In Idaho and Utah, voters approved big Medicaid expansions. But lawmakers have other ideas.

State lawmakers in Idaho and Utah are seeking to scale back voter-approved Medicaid expansions under the Affordable Care Act (ACA).

Under the ACA, states expanding their Medicaid programs must offer coverage to individuals with incomes up to 138% of the federal poverty line (FPL). The federal government under the ACA currently covers at least 90% of the cost of a state expanding Medicaid to individuals with incomes up to 138% FPL.

Voters approve Medicaid expansions in Idaho, Utah

Last year, voters in Idaho and Utah approved ballot measures directing their states' policymakers to expand their Medicaid programs under the ACA.

In Idaho, 62% of voters approved Proposition 2, which directs the state to expand Medicaid to individuals with annual incomes up to 133% FPL. Under the measure, the state would expand Medicaid coverage to an estimated 62,000 Idaho residents who did not otherwise qualify for Medicaid or subsidized insurance from the state's exchange market.

In Utah, 53% of voters approved Proposition 3, which directs the state to expand Medicaid to individuals with annual incomes up to 138% FPL. Under the measure, the state would expand Medicaid coverage to an estimated 150,000 Utah residents who currently do not qualify for Medicaid or subsidized insurance from the state's exchange market.

State lawmakers seek to scale back Medicaid expansions

However, lawmakers in both states are seeking to roll back the voter-approved Medicaid expansions, citing concerns over the costs of expanding Medicaid.

In Idaho, state lawmakers are eyeing various restrictions on Medicaid coverage that would curb the voter-approved expansion's effects. For instance, lawmakers are considering imposing work requirements on individuals with annual incomes up to 133% FPL who will be eligible for coverage under the state's ballot measure. To implement the work requirements, the state would have to submit a Medicaid waiver request to CMS and receive the agency's approval.

Meanwhile, Utah's state Senate on Monday voted 22-7 to advance a bill that would restrict its Medicaid expansion to residents with incomes less than or equal to FPL, which is about $12,140 for an individual, instead of the 138% FPL threshold approved by voters. The bill also would impose work requirements on Utah residents eligible for coverage under the state's Medicaid expansion. An estimated 90,000 Utah residents would be eligible for coverage under the bill's Medicaid expansion requirements, compared with 150,000 Utah residents who would be covered under the ballot measure's requirements.

The Utah measure also would place a limit on the growth of per capita costs for the state's Medicaid program and would freeze enrollment in the state's expanded Medicaid program if the costs exceed the amount provided in the state Legislature's appropriations. Utah would have to submit a Medicaid waiver request to CMS and receive the agency's approval to implement the changes proposed in the bill. The proposed legislation would automatically repeal Utah's entire Medicaid expansion if the Trump administration does not approve the request.

Paul Edwards, a deputy chief of staff for Utah Gov. Gary Herbert (R), said Utah officials "are in close contact with CMS, and we are encouraged by what we are hearing. But no one has put anything into writing."

Utah officials have said the bill could arrive at Herbert's desk for his signature in a week or two.

If passed, the bill is expected to cost Utah about $72 million more to implement over the next two years than the voter-approved Medicaid expansion plan. However, a fiscal note of a revised version of the bill released Monday shows the bill would cost Utah less than the ballot initiative after federal waivers are approved, although the costs over the first two years remain similar. According to that fiscal note, the bill is expected to save Utah $19.4 million per year beginning in 2024, because the state is expected to receive higher federal funding. 

Comments

CMS so far has been reluctant to approve proposals that would allow states to receive additional federal funds under the ACA without fully expanding Medicaid. If the administration approves a partial Medicaid expansion proposal, other states are likely to file similar requests.

Republican state lawmakers have defended the proposals, calling them fiscally responsible.

Herbert said, "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."

Utah state Sen. Ann Millner (R) said, "Now is the right time for us to do it—to balance expanding to meet the needs of our community and at the same time being fiscally responsible."

Similarly, Utah state Sen. Jacob Anderegg (R) said, "We are legislators. We're not the federal government. We can't print money or issue bonds on the open market to debt finance this."

However, advocates have criticized the measures.

Chase Thomas, executive director of Alliance for a Better Utah, said, "This is not a compromise or a fiscally responsible bill. It is simply a repeal of what the voters decided on the ballot. As this now moves over to the House, we hope that representatives will play fair and reject this expensive repeal of what the voters wanted."

In addition, Matthew Slonaker, executive director of the Utah Health Policy Project, said the bill in the Utah Legislature is "an effort to override the will of the people." Slonaker called the restrictions proposed in the measures are "outside the spirit" of the ballot initiative (Pear, New York Times, 2/4; Baker, "Vitals," Axios, 2/5; Raman, CQ News, 2/4 [subscription required]; Spence, Lewton Tribune/Idaho Statesman, 2/3).

Cheat sheet: What you need to know about the ACA

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The Patient Protection and Affordable Care Act, otherwise known as the ACA, is the comprehensive health care reform bill passed by Congress in March, 2010. The law reshapes the way health care is delivered and financed by transitioning providers from a volume-based fee-for-service system toward value-based care.

Download the ACA cheat sheet to get a quick overview of this significant U.S. health care legislation.

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