Just months after voters in Utah and Idaho approved ballot measures meant to expand Medicaid coverage to more low-income residents under the Affordable Care Act (ACA), legislators in both states are moving to place restrictions on the number of new people who would be covered.

Utah’s state Senate on Monday advanced a measure to cover those who make up to 100 percent of the federal poverty limit under Medicaid.

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Those who make between 100 percent and 138 percent of the federal poverty level would be required to purchase subsidized insurance plans on the ACA’s individual marketplace.

The plan would replace Proposition 3, a measure that would have covered everyone up to 138 percent of the federal poverty level under Medicaid paid for by a 0.15 percentage point increase in the state sales tax. The measure passed in November by a 53 percent to 47 percent margin.

The Senate-passed bill, which must now pass the state House before heading to Gov. Gary Herbert’s (R) desk, would require a waiver from the federal Center for Medicare and Medicaid Services (CMS) to cover costs.

CMS has not granted any similar waivers to other states. Arkansas and Massachusetts, which experts said asked for similar exemptions, were rejected.

If CMS refuses to grant the waiver, the Senate-passed bill would repeal the voter-passed Medicaid expansion.

In Idaho, top legislative Republicans met this week to begin hashing out proposals to replace Proposition 2, which would have expanded Medicaid coverage to those making less than 133 percent of the federal poverty level, and those who are not eligible for other state insurance — a provision designed to effectively include those who make 138 percent of the poverty level or less.

Proposition 2 passed with 60 percent of the vote in November. Unlike the Utah measure, though, the Idaho bill did not include any funding mechanisms to pay for the added costs.

“The legislature is reviewing how they would fund this and what sort of restrictions and sideboards they would put on expansion to keep it from busting the financial picture in Idaho,” said Fred Birnbaum, vice president of the Idaho Freedom Foundation, a group that has challenged the Medicaid expansion measure’s ballot language in court.

Legislators are considering implementing work requirements and lifetime limits on the amount of coverage someone could receive.

“There have been a lot discussions but no bills yet,” Birnbaum said. “The legislature does have an independent responsibility to fund things, and there was no mechanism in the ballot issue. So they’re doing their duty.”

Supporters of Medicaid expansion said the proposal in Utah and the early discussions in Idaho amounted to an affront to voters, who made their voices heard in states that allow citizens to place initiatives and referenda on the ballot.

“Now, we’re seeing activity in the legislature that would make some changes to the state plans,” said Robin Rudowitz, associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured. “They would be more restrictive than what was called for in the ballot measures.”

Thirty-four states and the District of Columbia — not including Idaho and Utah — have adopted Medicaid expansion under the Affordable Care Act.

Along with Idaho and Utah, Nebraska voters also approved Medicaid expansion in the 2018 midterm elections. Voters in Montana rejected expanding Medicaid, a measure that would have been funded by increased tobacco taxes; tobacco companies poured more than $17 million into opposing that measure.

Most of the 14 states that have not adopted expansion are Southern states in which Republicans hold total control.

Some of those states could see their own ballot measures to expand coverage on the 2020 ballot.

The Fairness Project, a Washington-based group that helped fund the ballot measures that passed in 2018, has said it will explore new pushes in six states that allow ballot measures: Florida, Missouri, Oklahoma, South Dakota, Mississippi and Wyoming.