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A bid to expand health coverage for tens of thousands of Utah's poor may already be on life support after a lukewarm response from House Republicans and a crucial parliamentary decision by House Speaker Greg Hughes that will make passing the bill much more difficult.

The GOP House members met for several hours Tuesday for their first full briefing on the Medicaid expansion plan — branded as Utah Access Plus — hammered out by legislative leaders and the governor's office, but many members came away with serious concerns about the slew of new taxes contained in the proposal and described the reception from the Republican caucus as lukewarm and unenthused.

Compounding the challenge is Hughes' decision that the 38 votes needed to pass Utah Access Plus will all have to come from the 63 Republican House members, and the votes of the dozen Democratic House members will not matter in the eventual outcome.

"It's completely anti-democratic. … It's obnoxious. It's unbelievable," said the House Democrats' leader, Rep. Brian King, who claimed it essentially disenfranchises half a million Utahns the Democrats represent.

"I don't know if they can get 26 [Republican votes], but if they could get 26 and you get 12 Democratic votes in favor of it, what the speaker is saying, in essence, is we don't care that a majority of the House wants this passed. It's just wrong on so many levels."

RyLee Curtis, a Medicaid policy analyst with the Utah Health Policy Project, said her group has worked for three years to educate lawmakers about the benefits of expanding coverage and public opinion polls show that Utahns support the move.

"To not pass a plan because it doesn't have a majority of the majority vote is just unfair," she said. "Utahns want this, and there are Utahns in need."

Hughes defended the decision, saying the Republican supermajority will need to own the issue and be certain of the direction it wants to move in.

"We think this is a generational decision. We think with a supermajority, we need to know what we want this plan to look like. We want to make sure we're not caught where a few votes could change or upend the entire plan," Hughes said.

Senate President Wayne Niederhauser, R-Sandy, said leaders in that body have not discussed whether they would count on the votes of the five Democrats in the body to pass the bill.

The Utah Access Plus proposal calls on health care providers — doctors, hospitals, pharmaceutical companies and others — to pay just more than $50 million in new taxes in order to receive a nine-to-one match from the federal government. That $450 million would be used to buy insurance subsidies for Utahns making less than 138 percent of the federal poverty level. That federal metric is $24,250 for a family of four, making the subsidy level about $33,000 for a family of four.

It was the product of months of negotiations after the House refused to pass Gov. Gary Herbert's Healthy Utah proposal, and several members say they have seen nothing to change the minds of the majority of the Republican House members.

"I didn't really see a change in direction, a change in what I expect the outcome to be based on the information we heard," said Rep. David Lifferth, R-Eagle Mountain. "I think people are still reeling from the [gas and property] taxes we increased last session … so I think to put another tax on top of that will be tough for a Republican Legislature."

Rep. Stephen Handy, R-Bountiful, who was a supporter of the Healthy Utah proposal, said his sense is that representatives are still trying to digest the information they received, but estimates that about half of the Republican members may be supportive at this point.

"Personally, I'd like to see if there's a way to make it work, but I think it's an uphill slog," he said.

When Herbert's Healthy Utah plan was voted on in the House, 10 Republicans voted for the measure. Assuming all 10 back the new Utah Access Plus plan — and there are no guarantees of that — another 28 Republicans would have to get on board in order for leaders to call a special session later this month and pass the bill.

The House GOP will meet Oct. 13, again behind closed doors, to take a straw vote and decide if there is enough support to warrant such a special session. If the Legislature does adopt the proposal, it would be the Spring of 2017 before the new coverage begins, lawmakers were told Tuesday, more than three years after the Affordable Care Act — commonly known as Obamacare — envisioned the coverage to take effect.

Already, the Utah Medical Association, which represents the state's doctors, has launched an intensive lobbying effort opposing the new tax on physicians, with doctors in each district contacting elected officials to try to dissuade them from an $800 annual increase in per-license fees.

Rep. Ray Ward, R-Bountiful, who is a doctor and had been a leading supporter of Healthy Utah, said the new licensing fee is problematic because doctors likely won't see an increase in income if Medicaid is expanded. Physicians are already seeing as many patients as they can, he says, so simply having the additional low-income patients with insurance won't necessarily bring in more money.

And Rep. Stewart Barlow, R-Fruit Heights, who is also a doctor, said adding tens of thousands of patients with more generous private insurance may actually make it harder for children and disabled Utahns on the Childrens Health Insurance Program and Medicare — which pay lower rates — to get in to see a physician.

"The sickest of the sick are going to be crowded out of our healthcare system," Barlow said.

Hughes said House leaders will provide members with all of the information available, but will not advocate for the plan.

"There is no pressure from leadership … and everyone has to own their own decision," he said. "The good information will drive the ultimate decision, and I'm not going to try to artificially influence it one way or the other."

Several members who were opposed to Healthy Utah say they didn't hear anything Tuesday to change their minds.

"The new proposal offers a dizzying array of new details that I'm trying to chew through," said Rep. Jeremy Peterson, R-Ogden. "The specific details aside, I am uncomfortable with the new proposal. It seems overly complicated in trying to bridge the gap to where it feels like we're twisting policy pretzels trying to do this."

And Peterson said he doesn't think he was alone.

"I get a sense a lot of my colleagues are in the same camp," he said. "I got a great sense of unease out of the room. There was no enthusiasm."

Rep. Jake Anderegg, R-Lehi, who has opposed Medicaid expansion since he entered the Legislature, said he didn't hear anything new out of the proposal, aside from the new assessments on providers. He still has doubts about whether the federal government can follow-through on its promise to pay hundreds of millions to the state, has concerns that providers will just charge patients more to cover the expense, and questions how it will impact the state budget long-term.

"With those three concerns, I still think expanding Medicaid would be a colossal mistake," he said, although he said he is still reviewing the documents and "trying to keep an open mind."

The complexity of the proposal meant members on Tuesday were working to try to understand the proposal, according to Rep. Mike McKell, R-Spanish Fork, who said he has doubts.

"I know with what we hard about the proposal, I'd be very concerned and I likely don't support it, but I'd like to spend time on the proposal and with constituents and providers," he said.

Likewise, Rep. Lowry Snow, R-St. George, said he wants to study the issue further and meet with doctors in his area to try to sort out how the new fees would impact health care outside the Wasatch Front.

Rep. Brad Daw, R-Orem, said he is concerned that the proposed provider taxes are uneven — doctors would pay far more than nurses, for example — and he has fears that the federal government has made a "pie-crust promise, easily made, easily broken," when it comes to funding the program.

If the federal commitment changes, either because of changes in the budget or a new administration, it will "wreak all kinds of havoc" for the state.

Twitter: @RobertGehrke