During the 2018 midterms, the citizens of Idaho voted by a margin of 61 percent to 39 percent to approve Proposition 2, an initiative to expand Medicaid to approximately 91,000 low-income residents. The vote seemed like a victory not just for health care reform, but also for direct democracy (a catchall term for any political process that relies on citizens’ direct participation). Not only was the measure estimated to improve Idahoans’ access to health coverage, it was projected by the state itself to result in substantial savings for taxpayers. But that sense of optimism was quickly shattered: Only two months later, the Republican-controlled Idaho state legislature is actively working to dismantle the very policy voters just approved.
The Idaho state legislature quickly introduced two pieces of legislation — one to end Medicaid expansion altogether, and the other to repeal that expansion in 2023, with the purported aim to then reevaluate its cost savings. And while these legislative efforts failed in Idaho’s House Health and Welfare Committee, there are still ongoing efforts to impose Medicaid work requirements, which could result in some Idahoans losing coverage.
Republican opposition to Medicaid expansion is not exactly surprising. But it’s striking that Idaho’s Republican majority is seeking so blatantly to reverse the state’s popular will: After all, Republicans are known for their broad distaste of federal intervention. Under the Affordable Care Act, states were left with the voluntary decision of whether or not to expand Medicaid, either legislatively or through direct democracy. But, in Idaho at least, it seems like direct democracy is, in fact, not a tool for expansion.
Not all states have faced such uphill battles carrying into effect their preferred policies. In Maine, for example, voters approved Medicaid expansion via ballot initiative in 2017, and their Medicaid expansion went into effect after the election of a new Democratic governor in 2018. But Idaho is not Maine, and the Gem State’s executive and legislative branches are apparently willing to overlook the large margin by which voters supported Proposition 2. (And it’s not as if their obstinance over health care should come as a shock: Before Proposition 2, the Idaho legislature shot down a series of bills aimed at expanding Medicaid.)
Republicans have sold efforts to dismantle Medicaid expansion as a matter of course correction — basically, that Idaho voters were not adequately informed about the matter on which they were voting. Voting with limited political knowledge is hardly unusual for Americans. However, a large body of research shows that voters effectively take information shortcuts in order to vote in a way that is consistent with their ideologies, even in elections centered on ballot measures and not just partisan elections. And while Idaho has consistently been a reliably red state, Medicaid’s popularity has largely transcended party lines at the national level even amid heightened partisan polarization, meaning that both traditionally red and blue states have expanded Medicaid, and majorities of both parties view the program favorably.
Indeed, people have good reason to favor Medicaid expansion. According to the Kaiser Family Foundation, expansion is associated with lower uninsured rates and improved access to care such as early-stage diagnosis rates, access to medications, declines in uninsured emergency department visits, and improvements in medical disparities by race, income, education, and employment status.
At stake, with Idaho’s efforts to undermine Medicaid expansion votes, is not just public health, but also public trust in government. With broader mechanisms of political participation and democratic engagement, some have found evidence that citizens not only gain greater knowledge of politics, but may also perceive the government as being more responsive to constituent demands. And while the act of circumventing the legislature to advance policy change via direct democracy may undermine elected officials, it can nevertheless compel greater attentiveness to public opinion about public policy.
Or so can be the case when states carry into effect the policies adopted through this mechanism.