Voters in 4 Red States Considering Medicaid Expansion Proposals

Health care policy watchers this week will be closely eyeing developments in four conservative states, where supporters are pushing ballot measures to expand Medicaid eligibility to include hundreds of thousands of people who earn less than $17,000 a year.

The initiatives in Idaho, Montana, Nebraska and Utah—all backed to varying degrees by the Fairness Project, a nonprofit dedicated to using ballot initiatives to bypass intransigent legislatures—have survived strong opposition. In three of the states, Republican legislators have shot down past attempts to expand Medicaid coverage under “Obamacare,” or the Affordable Care Act.

Montana’s Initiative 185 would remove a sunset provision put in place when lawmakers narrowly passed Medicaid expansion legislation in 2015, and it would pay forecasted state costs by hiking sales taxes on cigarettes and other tobacco products. The initiative survived a lawsuit filed by the tobacco industry and it has managed to keep the polls close despite an avalanche of tobacco industry opposition funding—some $17 million, according to the National Center for Money in Politics.

Supporters of these efforts to expand Medicaid have argued it makes financial sense to expand health insurance to some of the poorest residents of states, along with providing them with the stability of coverage. Opponents have counted that states can’t afford the 10 percent share they are expected to pay for the expansion population, especially as health care costs rise.

Earlier this year, after long resisting expansion of Medicaid, Virginia lawmakers approved a measure to give coverage to 400,000 residents. There are now 33 states, along with the District of Columbia, that have expanded the program. That includes Maine, where voters last year supported a ballot initiative similar to those being considered this season. Outgoing conservative Gov. Paul LePage, however, has opposed appropriating money to pay for it.

Expansion backers have been cautiously optimistic in each of the states that will consider the idea on Tuesday.

A mid-October poll conducted by the Salt Lake Tribune and the Hinckley Institute of Politics found that 59 percent of voters in Utah, one of the most conservative states in the country, support Proposition 3, which would expand Medicaid for the first time in the Beehive State and fund state portions of the cost by increasing the state sales tax from 4.70 percent to 4.85 percent. Thirty-seven Republican state legislators have formally opposed the initiative.

State Rep. Robert Spendlove, a longtime critic of the Affordable Care Act, said the proposition would bring to life a “zombie program financially devastating to the state.” If the measure wins a majority of votes on Tuesday, it would be the first ballot initiative passed in Utah since 2007.    

Idaho’s Proposition 2 landed a spot on the ballot despite stiffer state initiative-process provisions put in place in 2013. Large numbers of volunteers with Reclaim Idaho, the group behind the proposition, gathered more than 56,000 valid signatures in at least 18 of Idaho’s 35 legislative districts. In September, the Idaho Freedom Foundation, a libertarian think tank, formed a group called “Work, Not Obamacare” to oppose the initiative.

Nevertheless, support for Proposition 2 is polling at around 60 percent, and Republican Gov. Butch Otter last week came out as a supporter, referring to it in a video ad as an “Idaho-grown” health care solution.   

In Nebraska, conservative efforts to oppose Initiative 427 suffered a setback in the final stretch of election season when Omaha billionaires Warren Buffett and Walter Scott Jr. each donated $200,000 to the Insure the Good Life committee backing the initiative. Overall, the committee had collected $1.2 million in new contributions, according to a report at the end of October.

Democratic state Sen. Adam Morfeld told the Daily Nebraskan that he isn’t surprised the initiative is speeding into Election Day on greased wheels.

“We’ve made excuses [in the legislature] for the last seven years to not expand Medicaid, but we haven’t done anything as an alternative…and people have gone bankrupt because they can’t afford basic medical services,” he said.

The initiatives aim to close—or, in Montana, to keep closed—the so-called “Medicaid gap” which, in the 17 states that so far haven’t expanded Medicaid coverage, yawns below mostly working poor residents who make too much money to qualify for traditional Medicaid and too little money to qualify for Affordable Care Act subsidies meant to help them afford private coverage.

While momentum behind expanding Medicaid has grown in recent months, efforts around the country to pass larger government-run health coverage—including so-called single-payer “Medicare for all” coverage—have mostly occurred behind the scenes.

In 2017, California Assembly Speaker Anthony Rendon, a Democrat, tabled single-payer “Healthy California” legislation—Senate Bill 562—saying that funding had to be more fully worked out before he could support it.     

In Washington state, where Democrats now control all the levers of state government, supporters of  the long-brewing “Health Care For All” public option proposal have paused efforts and are waiting for the results of a public health care funding study commissioned by the legislature and being conducted by the Washington State Institute for Public Policy.  

Indeed, even if all four initiatives in the Great Plains and Rocky Mountain states fall short on Tuesday, the fact that they have notched solid poll numbers among voters, faced down serious opposition, and attracted Republican supporters has bolstered the feeling among advocates that momentum is shifting, not just around Medicaid, but in the wider debate around government-supported health care coverage.

The Fairness Project is already celebrating a major victory in the battle for hearts and minds. “The partisan dam holding back full Medicaid expansion is breaking,” Executive Director Jonathan Schleifer told Forbes last week.

The shift comes in the wake of the great disappointment many of the left-leaning groups behind universal health care efforts felt after the 2016 election, when anti-Obamacare Republicans gained full control in Washington, D.C.

Indeed, the four states where the Medicaid initiative battles are being waged went for Donald Trump by wide margins. Yet, in all of those states and more, the conservative critique of government involvement in the health care market as anti-American socialism has faded.

As has been widely noted, Republican candidates for public office all around the country have taken note and, for the first election season since Tea Party-wave year 2010, aren’t running on anti-Obamacare platforms. On the contrary, many high-profile Republicans are now unabashedly running on support for ensuring that people with pre-existing conditions are covered—a centerpiece of Obama’s health care law.       

Colorado state Sen. Jeanne Nicholson, vice chair of the Colorado Foundation for Universal Health Care, told Route Fifty that her group holds bi-weekly meetings with like-minded organizations in six other states. Depending on how elections go for Democrats in Colorado this week, her group plans to push for state-based public-option universal health care legislation next year or a similar ballot initiative in 2020.  

“You can see the narratives [on health care] changing every week,” she said.

In 2016, Colorado voters went for Hillary Clinton over Donald Trump by 5 points, but they also voted in a landslide—79 percent to 21 percent—against Amendment 69, a state-based single-payer health care ballot initiative similar to one pushed by then-Democratic primary contender U.S. Sen. Bernie Sanders. Insurance companies spent millions to oppose the amendment. And Democratic leaders also balked. NARAL Pro-Choice Colorado and Planned Parenthood of the Rocky Mountains opposed it, pointing out that, because Colorado’s constitution bans public funding for abortions, the initiative would have stripped access to the procedure from hundreds of thousands of residents.   

“We’ve learned a lot since then—but so have voters and so have other interest groups,” Nicholson said. “Progressive groups that opposed the initiative in 2016 seem much more open to the idea now. We’re much more attuned to details on policy and timing and building support early on in the process. We’re sharing stories with the groups in other states about hurdles and we’re looking to do more research on health care plans and on messaging.

“We’ll have a lot to talk about after Election Day,” she said.