SALT LAKE CITY — Last November, a majority of Utah voters approved full Medicaid expansion, only to see their elected state representatives pare back Proposition 3 due to cost concerns and what some viewed as a slippery slide toward universal health care.

But full implementation of their Legislative alternative — Senate Bill 96 — hinges on receiving federal waivers to the Affordable Care Act, a process that could take 12 to 18 months and even then, possibly end up in court.

The Utah Department of Health, tasked with implementing SB 96, is currently taking public comment on the Legislature’s proposed waivers. During its second of two live hearings in Salt Lake City, several individuals came forward in opposition to the changes made to Prop 3. Nathan Checketts, who directs the Department’s Division of Medicaid and Health Financing, was on hand to document their concerns.

“I knocked on a lot of doors to get Prop 3 passed,” June Taylor told Checketts. “I’m not at all happy with this waiver. I think it’s an ill-thought-out effort to limit the number of people who get Medicaid by imposing per capita caps.”

Taylor also criticized the Legislature’s sole focus on cost rather than the potential economic benefits of having a healthy workforce.

Melanie Hopkinson called the passage of Prop 3 unusual in light of Utah’s conservative bent.

“They voted to increase their taxes, because that’s how important the issue was to them,” Hopkinson said. “This should not be about money, it should be about a basic human right, which is healthcare for everyone — especially the most vulnerable people in our society.”

Bill Tibbitts, associate director of the nonprofit Crossroads Urban Center, warned that the waiver could eventually get held up in an extended court battle.

“This idea of changing the way Medicaid finance works is something that Congress looked at and rejected several times,” Tibbitts said. “It’s contentious and there’s likely to be litigation.”

Rather than seeking waivers from the federal government’s executive branch, Tibbitts said that Utah lawmakers should have worked with their federal delegation to get a bill through Congress.

Bill Cosgrove, a retired pediatrician who chairs UDOH’s Medical Care Advisory Committee, worried about the limits of SB 96 regarding the 40,000-plus Utahns who fall in the 101 to 138 percent coverage gap.

“They are technically eligible for subsidized coverage in the Marketplace, but it takes at least a Masters Degree and some help — it’s a difficult process,” Cosgrove said of the federal website that features various healthcare insurance plans and subsidies. “It looks on the surface to be set up to dissuade people from being eligible. And if they go get eligible, there’s still the copays” that many low-income Utahns can’t afford.

Under President Donald Trump, opposition to the Affordable Care Act has taken the form of diminished funding for signup assistance and shorter annual enrollment periods via the online Marketplace.

What voters approved

The ballot initiative called Prop 3 raised the state sales tax from 4.70 percent to 4.85 percent to fund full Medicaid Expansion for approximately 150,000 Utahns earning up to 138 percent of the federal poverty level.

Under the Affordable Care Act (signed into law in 2010 by former President Barack Obama), federal tax dollars cover 90 percent of the cost, leaving states to pick up the remaining 10 percent. A 2012 Supreme Court ruling gave states the right to opt in or out of full Medicaid Expansion.

What lawmakers passed

SB 96 expands Medicaid to approximately 70,000 to 90,000 Utah parents and adults earning up to 100 percent of the federal poverty level ($12,490 for an individual or $25,750 for a family of four). In the gap between 101 and 138 percent of the federal poverty level, about 40,000 Utahns access subsidized insurance through the federal Marketplace.

After the public comment period ends, Utah’s Per Capita Cap Plan waiver goes to the Centers for Medicare and Medicaid Services for federal approval. The Legislature’s plan includes a self-sufficiency requirement, enrollment cap, 12-month continuous eligibility, employer-sponsored insurance enrollment, lockout for program violations, plus a per capita cap.

Timeline for SB 96

Apr. 1 — Medicaid coverage extended up to 100 percent of the federal poverty level, with a 70-30 match in federal/state funds.

Jan. 1, 2020 — If the Per Capita Cap Plan has not been approved, a waiver for a Fallback Plan will be submitted for federal approval by March 15 (after the 2020 Legislative session ends). Both of these rely on a 90-10 match in federal/state funds.

July 1, 2020 — If no waiver approvals materialize, the state will implement full Medicaid Expansion (up to 138 percent of the federal poverty level with a 90-10 federal/state match.)

Want to weigh in?

Through the end of June, the Utah Department of Health is still taking public comments by mail or email. Those can be submitted electronically. A summary of the comments will be included with the federal waiver application to CMS. For more information, go to

Cathy McKitrick is a freelance journalist. You can follow her on Facebook or Twitter (@catmck). She can also be reached at

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