Voters take Medicaid Expansion into their own hands
Direct democracy gives citizens in some states a work-around to access Obamacare’s most effective way to extend health insurance coverage, but even winning a vote leaves roadblocks to expanded Medicaid
The Affordable Care Act’s Medicaid expansion, which extended Medicaid coverage to all adults with incomes below 138 percent of the federal poverty line ($36,156 for a family of 4 in 2020), has proven the single most effective tool in the ACA’s box to cover the uninsured.
Of the 20 million people in the United States who gained coverage through the ACA by 2019, roughly half acquired insurance through Medicaid expansion. Despite being coverage for people without access to anything else, Medicaid isn’t substandard; rather, it tends to be comprehensive high-quality insurance. Though exact provisions vary from state to state, Medicaid plans generally provide broad coverage — sometimes including vision or dental plans — and charge recipients extremely low or no charges for premiums or out-of-pocket costs.
The impact of the expansion has extended beyond having insurance, as comprehensive research strongly suggests that expansion improves access to health care and health outcomes as well.
The only problem for expansion that Medicaid is run jointly by the federal government and states, and the Supreme Court ruled in 2012 that states have the choice to accept or refuse expansion. While states have steadily climbed on the bandwagon since 2014, progress has been uneven. 36 states have accepted the expansion, while 14 have thus far refused. Unsurprisingly, most of the states left are those with governments dominated by ideologically radical Republicans who have dug in against any expansion of the social safety net, no matter how low the cost or high the benefits to citizens.
With ideological opposition hardened in the legislatures of many of the remaining states that have not expanded, activists have turned to a new tool: direct democracy.
In 24 states voters have the right to circulate petitions that propose legislation or a constitutional amendment. If those petitions get enough signatures, the proposal goes up for a popular vote. Of the 14 states that haven’t passed expanded Medicaid yet, six have the ability to put it on the ballot.
The strategy makes sense. Even in states dominated by Republicans, Medicaid has much greater support among the general population than it does among elected officials.
So far, four states have gotten an expansion initiative on the ballot; and in all four it has passed. Maine led the way in 2017, with Nebraska, Utah and Idaho following in 2018.
Each success has raised the determination of organizers in other states. In 2020, activists succeeded in getting expansion on the ballot in two more states; Oklahoma will vote on expansion on June 30, with Missouri slated to go to the polls on August 4.
But despite the success of these ballot initiatives, Conservative state officials still have considerable power to block, modify or slow-walk implementation. Health policy researchers Phil Singer and Daniel Nelson have noted that in most states initiatives can simply be modified repealed through the regular legislative process or functionally blocked in the budget process if they don’t include a funding mechanism in the ballot language. In a study of the most direct-democracy crazed state in the nation, California, Arthur Lupia, Elisabeth Gerber, Matthew McCubbins and D. Roderick Kiewiet argue that unless voters can provide a credible threat to remove office holders who defy their wishes on a citizen’s initiative, states can ignore voter wishes without penalty. Therefore, in states where Republicans have unified control the legislature, courts and governorship, they retain considerable to alter voter wishes.
This has happened in all four states that have passed Medicaid expansion through voter initiative. In Maine, reactionary Republican governor Paul Le Page blocked implementing the initiative for a year. Republican-dominated legislatures in Utah and Idaho passed alternative expansion plans that cut the number of people who qualified and implemented work requirements for Expansion recipients. Nebraska’s governor delayed implementation to the fall of 2020 while also limiting the proposed benefit package for expansion participants.
However, despite problems in all four states — and overwhelming Republican majorities in Utah, Idaho and Nebraska — events and federal requirements have interfered to largely implement Medicaid expansion. In Maine, voters replaced Le Page in the 2018 election with Democratic governor Janet Mills, who implemented the Expansion in her first week in office. Federal courts have thus far struck down work requirements for Medicaid, which has stalled some modifications sought in Utah and Idaho, both of which have had other critical parts of their waivers denied or delayed by the Federal government. Both states fully expanded this year, at least for now. Nebraska is still on track for expansion in the fall.
The upshot is that if voters pass Medicaid expansion in Oklahoma and Missouri, the two states’ ideologically conservative legislatures and governor will likely do what they can to delay and downgrade the expansion. However, experience has shown thus far that a large part of the expansion will get implemented due to a combination of federal limitations on state waivers, clearer ballot language and the pressures of COVID.
For 400,000 people who need health care and would be eligible for expansion in the two states, that’s important indeed.
