image showing a line of voting booths, with legs showing

Medicaid Expansion Goes to the Polls

With the 2018 midterm elections fast approaching, there are key some voter propositions with important health implications.

Most notably, this November, voters in three conservative states — Idaho (Proposition 2), Utah (Proposition 3), and Nebraska (Initiative 427) — will be deciding on whether to expand Medicaid. In addition, voters in Montana will decide whether to permanently extend their state’s Medicaid expansion. This is coming at the heels of the closely watched November 2017 referendum where Mainers decisively supported Medicaid expansion 59 percent  to 41 percent.

So why is Medicaid expansion even on the ballot? Under the ACA, states were originally meant to expand Medicaid coverage up to 138 percent of the federal poverty line (FPL) with the federal government kicking in the vast majority of the funding. This would guarantee the uninsured would either be eligible for Medicaid, if they earned under 138 percent of the FPL, or for subsidized private health insurance plans on the health insurance marketplace exchanges, if they earned 100-400 percent of the FPL.

The way the legislation was written, those eligible for Medicaid and/or earning less than 100 percent of the FPL would be ineligible for any federal subsidies for marketplace exchanges. The idea behind this restriction was saving the government money — it is more expensive to subsidize private insurance through the exchanges than through Medicaid.

However, the authors of the legislation did not foresee NFIB v. Sebelius, the Supreme Court ruling that made Medicaid expansion under the ACA optional for each state. This ruling has led to a coverage gap in the states that refused to expanded Medicaid: those making under 100 percent of the FPL are ineligible for Medicaid (as they don’t meet their state’s stricter eligibility criteria), and ineligible for subsidized plans on the ACA exchanges.

This is what policy wonks call the “Medicaid gap.” In addition, those making between 100-138 percent, who should be eligible for Medicaid, are also likely financially worse off with private insurance through the exchanges, as they must pay premiums and have higher co-pays.

It is not surprising that states which have expanded Medicaid have seen more dramatic decreases in the uninsured rate. Non-expansion states have nearly twice the rate uninsured compared to expansion states (12.2 percent versus 6.6 percent).

According to an analysis by the Kaiser Family Foundation, Medicaid expansion in the states would cut the number of uninsured in half, consistent with the difference in rate uninsured in expansion and non-expansion states. In total, about 2.2 million people are in the coverage gap. In addition, another 1.5 million people make 100-138 percent of federal poverty line and would also be eligible for Medicaid if it were to the expanded.

Currently, 17 states have not expanded Medicaid, with a striking predominance of Southern and Western/Plains states (see map). The one Midwestern state that has not expanded Medicaid, Wisconsin, had eligibility criteria to 100 percent of the FPL prior to the ACA’s enactment.

To be frank: This is not just a function of which party controls the legislatures and state houses. Many of the Midwestern states that expanded Medicaid were and are controlled by Republicans. To me, this represents cultural and political differences beyond political partisanship. Therefore it is particularly interesting to see that voters in some states are taking matters into their own hands.

In Idaho, Utah, and Nebraska about 100,000 uninsured individuals fall in the Medicaid gap and and have no affordable insurance options. Advocates in these three states put up ballot proposals because legislators and/or governors have been resistant to Medicaid expansion legislation. Given the conservative nature of these states, it is an open question how these ballot proposals will fare. Yet, the limited polling data we have suggests that Medicaid expansion is a popular. Nationally, about two-thirds of the public is in favor of Medicaid expansion in their state.

The limited statewide polling available suggests that voters in these states support Medicaid expansion, despite with disapproval of the ACA. But it is unclear if this polling support will translate to real changes in state policy.

Of course, the framing of the question in polls matters a lot. It remains to be seen if these poll numbers will translate into real votes, especially after well-financed opposition groups begin running ads. The propositions all have different frames. Notable, one (Utah’s) includes a funding mechanisms via a sales tax increase, which may discourage some voters from supporting the proposition. Lastly, from what we’ve seen in Maine’s ballot initiative, just because voters approve a ballot overwhelmingly doesn’t mean that elected officials will execute the law.

For those interested, a quick description of each of the initiatives as it will be presented to voters (NB: I’m presenting the key portions of the summary text):

Idaho – Proposition 2: Amend’s Idaho’s code to expand Medicaid eligibility and compels the department of health and welfare to take all necessary actions to enact the proposal.

Utah – Proposition 3: Enacts a law to expand Medicaid health coverage to based on income, for previously ineligible low-income adults. Increase state sales tax by 0.15%.

Nebraska – Initiative 427: The state shall amend it Medicaid plan to expand eligibility to cover certain adults ages 19 through 64 whose incomes are 138% of the federal poverty level or below as defined and authorized by federal law, and to maximize federal financial participation to fund their care.

As you can see, though each of these proposals have ostensibly the same policy effects, the wording shown to voters (the summary text) are slightly different. Utah has a funding mechanism tied with the proposal, while the initiative in Nebraska highlights the federal money left on the table by states that have not expanded Medicaid. It’s hard to say how much of an impact this will have on the outcome.

This midterm elections are being closely watched by all quarters. It is open question of which party will control Congress and there are numerous gubernatorial and state legislatures races up for grabs that will determine the 2020 redistricting process. Thus, this election may determine the balance of powers between the two parties not just for 2018, but for the next decade.

However, I will also be watching closely for these proposition results, as the outcome will be the difference between being insured and uninsured for many Americans. And this is true not just for the residents of these three states, but also those in the other non-expansion states, where many more are wondering if analogous efforts will be feasible.


Rahul Nayak is a 2018-2019 Petrie-Flom Center Student Fellow

Rahul Nayak

Rahul Nayak was a fourth-year medical student at Harvard Medical School during his fellowship year. As part of the Program on Regulation, Therapeutics, and Law (PORTAL) at Brigham & Women's Hospital, his research interests are in pharmaceutical policy, physician prescribing habits, and access to health care. He attended Duke University, where he studied biomedical engineering and economics. He then completed a two-year fellowship at the NIH Department of Bioethics. His research has led to first-author publications in JAMA, Annals of Internal Medicine, Health Affairs, and Bioethics. He is currently a resident in the internal medicine residency program at Massachusetts General Hospital. Rahul was a Student Fellow during the 2018-2019 academic year, and completed a project entitled “Public Support for Late-Stage New Drug Discovery,” which examines the role of public-sector research on new drug discovery.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.