The Medicaid Wave.
This piece originally appeared on the Health Affairs blog.
Election Day 2018 will go down as a major turning point in the battle over the implementation of the Affordable Care Act (ACA). Going into Tuesday, 33 states and Washington, D.C. had decided to adopt the ACA’s Medicaid expansion, a part of the law which allows states to use mostly federal money to provide health insurance to its poorest residents. The remaining 17 states are in the Deep South, mountain west, or the middle of the country, and have been led by Republican governors and legislatures who have ardently refused expansion. Key elections on Tuesday blew apart the narrative that this map is indefinitely entrenched.
Supporters of the law in some of the reddest of red states—Idaho, Montana, Nebraska, and Utah—believed that their elected officials were more conservative than their voters. In 2017, a team in Idaho bought an RV, painted it green with giant white letters, “Vote Yes for Medicaid,” and drove around the state collecting enough signatures to put expansion directly on the ballot in November. They used the 2016 vote in Maine as a blueprint, believing that when asked directly, voters would support Medicaid expansion despite opposition from their Republican governor. Advocates in the other three states made the same gamble.
They were mostly right. Three out of four Medicaid expansion ballot questions were successful on election night, winning by more than 20 percentage points in Idaho, nearly 10 points in Utah, and by six points in Nebraska. The only loss was in Montana, which connected the expansion of Medicaid to an increase in the tobacco tax. These are dramatic and resounding victories in states that not long ago seemed out of reach for supporters of the ACA.
These votes are estimated to bring insurance to 62,000 people in Idaho; 90,000 Nebraska; and 150,000 in Utah. Based on the lessons of other Medicaid expansion states, we can also expect these states to see hundreds of millions of dollars come into the state, along with health care jobs and increased financial security for struggling rural hospitals.
The success of these ballot initiatives to expand Medicaid serves as an implicit rebuke of the Republican Party’s anti-ACA stance over the last eight years. However, the initiatives likely could not have passed prior to 2018. The attempt by Congressional Republicans in 2017 to repeal the ACA helped people across the country understand how the ACA could help them. Donald Trump, Paul Ryan, and Mitch McConnell were ironically able to accomplish something that eluded Barack Obama, Nancy Pelosi, and Harry Reid since 2008—convincing Americans to like the ACA.
What’s Next?
The first question to ask when considering what happens next in Medicaid politics is whether these votes will stand. The newly expanded states still elected Republicans to all major state offices on Tuesday. In some cases, these candidates ran on a platform of opposing Medicaid expansion. They could drag their feet on implementation or even pass a law undoing Tuesday’s ballot questions. Again, Maine is the blueprint where outgoing Republican Governor Paul LePage has defied court orders by refusing to act on the success of the 2016 ballot question.
Outright obstruction is unlikely in Idaho, where the margin of victory was greatest and where incoming governor Brad Little has said he would respect the vote of the people. Governor Herbert is unlikely to lead a charge to repeal the new increase in coverage in Utah, but some members of the legislature say they would have no reservation about passing a law undoing the ballot initiative. Nebraska Governor Pete Ricketts won re-election Tuesday but has not yet indicated how his administration would approach the new expansion.
The second question to consider about the future of Medicaid politics is which states are likely to be the next battlegrounds for expansion. All eyes are now on Kansas, where the election of Democrat Laura Kelly as governor provides a clear path to expansion. Legislators on both of sides of the aisle there have told me how important Medicaid is to the sustainability of their rural hospitals, and in 2017 the Republican-controlled legislature passed an expansion bill that was vetoed by Republican Governor Sam Brownback. If the legislature were to pass the same bill in 2019, Kelly would sign it.
Wisconsin could also become a battleground but expansion is unlikely to occur there in the near-term. Republican Governor Scott Walker has tried to cover the uninsured in a way that is less comprehensive and more expensive than Medicaid expansion. His defeat on Tuesday at the hands of Democrat Tony Evers might give advocates in the Badger State some hope, but the legislature remains under conservative Republican control.
Andrew Gillum’s defeat effectively kills the possibility of expansion through the legislative process in Florida. Along with Texas, Florida is one of advocates’ biggest targets given its size and the large numbers of residents who lack insurance: Nearly 9 percent of the country’s uninsured people live in Florida. Expansion supporters there should take a hard look at which just happened in Idaho, Nebraska, and Utah and ask whether a ballot initiative could be successful in Florida in 2020.
Finally, a more nuanced but equally important question is how Tuesday’s election will affect the nature of Medicaid in states that have already expanded. A growing number of Republican governors have sought waivers to modify their Medicaid programs to include requirements that beneficiaries work a certain number of hours per month. The election of Republican governors in Arizona, Ohio, and New Hampshire means that these states are likely to continue down this path. However, Democrat Gretchen Whitmer’s victory in Michigan is likely to re-open debate there about whether to return the program to its more generous and less restrictive roots.
2018 will be remembered as the year with the greatest increase in the number of states expanding Medicaid coverage since the expansion went into effect in 2014. The success of ballot initiatives in Idaho, Nebraska, and Utah gives advocates in the remaining 14 non-expansion states a model to follow. The pundits and scholars who predicted that every state would eventually expand Medicaid may just turn out, someday in the foreseeable future, to be right.
David K. Jones is an assistant professor of health law, policy & management.