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An initiative to put the question of full Medicaid expansion on the November 2018 ballot in Utah will take its official first step Monday, advocates told the Deseret News.

SALT LAKE CITY — An initiative to put the question of full Medicaid expansion on the November 2018 ballot in Utah will take its official first step Monday, advocates told the Deseret News.

An application for the approval of the ballot initiative will be submitted to the office of Lt. Gov. Spencer Cox on Monday, at which point his office will have 30 days to review the initiative.

The initiative would raise $70 million to $80 million in taxes through a slight bump in Utah's sales tax rate to pay for the expansion, said Jason Stevenson, spokesman for Utah Health Policy Project, a federal health exchange enrollment hub and health care think tank that is one of several organizations putting their weight behind the initiative.

Polling over the last few years has consistently shown a high level of support for Medicaid expansion in Utah, Stevenson said.

"All the polling that has been done on the issue showed great statewide support on this — well over 50 percent," he said.

He added that support appears strong among both Democrats and Republicans.

The organization pushing for the ballot initiative is a newly formed political issues committee called Utah Decides Healthcare, which will also be the name of the campaign.

"Our belief is you don’t go to the ballot measure (for) the first thing. But we have been waiting for Congress to act and we have been waiting … for the Legislature to act," said Maura Carebello, president of Salt-Lake based Exoro Group, a public policy general consultant that has coordinated with others to help the initiative get drafted.

The initiative is supported by numerous Utah advocacy groups. The signatories placing their name on the ballot application to be turned in Monday include Republican state Sen. Brian Shiozawa of Salt Lake, who is on the state Legislature's Health Reform Task Force. Carabello and Stevenson characterized Shiozawa's support as a feather in their cap, saying it was proof that the tax-raising measure can gain support from conservatives.

Carabello said Shiozawa's backing speaks to the "cleanness of" the initiative and added "we expect many local elected officials will join us on this." She said the initiative "does not have a leaning" to one political ideology.

"That's why coalitions are awesome," she said. "We've agreed that this is an issue that all these disparate (stakeholders) are united on."

Stevenson said Shiozawa, who works as an emergency room doctor, "sees some of the most expensive health care and how Medicaid expansion can address that issue."

Multiple attempts to reach Shiozawa for an interview Friday were unsuccessful.

Stevenson said about 80,000 people statewide earn too little to qualify for purchasing their own insurance on the federal health exchange, but are not considered eligible for Medicaid. The ballot initiative would accept Medicaid expansion as enabled under the Affordable Care Act, thus extending federal insurance coverage to all of those people, "closing the gap completely in Utah," Stevenson said.

Generally, adults with dependents who make 55 percent of the federal poverty level but under 100 percent of that level do not qualify for either Medicaid or plans offered on the federal exchange, according to Stevenson.

That gap is even larger for low-income, able-bodied adults without dependents who cannot qualify for Medicaid unless they belong to a small group of homeless or otherwise extremely needy individuals targeted by a limited expansion measure that remains up for final approval from the federal government.

Stevenson said gaps for both those groups would be eliminated under the terms of the ballot initiative, which would set in motion a request to the federal government to make all Utahns who are under 138 percent of the federal poverty level eligible for Medicaid.

Under statute, the federal government would begin funding 90 percent of that Medicaid expansion, with the state covering 10 percent, Stevenson said.

Although technically no children or teenagers fall under a Medicaid gap, "what we know ... is when parents don't have coverage, kids don't have coverage" because their parents often don't enroll them, according to Stevenson. That means covering more adults would lead to more children getting covered, he said.

The Utah Decides Healthcare ballot initiative would raise sales tax in Utah from 4.7 percent to 4.8 percent, Carabello said. The money raised from the tax increase — estimated at $70 million to $80 million — would be enough to completely cover new state expenditures, she said.

Carabello believes that for those affected, the sales tax bump is well worth it.

"The human implications of this are staggering in terms of quality of life," as well as simply being alive, she said.

But it makes economic sense too, Carabello said, noting that "paying for this also decreases the staggering costs of emergency care," which she called "an extremely wasteful (burden) on our health care system."

She cited a hypothetical example of a man staying in a homeless shelter getting long-term care at a local clinic using Medicaid to pay the provider instead of relying on an emergency room to get significantly more expensive care for the same ailment and not having any insurance with which to pay.

Many health-care focused groups in the state are poised to support the effort, including the Utah Academy of Pediatrics, Voices for Utah's Children, Utah Legislative Coalition for People with Disabilities, Utah Disability Law Center, Utah Academy of Family Physicians, Utah Nurses Association and the Utah Chapter of the American Academy of Pediatrics.

National advocacy groups that have thrown support behind the initiative include Families USA and The Fairness Project, Carabello said.

Hughes skeptical

Utah House Speaker Greg Hughes, R-Draper, said he has reservations about the fiscal sustainability of the plan, though he cautioned he has not seen the initiative language.

"Increasing taxes to generate a specific dollar amount to expand Obamacare Medicaid won’t work," Hughes said in an email. "Obamacare expansion rules don’t work that way. If Utahns pass this initiative and obligate the state, then we are on the hook for 10 (percent) of an unknown cost. ... It poses a risk to our entire state budget. What area of out state budget will they suggest we cut to continue paying for this entitlement program that has no caps, public education?"

Carabello anticipated that type of criticism.

"It's a red herring if someone tells you it's all over if we enter into this road," she said. "That would be a fine political tactic. It would not map back to sound (economics)."

Stevenson said earlier Friday that "we have a pretty good beat on who would be affected and how much it would cost."

But Hughes worries about committing to expansion while at the same time underestimating its costs.

"Utahns are fiscally conservative. We don’t want our tax dollars obligated toward things we can’t control or can’t afford," he said.

Hughes also called it a "mistake to set tax policy or our annual budget, issue by issue, line by line via the ballot box." The House Speaker has been a prominent voice in the debate over Medicaid expansion in recent years.

Rep. Jim Dunnigan, R-Taylorsville, who co-chairs the Lesiglature's Health Reform Task Force, also told the Deseret News he is concerned that a ballot initiative creates a law in "a fairly inflexible way." By contrast, he noted, "you can modify (legislation) throughout the process" while a bill is considered in the Legislature.

Dunnigan also worries whether jumping in to full Medicaid expansion will prove fiscally unsustainable. He cited the possibility that the federal government could later decide to reduce its matching funds rate, potentially devastating state coffers.

"It's hard to know whether the matching rate will stay," he said. "If we go in thinking we're going to get 90 percent and we get 70 percent, are we going to be able to afford that?"

Derek Monson, executive director of policy for conservative think tank Sutherland Institute, expressed deep skepticism in an email to the Deseret News.

"I am ... concerned that a .1 percentage point increase in the sales tax will not be sufficient to pay for the program, likely leading to a decision to take even more funds from working families to pay for a bad health care policy," Monson said.

Monson contends Utahns "already struggle to provide adequate access to health care for Medicaid patients" without adding more people to the program, and that "ballot initiatives often generate bad policies that do not stand up to legislative scrutiny."

"The raft of ballot initiatives being pushed right now is certainly going to impact the ability of voters to learn about and understand them all, and is therefore going to impact each initiative’s chances of success," he added.

Carabello said she is not worried Medicaid initiative will be drowned out by the handful of other measures that could make it to the ballot in 2018.

"My point of view is voters are sophisticated. All of these issues are legit. They can listen to the case for support for each," she said.

Carabello acknowledged gathering enough signatures for a ballot initiative is "a lift" and that there is an "urgency to start the clock on signature gathering." In addition to volunteers, there will be paid signature gatherers as part of the campaign, she said.

"We're going to take both paths," Carabello said. "We're not going to leave anything up to chance."

The group must collect more than 113,000 signatures from voters in 26 of the state's 29 senate districts. The Utah Decides Healthcare group must also hold several public meetings about the initiative throughout different areas of the state.