Utah lawmakers expressed concern Thursday about the possibility that voters could expand Medicaid after years of debate at the Legislature.

The initiative poised to make the November ballot would eventually cost the state about $47 million more than a smaller expansion passed by lawmakers that still needs federal approval, according to a legislative analysis.

The ballot-initiative plan would also bring back $535 million more in federal subsidies than the bill approved by lawmakers, the analysis found.

Still, the larger cost to the state was concerning for several lawmakers who met to discuss the issue the week before it’s expected to be certified to get on the ballot.

“I’m concerned about it because I don’t know how sustainable it is,” said Republican Rep. Ed Redd of Logan. “What happens during an economic downturn?”

While he worries about what could happen if revenues are down and demand is up, supporters say their plan’s funding mechanism is solid. Voters would be asked to approve a sales tax increase amounting to about 15 cents on every $100.

“This is about real Utahns, it’s your friends, your family, your neighbors,” said organizer RyLee Curtis, adding that their plan for a bigger expansion generally gets a favorable reception with voters.

Advocates decided to go to the voters after years of trying unsuccessfully to get the Republican-dominated state Legislature to approve a Medicaid expansion under former President Barack Obama’s health care law. Similar efforts are underway in a handful of other states, including Idaho and Nebraska.

The Utah push was already underway when lawmakers passed a limited Medicaid expansion earlier this year. It would cover about 70,000 more low-income people, about half of what advocates wanted.

It would also have a work requirement and cap the state’s spending.

By the year 2121, it would cost Utah about $30 million a year, compared to about $77 million for the ballot initiative proposal, the analysis found.

But the lawmakers’ plan must still be approved by the federal government. President Donald Trump’s administration has been warmer to the idea of work requirements, but lawmakers’ unusual plan to cover fewer people could get a cooler reception.

Medicaid is a federal-state collaboration originally meant for poor families and severely disabled people. Over the years, it’s grown to become the largest government health insurance program, now covering 1 in 5 people. Under Obama’s health law, states got the option of expanding Medicaid to cover more low-income adults. Thirty-two states and Washington, D.C., expanded.

But 18 mostly conservative states held out. In Utah, lawmakers have also been concerned about whether the U.S. government can afford its share.

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Lawmakers concerned about Medicaid expansion ballot plan