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Idaho voted to expand Medicaid. Republican lawmakers are trying to roll it back.

As new revelations about Chief Justice John Roberts’s Supreme Court Obamacare ruling come out, states are still fighting over Medicaid expansion.

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Idaho Republicans are working to roll back the Medicaid expansion approved by their voters in November, another case of GOP lawmakers refusing to accept a Democratic mandate to expand health care to their constituents under the Affordable Care Act, and a reminder of the complicated legacy left by the Supreme Court’s 2012 decision on the health care law.

The Idaho ballot referendum passed overwhelmingly in November, 61 percent to 39 percent. The initiative called for a no-frills expansion, extending eligibility to 138 percent of the federal poverty level ($17,200 for an individual, $29,400 for a family of three), as written in the ACA. If implemented, it would offer health insurance to an estimated 120,000 of the state’s poorest residents.

But under a bill passed by the Idaho House on Thursday, Medicaid eligibility would be expanded only partially, up to 100 percent of the poverty level. People above that threshold (roughly 40,000) would have to purchase private coverage through the state’s insurance marketplace set up under the ACA instead.

In addition, Medicaid beneficiaries would be required to work 20 hours a week, look for work, or be in school in order to continue receiving benefits. Exceptions would be made for children, the elderly, parents, and people “physically or intellectually unfit for employment.” If a person failed to meet that work requirement, they would lose their insurance coverage for two months before being allowed to reapply for Medicaid.

There was bipartisan opposition to this plan in the Idaho House, but the bill still passed with ease because of the overwhelming Republican majority. The Idaho Senate is advancing its own plan, which preserves the full Medicaid expansion and merely includes a provision to help beneficiaries access job training and other work-related activities. Benefits would not be conditioned on work, as in the House bill.

Newly elected Gov. Brad Little, a Republican, has said that he supports Medicaid expansion but that “we don’t want to have an incentive for people not to work.” The ballot initiative passed by voters had required the state to submit a Medicaid expansion plan to the feds within 90 days of the referendum’s passing, but that has been delayed as lawmakers seek to amend the expansion more to their liking.

Republicans have a tough time just expanding Medicaid, even when voters want to

CNN revealed this week a little more about the history that led to Medicaid expansion becoming optional — setting up the kind of debate we’re seeing in Idaho. Expansion was supposed to be mandatory, but conservative-led states challenged that provision, along with the rest of the law, in the 2012 lawsuit that determined Obamacare’s constitutionality.

On the Supreme Court, Chief Justice John Roberts, according to CNN’s Joan Biskupic, initially ruled that Medicaid expansion could be required, as the ACA originally prescribed. But as he looked for a way to uphold the rest of the law — including the individual mandate, which he initially voted against — Roberts ended up negotiating with the liberal justices, trading the individual mandate for the expansion. The mandate was allowed to stand, and the rest of the law with it, but Medicaid expansion was ruled to be optional. States couldn’t be forced to accept it — and for the past seven years, it has been a major point of debate in statehouses. Republican-led legislatures in 14 states have still refused to expand Medicaid, leaving more than 1 million people without health coverage.

Voters have increasingly taken matters into their own hands with ballot initiatives like the one in Idaho. Maine, Utah, and Nebraska have also voted to expand coverage in the last two years, but in almost every case, Republican officials have sought to override that vote.

The fight in Idaho is following the same arc as the previous debate in Utah, where voters approved a full Medicaid expansion and then Republican policymakers sought to undo it. The Utah Legislature approved a plan for a partial Medicaid expansion with the addition a work requirement; the Trump administration is expected to decide whether or not to approve the state’s proposal any day now.

Legal challenges likely await if these altered Medicaid expansion plans are approved in Washington, DC. As Vox previously reported:

Two states, Arkansas and Massachusetts, have already asked the Trump administration to let them shift to a partial Medicaid expansion, covering people up to 100 percent of the poverty line. People above that threshold would have to buy coverage through the private insurance marketplaces set up under the health care law.

But those states haven’t received federal approval, with Trump’s health department remaining silent on this question. As the New York Times’s Robert Pear reported last summer, administration officials have hotly debated the expansion question, with some arguing in its favor (to head off states like Utah deciding to fully expand Medicaid) while others refuse to do anything proactive that would help expand Obamacare’s coverage to more people.

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Massachusetts could then sue if Utah’s waiver is approved. Litigation was likely to follow anyway from supporters of the ballot referendum if Utah Republicans move ahead with their plan. The state could be walking into a legal landmine — all in the name of extending health insurance to fewer people than the plan already approved by the state’s voters, and at a higher initial cost.

But that hasn’t stopped Idaho Republicans from heading down the same road, seeking to reverse the will of the voters to provide fewer of their poorest residents with insurance.

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