By most accounts, the biggest winner of the U.S. midterm elections was Medicaid Expansion. On November 6, 2018, three states passed ballot measures to expand Medicaid, while the residents of two other non-expansion states voted in Democratic governors in favor of expanding Medicaid. This recent overt display of support for expansion comes on the heels of a number of additional states that have reconsidered, and expanded, Medicaid.

The ballot measures passed in three Republican majority states, i.e., Idaho, Nebraska, and Utah, will increase the number of Medicaid Expansion states to 37.¹ For Idaho, expanding Medicaid had become more favorable over the past couple of years.² The ballot initiative passed easily, with 61% of residents voting for expansion, and 39% voting against it.³ However, the ballot did not include any plan for paying for the expansion, which task will now be the responsibility of the state legislature.⁴ Upon expansion, an estimated additional 69,000 residents will be covered (reducing Idaho’s uninsured rate from 14.6% to 9.9%).⁵

In Nebraska, the expansion ballot initiative passed by a relatively tighter margin (53% in favor to 47% opposed).⁶ Of note, Nebraska’s governor has stated that while he would “follow the will of the voters,” he would not sign any bill that financed Medicaid Expansion through a tax increase – no financing plan is currently in place for the expansion.⁷ Upon expansion, an estimated additional 45,000 Nebraskans will be covered (reducing the uninsured rate from 12.4% to 9.6%).⁸

Utah’s expansion initiative margin of victory was the same as in Nebraska – 53% in favor to 47% opposed.⁹ Unlike Nebraska and Idaho, however, voters agreed upon a partial financing plan for the expansion, by adding 0.15% to the state sales tax (which is expected to generate approximately $90 million in revenue).¹⁰ This passage is expected to expand Medicaid eligibility to approximately 150,000 Utahans, lowering the state’s uninsured rate from 13.3% to 10.5%.¹¹

The state of Montana, on the other hand, voted to reject a plan to preserve the funding for their current Medicaid Expansion program through 2019.¹² The initiative, the “single most expensive ballot measure in Montana history,” with over $17 million alone coming from tobacco companies,¹³ was shot down, with 53% of votes against the measure, and 47% of votes in favor.¹⁴

A significant reason for the opposition was that, attached to the expansion extension measure was the $2-per-cigarette-pack tax hike, as well as additional taxes on other tobacco products, such as e-cigarettes (which are not currently taxed), which would have helped to fund expansion going forward.¹⁵ If the state legislature does not find an avenue to continue funding Medicaid Expansion in Montana, it will expire in 2019, leaving almost 100,000 individuals without health insurance,¹⁶ and making it the first state to un-expand Medicaid.¹⁷

In addition to the three states expanding Medicaid through ballot initiatives, two states, Kansas and Wisconsin, voted in Democrats who made Medicaid Expansion a campaign priority, replacing Republican governors who had previously stonewalled expansion efforts in those states. In the Kansas gubernatorial race, Democrat Laura Kelly defeated Kansas Secretary of State Kris Kobach.¹⁸ The former governor, Sam Brownback, vetoed a 2017 expansion bill presented to him by the Kansas legislature, denying extending coverage to approximately 150,000 Kansans.¹⁹ In Wisconsin, Democrat Tony Evers narrowly defeated incumbent Governor Scott Walker.²⁰ Although Evers has stated his intent to work with the state legislature to pass an expansion bill, the legislature has explicitly opposed expanding Medicaid.²¹ Any potential development in the state will be unique, as Wisconsin’s application to add work requirements to its current Medicaid program was recently approved by CMS, adding a novel wrinkle to any potential expansion.²²

The recent wave of voter decisions regarding Medicaid Expansion builds upon the development of another two states over the course of 2018. As discussed in the June 2018 Health Capital Topics article,²³ Virginia and Maine have recently taken steps to expand Medicaid in their respective states. In May 2018, Virginia’s Republican-controlled Senate voted to expand Medicaid to cover “an additional 400,000 low-income adults” starting in 2019,²⁴ but is seeking a work requirement amendment that non-disabled adults must either work or volunteer to be eligible for the expanded program.²⁵ In the fall of 2017, Maine voters became the first in the nation to approve Medicaid Expansion through a public referendum, but Maine’s Governor, Paul LePage, refused to move ahead with the expansion.²⁶ The newly-elected Democratic governor, however, has stated that one of her first acts, upon the commencement of her term in January 2019, will be to implement the expanded program.²⁷

Despite the ebb and flow of public support over the past seven years related to the Patient Protection and Affordable Care Act (ACA), which instituted the Medicaid Expansion program, Medicaid Expansion support appears to be gaining steam. In states where elected leaders would not adhere to the will of their constituents, residents nevertheless largely either voted to expand Medicaid through popular referendums or ousted leaders who would not expand the program. Whether the remaining 14 states that have not voted to expand Medicaid will now follow suit before they lose out on more federal government funding through the program (which funding will be reduced to 90% in 2020²⁸) remains to be seen.