When the Affordable Care Act opened the door for Medicaid expansion, the list of states that were poised for expansion was assembled quickly, largely based on which party controlled the state’s top office.
But as the 2018 midterm elections proved, there’s more than one way to expand Medicaid. Ballot initiatives in Idaho, Montana, Nebraska and Utah placed Medicaid expansion in the hands of voters.
Idaho, Nebraska and Utah all voted for expansion. In Montana, where Medicaid had already been expanded, voters defeated a measure that would have extended the expansion beyond its current expiration date of June 30, 2019, and would use a new tobacco tax to help pay for it. And previously, at the end of 2017, voters in Maine approved Medicaid expansion through a ballot initiative.
But approving Medicaid expansion by public referendum and actually expanding it are two different things, as voters in Maine know. Despite a narrow victory at the ballot box, it took nearly 10 months for then-Governor Paul LePage to submit the expansion application to the CMS. When he finally did, he also enclosed a letter asking the CMS to deny the request for expansion, citing budgetary concerns. It took a new governor, elected this past November, to sign an executive order and implement Medicaid expansion in Maine in January 2019.
“Even though states are having a hard time affording it, public support for expansion is pretty widespread,” says Marie Hinds, Parallon’s director of government relations for Medicaid eligibility. “As a result, I think it’s safe to say that we could to see more of these types of initiative on future ballots.”
The Fairness Project, which provided grassroots support to the ballot measure supporters in Idaho, Nebraska and Utah, told Forbes that they’re looking at six states as possible sites for Medicaid expansion ballot initiatives in 2020—Florida, Mississippi, Missouri, Oklahoma, South Dakota and Wyoming.
“Ballot measures in Idaho, Nebraska and Utah have opened up an entire new front in the fight to expand access to healthcare to every American,” Johnathan Schleifer, executive director of The Fairness Project, told Forbes. “We proved that, with the right resources and organization, Medicaid expansion can win anywhere.”
But expansion by ballot can get messy, Hinds says, especially if state officials use the tools available to them—like 1115 waivers—to push back against voters. In Virginia, expansion was approved by the legislature, not by referendum, but Hinds points to the state as one example of “waiver creep.”
“Waiver creep is where states use mechanisms like work requirement demonstrations and other limitations to essentially rein in the expansion,” explains Hinds, who is also monitoring Utah for the same issue. “With a Medicaid Section 1115 waiver, the state can make a change as to how many people get covered, whether the public voted for it or not.”
All of this push and pull puts hospitals and ultimately patients in the crosshairs.
“In states where there are successful ballot measures, our job is to be vigilant, and staying on top of Medicaid eligibility rules and regulations becomes even more important,” she says. “We must be flexible and act quickly when change happens.”