(CNN) Utah voters approved Medicaid expansion last November, but Republican state representatives -- who have long opposed broadening coverage for low-income residents -- are now moving to limit the extent of the changes.
The state Senate could vote as early as Monday on a bill that would restrict coverage to those at or below the poverty line, instead of up to 138% of that threshold, as is standard under the Obamacare provision to expand Medicaid. It's expected to pass the GOP-controlled Utah House and Gov. Gary Herbert, a Republican, is likely to sign it.
It would also mandate beneficiaries to work, place a per-capita cap on spending and impose a lock-out period for those who violate certain requirements. And the bill would close the program to new enrollees if costs are projected to exceed the funds the legislature appropriated, said Republican state Sen. Allen Christensen, who sponsored the measure.
The legislation would require a federal waiver that may be tough to get. Last year, the Trump administration failed to rule on a similar Utah proposal to broaden Medicaid only up to the poverty level before voters embraced a much more comprehensive expansion plan.
The battle over expansion in Utah is reminiscent of the fight in Maine, the first state to pass expansion at the ballot box in 2017. Former Maine Gov. Paul LePage refused to implement expansion for more than a year, defying state court orders. His successor, Janet Mills, quickly moved to expand Medicaid after taking office last month.
The Utah ballot measure, which garnered 53.3% of the vote, is set to go into effect April 1 and was projected to cover as many as 150,000 residents. The more limited version would leave out 70,000 people who make more than the poverty line, which is roughly $12,000 for an individual and $25,000 for a family of four.
Though they remained relatively quiet prior to the election, Herbert and GOP lawmakers now say changes are needed because the 0.15 percentage point increase in the state sales tax won't cover the costs of expansion by the third year.
This new analysis negates an earlier report from the governor's office that showed that the levy would provide enough money. Christensen says those above the poverty line can get subsidized policies on the Obamacare exchanges, though many advocates argue that coverage can still be too pricey for the poor.
"We are looking for a win-win consensus and making sure we follow the will of the people, but do it in a fiscally prudent way," Herbert said Wednesday on a podcast from UtahPolicy.com, an information site for state policymakers.
Proponents of Medicaid expansion, however, are fighting back. Hundreds descended on the state Capitol Monday to protest lawmakers' efforts to curtail the bill. Utah Decides, which pushed for the ballot measure, is running a TV ad urging residents to call their legislators and Herbert to "tell them to leave our health care alone."
"They are blatantly disrespecting and disregarding what voters wanted," said Jonathan Schleifer, executive director of The Fairness Project, which helps fund grassroots initiatives in Utah and elsewhere.
Republicans are moving ahead with Medicaid expansion in two other states -- Idaho and Nebraska -- where voters approved ballot measures in November.
In Nebraska, GOP Gov. Pete Ricketts has long opposed broadening Medicaid, but said in his State of the State address last month that his budget "reflects the vote of the people of Nebraska" and that officials are working to implement expansion. State Sen. Adam Morfeld, a Democrat, said he's not aware of any efforts in the legislature to derail expansion.
"Implementation is well on its way in Nebraska," Morfeld said.
The Idaho Freedom Foundation is challenging the ballot measure in court, saying it is unconstitutional. The state Attorney's General Office argues the case should be dismissed. Meanwhile, Idaho Gov. Brad Little, a Republican, has included Medicaid expansion in his budget.
"For months I made it clear I would honor the will of the people" Little said in his State of the State address last month, noting he will also pursue plans to move people off Medicaid and into private coverage. "I intend to work with you to implement Medicaid expansion using an Idaho approach."