Medicaid at the 2018 Ballot Box: What to Look For (Part 1)

Next Tuesday (as usual) I will be staying up late to see what happens in the midterm elections. But for the first time in more than twenty years of working on Medicaid there will be so much to watch out for that will directly affect Medicaid!

Today I will start with the 17 states that have not yet expanded Medicaid. The research on the value of expanding Medicaid is clear with respect to improved health outcomes and better economic prospects for those who benefit from expansion and the providers who serve them. This report from the Kaiser Family Foundation summarizes over 200 (!) studies that have been conducted.

Another recent study by health economists at Harvard and MIT looks at the impact expanding Medicaid has on state budgets. Despite opponents claim to the contrary, the study finds that expanding Medicaid has not led to increases in state spending nor any significant reduction in state spending on education and other programs. That is because of the generous federal match and the fact that states are already paying to address some of the health care needs of some of those who would become eligible through expansion.

The chair of the Department of Economics at the University of Utah was just quoted in the New Yorker saying the benefits of Medicaid expansion are so self-evident that “Basically this is getting boring for an economist.”

The research and evidence are overwhelming, but as we all know facts don’t always rule the day. What might the number of states that haven’t expanded look like a year from now?

Three of those states put the question directly on the ballot – Idaho, Nebraska, and Utah. The main opposition in all states appears to be the Koch-funded network including the Foundation for Government Accountability.

Idaho: Polling has been looking good here, but Idaho’s Proposition 2 got a big boost earlier this week when the current Republican Governor Butch Otter (who is retiring) endorsed the initiative and even cut an ad for supporters. You can read more about proponent’s campaign here.

Utah:  Proposition 3 on the ballot would extend Medicaid coverage to 155,000 Utahns according to the state’s Legislative Fiscal Analyst. Both of the state’s major newspapers recently endorsed the ballot initiative.

Nebraska: There is not much polling here but Initiative 427 would extend coverage to approximately 87,000 people over the next few years according to the state’s Legislative Fiscal Office at a cost to the state of just under $39 million. Note that the estimate includes some currently eligible (most likely children) Medicaid beneficiaries who would enroll as a result of what we call the “welcome mat” effect. The fate of rural hospitals has become a critical issue in Nebraska as elsewhere.

In addition to the ballot initiative states, the issue of Medicaid expansion has played a considerable role in a number of gubernatorial races that are currently considered toss-ups. Most notably these states include Florida and Georgia, where the Democratic candidates Gillum and Abrams have made Medicaid expansion a key part of their pitch. In Florida the Republican Senate passed a version of Medicaid expansion in 2015 only to see it die in the House, but both of these newly elected Governors would face an uphill battle in the legislature, however, depending on how the election turns out, more Republicans might be willing to cross party lines as we saw happen in Virginia earlier this year. Both states have rural populations that have much to gain as our recent report on Medicaid expansion and rural areas found.

While these two are the marquee draws, other important races to keep an eye on include Kansas where a Democratic victory for Laura Kelly would definitely kick start a debate in the legislature as well as Democratic wins in South Dakota and Oklahoma. North Carolina is another state where the outcome of state legislative races could create an opportunity to open the door for Governor Cooper to push expansion forward.

For my next installment I will take a look at states that already have expansion that could face changes (helpful or unhelpful) with respect to pending waivers or existing expansions. A sneak preview here – keep an eye on Alaska’s Governor race, the Montana ballot initiative to include a tobacco tax to fund their expansion, and Governor’s races in Wisconsin and Michigan where harmful waivers might be pulled back if the Democratic candidate wins.

Joan Alker
Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy