"I voted" sticker on a finger.

Election Round Up: Medicaid Expansion is an Electoral Winner

With the midterm elections now behind us, I thought it was time to revisit a prior blog post where I discussed the prospects of state Medicaid expansion ballot propositions in Idaho, Utah, and Nebraska. I had predicted that despite the conservative nature of these states, Medicaid expansion would have a good chance of passing due to the program’s popularity.

Indeed, voters in all three states endorsed Medicaid expansion. It received 60 percent support in Idaho and 53 percent in both Utah and Nebraska.

The latter two results were closer than what I was expecting.

In the case of Utah this may because a funding mechanism was explicitly included as part of the ballot proposal. Regardless, this means that roughly 300,000 people will be newly eligible for Medicaid. Not only do may patients stand to benefit, but this could be a huge boon for struggle rural and safety-net hospitals.

One surprising result was that Montana voters narrowly rejected (53 percent) a ballot proposal that would continue to fund their state’s Medicaid expansion through a tobacco tax. The ballot proposal received significant opposition funding from a tobacco manufacturers consortium (Altria), who spent over $17 million to defeat the proposal. This certainly adds turmoil to the future of Medicaid expansion in Montana, but it seems like a deal of some kind will be made to continue coverage.

Interestingly, the results from the gubernatorial elections may add to Medicaid coverage. Maine elected Democratic candidate Janet Mills as their next governor. In addition, Democrats now decisively control of both houses of the legislature. Thus Medicaid expansion, which voters approved last year, but bureaucratically held up by the outgoing Governor, will soon be implemented. Kansas elected Democratic candidate Laura Kelly as governor. In 2017, a coalition of Democrats and moderate Republicans in the legislature had voted to expand Medicaid. However, then Governor Brownback vetoed the bill. While I am unsure if the same coalition will be able to come together to expand Medicaid, according to state insiders it seems to be a foregone conclusion that Medicaid expansion will occur.

This would leave just 14 states that haven’t yet expanded Medicaid.

One of these states, Wisconsin has maintained its eligibility criteria at 100 percent of the federal poverty line. Therefore, no one falls in the Medicaid gap in Wisconsin, unlike in other non-expansion states. However, this still leaves many who remain uninsured and without affordable health insurance options.

With the success of ballot initiatives in three conservative states, you may be wondering what we can expect moving forward.

It turns out that not all states allow ballot proposals that are citizen-driven (or ballot initiatives likes this at all). In some states it requires legislature-approval.  It is unlikely that conservative legislatures blocking Medicaid expansion would allow  a legislature-driven proposal to make the ballot. However, in at least six non-expansion states (Florida, Mississippi, Missouri, Oklahoma, South Dakota, and Wyoming) citizens could bypass the legislature and get a ballot initiative for Medicaid expansion.

Several other states have governors with an interest in expansion, including North Carolina and now Wisconsin. However, it is unclear how much leverage these governors will have to push for expansion with their Republican legislatures.

Of the non-expansion states, Florida would have the most people who stand to benefit from Medicaid expansion, second only to Texas, with an estimated 400,000 to 600,000 people who could be eligible. Florida ballot proposals have a higher bar than most states, requiring 60 percent of voters to approve, which was met most notably with the restoration of voting rights to nearly 1.5 million citizens. Polling suggests that 65 percent of Florida voters support expansion.

Though the 2018 elections are only just over, it seems like the race for 2020 has already started. I look forward to seeing what is store for Medicaid expansion over the next two years.

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

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.

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