Ravell Call, Deseret News
Alan Ormsby, left, of AARP Utah, Karina Andelin Brown and the Right Rev. Scott B. Hayashi, bishop of the Episcopal Diocese of Utah, deliver the Utah Decides Healthcare ballot proposal to Thais Stewart, a receptionist in the Utah Lieutenant Governor's Office, at the Capitol in Salt Lake City on Monday, Oct. 2, 2017. If approved by voters on Election Day in November 2018, the proposal will ensure medical care for all individuals and families in Utah with incomes less than 138 percent of the federal poverty line.

SALT LAKE CITY — The most extensive form of Medicaid expansion to be approved by state lawmakers under the Affordable Care Act cleared its final hurdle in the Legislature by passing the Senate on the final night of the session.

But exactly what the future holds for the federal program's role in Utah remains to be seen.

The expansion requested by HB472 would expand Medicaid coverage to an additional 65,000 to 70,000 Utahns if approved by the federal government, its sponsors estimate, but some health advocates warn that approval will never come.

Stacy Stanford, a policy analyst for Utah Health Policy Project, warned this week that "the proposal in HB472 is a nonstarter with the federal government, with an extremely unlikely chance of approval."

Stanford said there is no precedent for the federal government accepting a partial Medicaid expansion that includes a 90 percent federal matching rate, and that there would even be legal hurdles to doing so.

But the bill's floor sponsor, Sen. Brian Zehnder, R-Holladay, told fellow lawmakers Thursday that the Trump administration was giving promising signs that Utah's waiver request could be granted.

"We have been invited to apply for this waiver by the current administration in Washington. That is very encouraging to me and many others in this room," he said.

HB472 instructs the state Department of Health to submit an expansion waiver request with the federal government by Jan. 1 of next year.

Also complicating the question of expansion is a potential ballot measure that calls instead for the fullest Medicaid expansion possible: coverage for everyone in the state who belongs to households earning at or under 138 percent of the federal poverty line.

"We're still moving forward with our campaign," said RyLee Curtis, spokeswoman for that campaign called Utah Decides Healthcare. "(The bill) doesn't change our plans at all. In our eyes, it doesn't fix the problem."

Curtis predicted the initiative would bring coverage to approximately 150,000 Utahns who fall in what is frequently described as a Medicaid coverage gap.

The Utah Health Policy Project has said Utahns in that gap are earning too much to qualify for Medicaid and too little — or at 138 percent or less of the federal poverty line — to qualify for critically important subsidies on the federal health exchange.

"For Medicaid to be expanded, anything less than that is not acceptable to the ballot initiative," Curtis told the Deseret News.

She added that the campaign is "still on track to hit our goal" with the signatures required by April 15 to qualify for the ballot, but declined to give a specific number.

Utah Decides Healthcare is seeking a 0.15 percent sales tax increase to raise $91 million in state funds, thereby drawing down $800 million in matching federal money to fund coverage for newly insured enrollees.

Because the ballot initiative calls for the full expansion that was intended under the Affordable Care Act, the new funds would be granted mandatorily rather than being subject to a waiver, Curtis said.

HB472 calls for expansion of coverage to Utahns up to 100 percent of the federal poverty line, using a 90 percent federal funds matching rate. Rep. Robert Spendlove, R-Sandy, the bill's sponsor, has said it is structured to ensure the state would spend no new money on the program and would be able to rescind the expansion if the federal matching rate falls below 90 percent.

HB472 also mandates that "certain qualified adults … meet a work activity requirement," its summary states.

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The Legislature has debated expanding Medicaid for several years, but prior to Spendlove's bill, efforts at large-scale extension of coverage, including Gov. Gary Herbert's Healthy Utah plan that he pushed in 2015, were never able to gain enough support due in large part to opponents' fears of overwhelming the state budget.

A limited form of expansion, estimated to affect 4,000 to 6,000 people and targeted to homeless and otherwise extremely poor Utahns needing behavioral health or substance abuse disorder treatment, passed the Legislature in 2016 and was formally approved by the federal government in November 2017.

Sen. Gene Davis, D-Salt Lake City, ran a bill seeking full Medicaid expansion this session, but the Senate Rules Committee never assigned it to a committee hearing.