Utahns rally at the state capitol to demand Medicaid expansion be enacted on January 28, 2019. Photo: Rick Bowmer/AP/REX/Shutterstock/Rick Bowmer/AP/REX/Shutterstock

The Idaho Supreme Court has rejected a legal challenge to Medicaid expansion in the state, which voters approved at the ballot box in November. As the Idaho Statesman reported, the right-wing Idaho Freedom Foundation had sued to block expansion on the basis that it “gave too much power to the federal government and the Idaho Department of Health and Welfare.” The ruling is a victory for activists who helped pass Idaho’s Medicaid expansion, but other obstacles persist. In both Idaho and in Utah, where voters also passed Medicaid expansion by referendum last fall, the implementation plans proposed by Republican legislators would severely restrict the program’s reach.

Last Sunday, the Statesman reported that a group of 15 Republican legislators have met to discuss a wide range of restrictive waiver proposals, ranging from work requirements to lifetime coverage limits. They also intend to ask the Centers for Medicare and Medicaid Services to approve the waivers before they proceed with legislation that implements expansion, which could create months-long delays. In Utah, legislators have revived parts of a pre-referendum proposal — which CMS has yet to approve — that would have partially expanded Medicaid, extending coverage to 70,000 people. As The Atlantic noted, that figure is less than half the size of the pool that would be covered under the full expansion approved by voters in November.

Since November, legislators in Utah’s House and Senate have proposed expansion bills with similar language. One, SB 96, would replace a voter-approved expansion plan with a program that would “apply only to people in poverty, establish caps on spending, make eligibility and verification more complicated and restrictive for applicants, establish work requirements for beneficiaries, and introduce lockout periods for people who violate the conditions,” per The Atlantic. The Center for Budget and Policy Priorities, a left-of-center think tank, released a damning analysis of SB 96 on Tuesday. Citing a state fiscal analysis, researchers wrote that the bill would insure “48,000 fewer Utahans and would cost the state $50 million more over the next two years.” They continued:

Like the earlier waiver, the new bill depends on federal approval of unprecedented restrictions — far from guaranteed — to expand coverage to a smaller group of low-income Utahns than the voter-approved initiative would, and it includes provisions that restrict Medicaid eligibility, including an enrollment cap and the termination of coverage for people who don’t meet a rigid work requirement. Moreover, if implemented, SB96 will cost the state more than full expansion, at least initially and potentially on a permanent basis.

If SB 96 becomes law, its future is questionable. Expansion advocates could argue that legislators thwarted the will of the people, which sets up a possible legal challenge.

Idaho legislators risk a similar possibility with their approach to implementation. Both circumstances recall the example of former Maine governor Paul LePage, a Republican. LePage repeatedly vetoed expansion bills passed by the state legislature. Maine then became the first state in the nation to pass Medicaid expansion in a public referendum — only for to LePage to delay the program’s launch, and to request a waiver that would have allowed him to attach work requirements for beneficiaries, which CMS approved in December. When Janet Mills, Maine’s new Democratic governor, took office in January, the state still hadn’t expanded Medicaid. (Mills has since begun implementing expansion, without LePage’s desired work requirements.)

The tactics of legislators in Idaho and Utah may be savvier than LePage’s plan. They aren’t refusing to implement Medicaid expansion; they just hope that a Medicaid-hostile federal government will help them pass plans that drastically restrict the program’s reach. But public sentiment is firmly on the side of Medicaid expansion, and Maine provides another example that Republican legislators in Utah and Idaho should heed. Mills ran on a promise to expand Medicaid, and won. Not only did Maine elect a Democrat to replace its outgoing Republican governor, the state’s traditionally conservative Second Congressional District elected a Democrat who ran on Medicare for All. Voters who approved Medicaid expansion in Idaho and Utah may not react kindly to legislators who get in their way.