly, meaning coverage certainly won’t start in April.

Critics of Utah’s GOP see its actions as reminiscent of other Republican efforts across the country to stonewall the Affordable Care Act (ACA) and turn Medicaid into a more conservative program, even when it means going against direct democracy. In 2017, 59 percent of Maine’s voters approved a Medicaid-expansion ballot initiative. Then-Governor Paul LePage, a Republican, simply ignored that initiative, refusing to implement the reform until state legislators made changes in funding the program. Advocacy groups sued LePage. Janet Mills, a Democrat, was elected governor in 2018, and when she assumed office, she implemented the program. Other Republican governors have—with the blessing of the Trump administration—championed the implementation of work requirements in Medicaid, and have sought increased flexibility through waivers to create programs that cover fewer people, increase cost exposure for covered people, and make eligibility verification more frequent and onerous. In two other states, last November saw expensive, major campaigns to defeat Medicaid expansions from ballot initiatives.

As is true in Utah, these actions all highlight the tightrope the GOP is now walking. In national and state polls, Americans across party lines have indicated support for the ACA’s coverage expansion, have especially favored Medicaid expansions, and have favored funding mechanisms for those expansions. All of this was true and is true in Utah, and was made explicitly clear by direct democracy last fall. Yet the expansion could still fail to materialize, a development that would put representatives squarely against the will of the people they represent.