Three months after voters in Utah and Idaho defied their recalcitrant state legislatures to expand Medicaid through ballot initiatives, Republican lawmakers in those states are hitting back.
Nebraska voters last fall also approved a referendum to expand its Medicaid program. That effort remains on track, said Molly McCleery, director of health care access for Nebraska Appleseed, an advocacy group.
But in Utah — where 53 percent of voters favored the ballot question last November — a bill is quickly moving through the statehouse that would limit the number of people eligible for an expanded Medicaid program and require that most adults qualifying for the program have a job.
In Idaho, where 61 percent of voters in November approved full Medicaid expansion, a group of 15 conservative state lawmakers is drafting legislation to add a work requirement and monthly premiums for newly eligible adults.
The pushback shows the limits of the ballot referendums — otherwise called “direct democracy,” said Craig Burnett, an assistant professor of political science at Hofstra University in New York.
The reaction from Idaho and Utah lawmakers could chill other potential Medicaid expansion ballot referendums planned for 2020 in Florida and other states, said Jamila Michener, an assistant professor of government at Cornell University.
“The point of ballot initiatives is to exert influence on the lawmaking process directly, but if legislatures undermine that process, it could ring hollow their purpose,” she said.
Jonathan Schleifer, executive director of The Fairness Project, which helped finance the Medicaid expansion initiatives last year, called the action by Utah and Idaho lawmakers “outrageous.”
“We were not surprised by it, but we are disappointed,” Schleifer said. “This shows how out of touch these legislators are with their constituents, and they are disrespecting families and the principles of basic democracy.” The Fairness Project is funded by the Service Employees International Union-United Healthcare Workers West, a California union.
Republican lawmakers say they want to meet the will of voters but are trying to control state spending at the same time.
“We need to put some sideboards on the expansion,” said John Vander Woude, Idaho House majority caucus leader. He said the public did not know the true cost of the Medicaid expansion when it voted for it last fall.
Utah and Idaho are among the 17 states that have not accepted federal funds provided by the Affordable Care Act to expand their Medicaid program to all adults earning less than 138 percent of the federal poverty level (about $17,000 for an individual). Under the ACA, the federal government pays 90 percent of the cost of coverage for people added through the expansion, compared with about 60 percent for people in the traditional Medicaid programs.
After the voter referendums, state officials still have to budget for the expansion and make plans for its implementation.
The pushbacks follow a similar effort by former Maine Gov. Paul LePage, who stymied a voter-directed expansion there for more than a year.
The Utah Senate last week voted to limit expansion to only those Medicaid enrollees earning up to only 100 percent of the federal poverty level and add a requirement that most new adult enrollees work. The bill now moves to the House and may end up on Republican Gov. Gary Herbert's desk next week. He has indicated he may sign it.
Supporters of the ballot referendum note the Obama and Trump administrations have not let other states get ACA funding for a Medicaid expansion that does not cover people up to the full 138 percent of the poverty level. Jesse Cross-Call, an analyst for the left-leaning Center on Budget and Policy Priorities based in Washington, D.C., said that without administration approval of a partial expansion it’s likely “no coverage expansion would ever occur.”
Medicaid expansion has not always been this difficult to get through Republican-controlled states. Arizona, for example, approved expansion five years ago.
Utah’s ballot initiative would have expanded Medicaid to about 150,000 people. It included a 0.15 percent sales tax increase to pay for the expansion. It did not include a work requirement.
The Trump administration has approved Medicaid work requirements in six states, although only Arkansas has implemented it, as the issue faces litigation in federal court.
Utah lawmakers had some cover to reshape the Medicaid expansion voter referendum because the state’s hospitals didn’t support it. In other states, hospitals typically have been the biggest cheerleaders for full Medicaid expansion because it reduces the number of uninsured patients and, therefore, uncompensated care.
In Idaho, lawmakers seeking to limit the expansion want the Trump administration to approve the work requirement and premiums before expansion can occur. Typically, the federal government takes a year or more to evaluate a state’s request.
Expansion was expected to add coverage for 62,000 people.
Vander Woude said one concern for him and his colleagues was that the Idaho measure did not lay out how the state would pay for its portion of the expansion.
“The referendum had no financing to show what it would cost,” he said. “The best way to implement this is do it in a cost-effective way to get the results we are looking for.”
Vander Woude said ballot initiatives are a bad idea because they don’t include all the information voters need to make informed decisions. “I think it’s a dangerous way to pass laws,” he said.
He said it was misleading for advocates to stress to voters how the millions in federal funding for Medicaid expansion scheduled to go to Idaho would be directed to other states if Idaho did not expand. But he didn’t dispute that, by not expanding, Idaho has missed out on federal funds that would have gone to provide health services to the state’s poor.