Obamacare allies aim to expand Medicaid, the low-income government health program, in a handful of states via ballot measures. But they face staunch opposition before Election Day and no guarantee of success after it even if they win over voters.
On Nov. 6, voters in Idaho, Nebraska, and Utah will decide through ballot measures whether to allow more people on the Medicaid program, a move already advanced by 33 states and the District of Columbia. Voters in a fourth state, Montana, will decide whether to make the expansion permanent.
Obamacare advocates and healthcare groups, including hospitals, hope to use the ballot measures to circumvent entrenched Republican lawmakers. Yet, as November approaches, they face powerful opponents rallying opposition. And in Nebraska and Idaho, success would result in an immediate legislative funding battle, because the states don’t have plans for how they would pay their share of expansion.
“We are up against powerful opponents everywhere. … We aren’t taking anything for granted,” said Jonathan Schleifer, executive director of the Fairness Project, which worked to bring the ballot questions to voters.
In Obamacare, Congress expanded Medicaid, which is jointly funded by states and the federal government, to allow people making less than roughly $ 17,000 a year to receive it. People at that level of income are largely uninsured, and under the expansion, income is the only factor in qualifying for enrollment.
The Fairness Project’s pitch to voters is that Medicaid expansion is good for the state economy and for healthcare access. It has warned voters that their states are losing out on federal healthcare dollars if they don’t expand Medicaid, and has framed the program as a boon to hardworking people.
Meanwhile, Americans for Prosperity, an organization affiliated with the libertarian Koch brothers, is working to defeat initiatives in Utah and Nebraska.
In Utah, Americans for Prosperity is highlighting that the expansion would be paid for through higher taxes on non-food items.
In Montana, too, funding is the weak spot for Medicaid proponents. The ballot measure would make the state’s Medicaid expansion permanent and pay for it with a $ 2-a-pack cigarette tax and 33 percent tax on other nicotine products, including e-cigarettes.
Accordingly, the tobacco industry is fighting back through a political action committee dubbed Montanans Against Tax Hikes, arguing that taxpayers will be left on the hook because smokers will buy cigarettes out of state. The industry has spent more than $ 9.83 million to convince voters to vote “no.” If the expansion isn’t renewed, about 90,000 Montanans, a tenth of the state population, risk losing coverage.
The Healthy Montana Initiative that backs the tax has said that, because tobacco remains a top cause of preventable illness and death, the industry should fund the expansion. The group, primarily funded through hospitals in the state, has spent $ 4.15 million to encourage voters to support Medicaid expansion.
Prior to Obamacare, states varied in which populations they covered via Medicaid, but generally the program covered people with disabilities, pregnant women, children, and ongoing care for older adults. Traditional Medicaid still covers these groups, but the healthcare law aimed to make states more uniform by moving low-income people into the program. In 2012, a Supreme Court decision made the provision optional for states.
Opponents object to childless, able-bodied adults benefiting from Medicaid, and to growing the size of government.
“In every state that expanded Medicaid, we have seen an unsustainable burden put on the backs of taxpayers and the crowding out of resources for people who are truly in need,” Americans for Prosperity policy manager David Barnes said in a statement to the Washington Examiner. “Our network is deeply concerned about this troubling trend and will continue to advocate for a variety of free-market solutions to improve access to quality, affordable health care for all Americans.”
The federal government had paid for the full cost of Medicaid expansion beginning in 2014, but under Obamacare the support gradually tapers off to 90 percent of costs by 2020. That rate is higher than the 60 percent share it pays for traditional Medicaid.
For certain states, making up the 10 percent of costs will mean millions of dollars in spending every year. Medicaid already is one of the largest expenditures in states, next to education.
Nicholas Horton, research director at the conservative Foundation for Government Accountability, warned that if voters approve expansions then states would need to increase taxes or take funding away from other programs.
“Those are the only two choices states will have to fund the expansion. … Those are very serious conversations and questions that voters in states have to ask,” he said.
Opponents to expansion have pointed out that cost projections can be inexact. For instance, the number of people who enrolled in Medicaid under the Montana expansion was expected to be around 46,000 and cost $ 43 million, but more than 90,000 enrolled.
If the Nebraska measure passes, legislators who long opposed expansion will need to arrive at an agreement over how to fund it. The bill is expected to cost Nebraska $ 591 million over a decade, according to an analysis from the health department.
Should snags over funding occur, it wouldn’t be a first. Maine voters advanced a ballot measure in 2017 to approve Medicaid expansion, but GOP Gov. Paul LePage has refused to implement it until it is funded, despite court interventions.
Because LePage’s term is ending, the implementation of Medicaid expansion in Maine is likely to fall to his successor. On the Democratic ticket is the state’s attorney general, Janet Mills, who supports expansion, but she is running against Republican Shawn Moody, a business owner and expansion opponent who has echoed LePage’s position on finding a payment mechanism. When the measure does move forward, under a new governor or by court order, an additional 70,000 Mainers are expected to enroll in Medicaid.
Certain Republicans have said that they won’t get in the way of expansion if that’s what voters choose.
In Nebraska, Gov. Pete Ricketts has been opposed to expansion but has indicated in media reports that he would be hands-off if voters approve the move. State Sen. Bob Krist of Omaha, his Democratic challenger, supports the expansion.
In Idaho, Democratic candidate state Rep. Paulette Jordan has said her campaign is devoted not only to getting people to vote “yes” on expansion, but also to the development of Medicaid in the state. On Twitter, Idaho Democrats accused her GOP opponent, Brad Little, of being unclear on his position. Even if it passes, it will be up to the legislature to appropriate the money.
Looking ahead to 2020, a presidential election year when voter turnout surges, advocates already are eyeing other states where Medicaid expansion could become a reality through state ballots.
“Americans are sick and tired of people playing politics with healthcare,” Schleifer said. “They just don’t trust politicians to do the right thing.”