WASHINGTON — Despite the uncertainty and partisan gridlock that Tuesday’s election results ensure, one policy change seems guaranteed: hundreds of thousands more poor Americans in red states will qualify for free health coverage through Medicaid.
Voters in Idaho, Nebraska and Utah, which President Trump won easily in 2016, approved ballot initiatives to expand the government insurance program under the Affordable Care Act. Democratic victories in governors’ races also improved the chances of Medicaid expansion in Kansas and Wisconsin, and all but ensured it in Maine. As a result, Medicaid could see its biggest enrollment bump since the health law began allowing expansion in 2014.
For all the campaign warfare over the health law’s effect on insurance premiums and protections for people with pre-existing conditions, Medicaid has remained quite popular. In a Kaiser poll last month, 56 percent of people across the 17 states that had not yet expanded Medicaid said they favored doing so. And the share of people saying Medicaid was “very important” to them grew to nearly half during efforts to repeal the health law last year, Kaiser found.
“Medicaid per se is much more popular than the Affordable Care Act,” said Robert Blendon, a health policy expert at Harvard who has closely followed public opinion of the health law. “And the people organizing these referendums on Medicaid expansion aren’t making them about the A.C.A. They’re taking a program that’s been in the state for years and adding to it, saying, ‘All these other people need coverage and we can get outside money for it.’”
Somewhat unexpectedly, Medicaid expansion has also proven the sturdiest pillar of Obamacare, as the president and Republican Congress have chipped and pecked away at other aspects of the law. While they have essentially stopped promoting the insurance marketplaces, eliminated the requirement that uninsured people pay a tax penalty and allowed insurers to offer plans with fewer benefits, Medicaid, which now covers about 1 in 5 Americans, has kept gaining momentum.
The three states that approved expansion on Tuesday will join Virginia, which this spring approved Medicaid expansion, and Maine, where voters approved an expansion last year that has been blocked by the outgoing Republican governor, Paul LePage. In all, nearly 800,000 people could be newly eligible for the program across the five states.
That a bedrock of President Lyndon B. Johnson’s Great Society and longtime target of conservative politicians is drawing strong support in deep-red states is particularly striking. Gov. Pete Ricketts of Nebraska, who adamantly opposed Medicaid expansion in the past, did not fight his state’s initiative, and Gov. Butch Otter of Idaho, an Obamacare critic, went so far as to endorse the initiative there at the last minute, called it “good sense” and “the right thing to do.”
With the three successful ballot initiatives, the number of states that have expanded Medicaid coverage to most of their poor adult population will increase to 37 including the District of Columbia. Enrollment in the program has already grown by at least 15.6 million, or 28 percent, since 2013, the year before the health law’s main provisions took effect. That eclipses the 11.7 million people who have private health insurance through the law’s marketplaces.
Tuesday’s election results did provide one setback to Medicaid’s growth. Voters in Montana rejected a plan to preserve expanded Medicaid by sharply raising taxes on tobacco products to pay the state share of future costs. When the legislature expanded the program in 2015, it was for only four years. Now, about 100,000 low-income Montana residents could now lose Medicaid benefits unless the legislature agrees on another funding source by mid-2019. The tobacco industry poured more than $17 million into ads opposing the tax hike.
In Maine, where Mr. LePage is leaving office because of term limits, the Democratic candidate, Janet Mills, won. On Wednesday morning she showed up at a hearing in the protracted legal battle between Mr. LePage and Medicaid advocates, saying, “Dragging our feet any longer on this is inexcusable at this point.” She declared that she would move forward with expanding Medicaid to at least 70,000 low-income adults there as soon as she takes office in January.
Prospects for expanding Medicaid also improved in Kansas, where Laura Kelly, a Democrat who campaigned on it, won the governor’s race Tuesday, and Wisconsin, where Tony Evers, the Democrat, defeated Gov. Scott Walker. The Republican-controlled state legislature in Kansas voted last year to expand the program, but former Gov. Sam Brownback vetoed it.
Another state to keep an eye on is North Carolina, where Republicans lost their supermajority in the state House and Gov. Roy Cooper, a Democrat, has been trying to build support for Medicaid expansion.
But two closely watched states with particularly large numbers of uninsured people — Florida and Georgia, which together have close to two million residents with no coverage — appear unlikely to expand Medicaid any time soon, as both appear to have been won by Republicans who oppose it. In Georgia, the Democrat, Stacey Abrams, made expanding Medicaid a top priority, and a poll taken in January found that 75 percent of the state’s voters, including 51 percent of Republicans, supported doing so. Like most of the other Southern states that have continued to reject Medicaid expansion, Georgia and Florida residents who would benefit are disproportionately black and Hispanic.
To be sure, beneficiaries of Medicaid expansion still face threats to their coverage. The Trump administration has granted a number of requests from Republican-led states to impose work requirements on newly eligible adult beneficiaries, and while the courts will have the final say, they have already led to several thousand people in Arkansas losing coverage. And a lawsuit seeking to invalidate the health law, filed by 20 Republican governors and attorneys general, could end expanded Medicaid if the plaintiffs prevail.
Yet work requirements could also make expansion more appealing to conservative lawmakers and voters in the remaining holdout states.
“This may be precisely what allows people to feel comfortable in some states about having a Medicaid expansion,” said Gail Wilensky, an economist who oversaw Medicaid under President George H.W. Bush, speaking last week at a forum at Harvard University last week.
The biggest reason Republican lawmakers have opposed Medicaid expansion is concern that it will eat up too much of the state budget. In a number of states that have already expanded the program, enrollment has far exceeded expectations, driving up costs. But under the terms of the health law, the federal government pays at least 90 percent of the costs for the newly eligible adult population, compared with 62 percent on average for the traditional population of children, pregnant women and poor disabled and elderly people.
In Nebraska and Idaho, the ballot initiatives did not include a way to pay the state share of expansion costs. That could potentially make them vulnerable to the type of stalling that’s happened in Maine, where Mr. LePage has grounded his resistance in the fact that the initiative did not include a funding mechanism.
In Utah, the measure increases the state sales tax rate on items other than food to 4.85 percent, from the current 4.7 percent, to pay the state share.
The largest donor overall to the Medicaid ballot initiatives was the Fairness Project, which is backed primarily by a California labor union. The group spent more than $5 million on signature-gathering efforts, advertising, field offices and other efforts.
“This election proves that politicians who fought to repeal the Affordable Care Act got it wrong,” said Jonathan Schleifer, executive director of The Fairness Project. “Expanding access to health care isn’t a blue state value or a red state value; it’s an American value.”
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