Rick Bowmer/Associated Press Tiffiny Malo, left, and Pam Harrison, supporters of a voter-approved measure to fully expand Medicaid, at a rally to ask lawmakers not to change the law during the first day of the Utah Legislature on Monday.

The Utah Senate must vote again on the bill to significantly alter the Medicaid expansion enacted by voters, which it approved once this week against the opposition of all six Democratic senators and one of the chamber’s 23 Republicans. The state House is poised to act quickly on the legislation after the Senate is finished. “It’s moving very quickly,” said King, who expects the Utah House will pass the Senate bill by the end of next week. Republican Gov. Gary Herbert has not taken a public position on the Medicaid bill. In response to questions from HuffPost, Herbert’s office provided a statement from a spokesman. “Gov. Herbert has long supported the kind of common-sense guardrails for Medicaid expansion that are being discussed in the legislature. Many were components of his proposed Healthy Utah Medicaid expansion in 2015; most of these were part of legislation that he signed into law last general session. His primary concerns are that the state honor the will of the voters to fill the hole in the social safety net by helping those under the poverty line without health insurance and to implement without delay,” Paul Edwards said in the statement. Last week, Herbert said he believed the state should allow the expansion to move forward as approved by voters and then be revisited at a later date. During his State of the State address Thursday, Herbert said only that “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.” Because Republicans have supermajorities in the Utah House and Senate, however, the GOP would have the votes to override a veto even if Herbert decided to oppose the Medicaid legislation. The Affordable Care Act calls for Medicaid benefits to be available to anyone earning up to 133 percent of the federal poverty level, and the federal government finances at least 90 percent of the cost. This expansion was meant to be in place nationwide, but a 2012 Supreme Court ruling allowed states to refuse to participate. To date, 14 states have declined it. Utah, Idaho and Nebraska voters all approved expansion via ballot initiative last year, but the program is not yet in place in those states. Under the terms of the Utah initiative, benefits are supposed to become available April 1. The Utah ballot initiative was straightforward in its approach by simply instructing the state to join the Medicaid expansion without any changes to the state’s existing program or the need for federal approval. The Utah Governor’s Office of Management and Budget assessed that the sales tax increase would raise more than enough money to finance the state’s 10 percent share of the expansion’s cost, although it noted that the revenue and costs in future years may not match up. By contrast, the Utah Senate bill would trigger a complicated and uncertain process that would cover fewer people under Medicaid. The Senate began action on the measure before the Legislature’s budget scorekeepers could analyze the legislation’s effects, but it is designed to limit the Medicaid expansion’s reach. That’s despite the fact that the measure would leave the sales tax increase in place while also imposing a tax on hospitals that alone is intended to be large enough to cover the state’s entire share of the expense of Medicaid expansion. Under the Senate legislation, Medicaid benefits would be available only to those with incomes below the poverty level, which is about $12,000 for a single person. Utahns with incomes higher than that would continue to have access to subsidized private coverage via the health insurance exchange in the state. Unlike the Medicaid expansion voters approved, the state would receive about 70 percent of the funding for the partial Medicaid expansion from the federal government instead of the 90 percent offered by a full expansion. The bill lacks detail on many key elements of the modified expansion, leaving those to the state’s executive branch and federal officials to hash out. In order to maintain April 1 as the day benefits would come online, legislative Republicans are counting on all of that happening on an extraordinarily expedited basis. “This entire thing is being rammed through the Senate and the House as quickly as possible. It is a sloppy piece of legislation that couldn’t be further from what voters wanted, and they’re rushing it because they know that they’re going against the will of voters, that they’re disrespecting voters by doing so,” said Jonathan Schleifer, executive director of the Fairness Project, a Washington-based organization that supported Medicaid ballot initiatives in Utah, Idaho, Maine, Montana and Nebraska over the past two years.

It is a sloppy piece of legislation that couldn’t be further from what voters wanted, and they’re rushing it because they know that they’re going against the will of voters. Jonathan Schleifer, executive director of the Fairness Project