Designed to Fail: Utah’s Backdoor Repeal of Voter-Approved Medicaid Expansion

In November 2018, a majority of voters in Utah passed a Medicaid expansion ballot initiative providing Medicaid health coverage to low-income parents and other adults. For example, a family of three with an annual income of less than $29,435/year would be eligible.  Voters also approved a very small (0.15 percent) sales tax to pay for this new health insurance coverage for low-income families and individuals – in total 150,000 Utah residents. Coverage was mandated to begin on April 1, 2019.

The passage of the ballot initiative was a strong expression of the will of Utah voters in the face of state inaction. Over the years, Utah state legislators and the Governor have been battling a grassroots movement in the state for more affordable health coverage through Medicaid expansion with a clever strategy – oversell limited legislation that only expands Medicaid to just a few of the thousands needing affordable coverage and hope that public attention moves on.

The passage of the ballot initiative was a strong expression of the will of Utah voters…

Exhibit one is the Utah state legislature’s 2016 “targeted Medicaid program” that was trumpeted as expanding coverage to the very lowest income “4,000-6,000 Utah adults” (those below five percent of the poverty line) but only 500 adults actually enrolled by the start of 2018.  And this limited plan only passed after years of Medicaid study committees, task force proposals, and administration plans that went nowhere.  Another plan developed by the Governor came with a hefty tax on a long list of health care providers. This “poison pill” provision, to no one’s surprise, generated enormous opposition to the proposal, limiting further action and yet again delaying addressing the overall problem.

However, these limited moves on Medicaid, rather than ending discussion, fed public pressure to actually make health coverage more widely available.  So Utah legislators again revisited the health care question in 2018, passing a partial expansion bill requiring a waiver from the federal government and containing multiple barriers that would prevent people from gaining coverage, including overall spending caps and complex reporting requirements. Even the expected wildly optimistic state estimates said this plan would reach less than half of those eligible for a full Medicaid expansion. Utah persisted in pursuing a partial expansion at that time even though the Trump Administration had rejected similar requests from Arkansas and Massachusetts.

This history of legislative failure by design makes the repeal this week of the voter-passed Medicaid expansion by the Utah legislature and Governor more predictable. Utah lawmakers have spent years trying to look like they were responding to voters demanding new affordable health coverage options for low-income families and adults – but with strict barriers and limits that made the reality of any legislative changes much less than advertised. And that’s exactly what happened with the latest bill that repeals voter-passed Medicaid expansion and purports to replace it with what Utah’s Governor claims is “quality health coverage for the roughly 150,000 Utahns potential enrollees.”

Utah’s repeal bill replaces the voter-approved April 1st Medicaid coverage with three separate federal waiver proposals that will initially cost more and cover fewer people. Two of these waiver proposals are controversial partial expansions that will leave large coverage gaps. The first is a partial expansion without the extra federal funding available to the voter-approved expansion, so it would cost more and cover fewer people. The second is a partial expansion with the extra federal money – something that has never been approved, and if approved, would be challenged in the courts for violating Medicaid law.  

Only if Utah’s first two waiver requests for a partial expansion are denied would the state pursue a third option – yet another expansion waiver up to the same income level voters approved but with coverage starting in 2020 and with containing other barriers like reporting requirements and increased premiums and copays  – making a mockery of the voter-passed expansion that was slated to start April 1 of this year.

Under all three options, Utah wants to impose multiple barriers to coverage like work reporting requirements and locking people out for failure to comply with undefined “program requirements.” And to top it off, Utah also wants the OK from the federal government to limit or freeze enrollment in Medicaid – something no other state has been allowed to do. State officials have tried for years for such limited partial expansions and are hopeful that they will finally get approval from the Trump Administration – which is reportedly considering the issue.

Utah has come up with new poison pill provisions too – like a potential 10% cut to all other health and social service programs in the state in order to fund any expansion to the level voters approved in the ballot initiative.

It also has been widely reported that if federal waivers aren’t approved that the bill reverts to the ballot initiative. A close read suggests this isn’t correct. The relevant provision purporting to allow the voter-approved expansion to go into effect if federal waivers are rejected is actually just a line that allows the state to submit yet another waiver – with all the restrictions, “flexibilities and cost controls” the state would like to add – none of which were a part of voter-approved expansion.

Utah politicians are well-practiced at putting forward limited programs that do little to address the overall problem voter-approved Medicaid expansion would solve – 150,000 state residents simply needing guaranteed, affordable health coverage. I hope I’m wrong and 150,000 Utahns really do get what the Governor calls “quality health coverage.” However, the repeal effort should be seen for what it is – not an attempt to address the same problem with a good-faith solution, but more obfuscation and delays through limited enrollments and taxing barriers to coverage – and a clear reversal of the will of the voters.

Adam Searing is an Associate Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.