Ballot Initiatives Are Bringing Medicaid Expansion to Some of America's Most Conservative States

The passage of Medicaid expansion in three deeply conservative states is evidence that a less partisan presentation of policy is allowing voters to make decisions based more on their own interests, according to advocacy groups.
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Doctor's office.

According to the Kaiser Family Foundation, about three quarters of the American public holds a favorable view of the Affordable Care Act provision that grants states the option to expand Medicaid.

With so much of the 2018 mid-term coverage focused on Democrats' so-called "blue wave" in the House of the Representatives, there was relatively little mention of what appeared to be a signal of red-state reform: Medicaid expansion passed in Utah, Idaho, and Nebraska—all deeply conservative states—securing health coverage for hundreds of thousands more of the poorest Americans in the process.

The successful campaigns, all of them bankrolled by SEIU-United Healthcare Workers West, a union of California health professionals, were particularly stunning because all three states voted reliably Republican in the mid-terms (and voted for Donald Trump in the 2016 election by a margin of at least 20 percent). For progressives, they also reinforce the power of ballot initiates as a vehicle for reform.

Leaders at the Fairness Project, a progressive advocacy group, believe the red-state victories are evidence that ballot initiatives present a unique opportunity to reach voters on issues like health care and wages, the two biggest pain points for working Americans, without having to wade into issues of partisan politics or legislative gridlock. And while everything else about the current political moment is pushing people further and further into their partisan corners, the Fairness Project's executive director, Jonathan Schleifer, says, ballot initiatives "help pull people out of them."

"We take the party labels off of common-sense policies and we put them in front of voters, and when you do that, it's clear that voters want to help struggling families," he says. "It goes against the narrative that we've never been more divided."

Based on publicly available national polling data, voters do, in fact, want to help struggling families: According to the non-partisan Kaiser Family Foundation health tracking poll released in November, about three quarters of the American public—including 77 percent of the population living in non-expansion states—holds a favorable view of the Affordable Care Act provision that grants states the option to expand Medicaid. In those same states, KFF found that 59 percent of the population would be in favor of expanding Medicaid to cover more low-income Americans, while 34 percent said they would like to see their state leave its existing Medicaid coverage unchanged.

In a 2012 ruling, the U.S. Supreme Court handed a victory to the Affordable Care Act when it upheld the constitutionality of the law's individual mandate, which stipulates that most people must maintain a minimum level of health insurance coverage. A majority of the court also decided that the ACA's mandatory Medicaid expansion was unconstitutional, effectively leaving it up to the states to decide whether or not to opt to expand coverage.

But while 36 states and Washington, D.C., have adopted Obamacare's Medicaid expansion, some red states have continued to eschew the increased coverage proposals.

With 4.7 million uninsured, Texas boasts the most people under the age of 65 without medical insurance out of any state, according to a report released by the Urban Institute in December. And in Georgia, newly minted Republican Governor Brian Kemp continues to decry Medicaid as "a failed government program," despite the fact that 73 percent of the state's population supports an expansion. Both states are legally ineligible to put Medicaid expansion to voters by way of a ballot initiative, meaning that Republican wins during the 2018 mid-terms all but ensure that the possibility has stalled for the foreseeable future.

Conversely, in states like Maine and Wisconsin, Democratic victories in November have bolstered the prospects of health-care expansion in a big way. In Wisconsin, Republican Governor Scott Walker was recently ousted by Democrat Tony Evers, who ran a campaign centered around passing Medicaid expansion. And in Maine, an approved initiative to expand health-care access that had been held hostage by Republican Governor Paul LePage will now likely see the light of day under the tenure of newly elected Democrat Janet Mills.

In the remaining six states eligible to put Medicaid expansion on the ballot in 2020—Florida, Mississippi, Missouri, Oklahoma, South Dakota, and Wyoming—there's still hope for reform.

Bridget McCandless, president and chief executive officer of Health Forward in Kansas City, Missouri, says her organization has tangled with the state's Republican-led general assembly for years without luck. She called the passage of ballot initiatives in three red states last fall "an opportunity for advocates in the state of Missouri to understand that there was an opportunity to expand Medicaid in this state."

Although Schleifer could not disclose which states the Fairness Project plans to target in 2020, he says the group is currently "evaluating the viability" of campaigns in all six states eligible for ballot initiatives. McCandless confirmed in an interview with Pacific Standard that her organization has been working with the Fairness Project in order to collect preliminary data on the popularity of a potential ballot initiative to expand Medicaid in the Missouri.

"I think when you put Medicaid expansion to the people in an initiative petition, you see voters make decisions less on political reasons and more on human issues," McCandless says. "Being healthy or well isn't a red or blue issue, it's about taking care of our neighbors and making sure as many people as possible can access the care that they need."

While polling data on the popularity of expanding health care plays a big role in which states the Fairness Project will ultimately decide to pour resources into, Schleifer also stressed the importance of having enthusiastic grassroots partners on the ground.

"We want to respect their leadership," Schleifer says. "We don't parachute in with a campaign in a box and hand out a bunch of T-shirts and signs and get to work, it's really about partnering with local groups who are already doing the work."

Judging by the successes of the group's last three campaigns, it seems likely that it won't meet with much resistance from the remaining eligible states in 2020.

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